Chronic pain patient-spouse behavioral interactions predict patient disability

Pain in non-communicative older adults beyond dementia: a narrative review

Aging is associated with an increased risk of developing pain, especially in the presence of concurrent chronic clinical conditions. Similarly, multimorbidity can affect the perception and ability of older adults to appropriately respond to and communicate pain, and there is a clinical heterogeneity in the processing of painful sensations in different neurological conditions. The present narrative review is aimed at assessing the prevalent diseases associated with poor communication and pain in older adults, together with the available diagnostic instruments for the clinical assessment of pain in such a vulnerable population. Dementia was the most described pathology identified in the current literature associated with poor communication in older adults affected by pain, along with Parkinson's disease and stroke. Notably, a common pattern of pain behaviors in these neurological disorders also emerged, indicating potential similarities in the clinical presentation and appropriate diagnostic workout. At the same time, there are many differences in the way patients express their pain according to their main neurological pathology. In addition to this, although a plethora of observation-based tools for pain in patients with dementia have been developed, there is no gold standard, and the clinical utility of such measurements is still largely unaddressed. Meanwhile, there is substantially no standardized observation-based tool for pain in non-communicative patients with Parkinson's disease, and only a few for stroke. Overall, the present narrative review provides an update on the prevalent diseases beyond dementia associated with a communicative disability and a painful condition in older adults.

Pain: Behavioural expression and response in an evolutionary framework

An evolutionary perspective offers insights into the major public health problem of chronic (persistent) pain; behaviours associated with it perpetuate both pain and disability. Pain is motivating, and pain-related behaviours promote recovery by immediate active or passive defence; subsequent protection of wounds; suppression of competing responses; energy conservation; vigilance to threat; and learned avoidance of associated cues. When these persist beyond healing, as in chronic pain, they are disabling. In mammals, facial and bodily expression of pain is visible and identifiable by others, while social context, including conspecifics' responses, modulate pain. Studies of responses to pain emphasize onlooker empathy, but people with chronic pain report feeling disbelieved and stigmatized. Observers frequently discount others' pain, best understood in terms of cheater detection-alertness to free riders that underpins the capacity for prosocial behaviours. These dynamics occur both in everyday life and in clinical encounters, providing an account of the adaptiveness of pain-related behaviours.

No effect of social interaction on experimental pain sensitivity: a randomized experimental study

ABSTRACT

Quantitative sensory testing (QST) is a commonly applied paradigm to investigate pain, which is a subjective experience influenced by a myriad of social and contextual factors. Therefore, it is important to consider the potential sensitivity of QST to the test setting and the social interaction that naturally is a part of it. This may particularly be the case in clinical settings where patients have something at stake. Therefore, we investigated differences in pain responses using QST in different test setups with varying degrees of human interaction. In a parallel three-armed randomized experimental study, we included 92 participants with low back pain and 87 healthy volunteers allocated to 1 of the 3 QST setups: 1 setup with manual tests performed by a human tester, 1 setup with automated tests performed by a robot and orally guided by a human tester, and 1 setup with automated tests performed solely by a robot without social interaction with a human tester. All 3 setups consisted of the same pain tests in the same order, including pressure pain threshold and cold pressor tests. We found no statistically significant differences between setups on the primary outcome of conditioned pain modulation nor any secondary QST outcomes. While this study is not without limitations, the results indicate that QST procedures are robust enough not to be influenced by social interaction to an appreciable degree.

"I don't have chronic back pain anymore": Patient Experiences in Pain Reprocessing Therapy for Chronic Back Pain

In a recently published randomized controlled trial, two-thirds of the patients receiving a novel psychological treatment, pain reprocessing therapy (PRT), reported elimination or near-elimination of chronic back pain. The mechanisms of PRT and related treatments remain poorly understood but are hypothesized to center on pain reappraisal, fear reduction, and exposure-potentiated extinction. Here, we investigated treatment mechanisms from the participants' perspective. A sample of 32 adults with chronic back pain who received PRT completed semi-structured posttreatment interviews about their treatment experiences. The interviews were analyzed with multiphase thematic analysis. The analyses identified 3 major themes reflecting participants' understanding of how PRT led to pain relief: 1) reappraisal to reduce fear of pain, which included guiding participants to relate to pain as a helpful indicator, overcoming pain-related fear and avoidance, and reconceptualizing pain as a "sensation;" 2) the link between pain, emotions, and, stress, which included gaining insight into these connections and resolving difficult emotions; and 3) social connections, which included patient-provider alliance, therapist belief in the treatment model, and peer models of recovery from chronic pain. Our findings support the hypothesized mechanisms of PRT centered on pain reappraisal and fear reduction, but also highlight additional processes from the participants' perspective, including a focus on emotions and relationships. This study underscores the value of qualitative research methods in illuminating the mechanisms of novel pain therapies. PERSPECTIVE: This article presents participants' perspectives on their experience engaging in a novel psychotherapy for chronic pain, PRT. Through pain reappraisal, linking pain, emotions, and stress, and connecting with their therapist and peers, many participants reported an elimination or near-elimination of their chronic back pain with therapy.

Sexual function among women with vaginismus: a biopsychosocial approach

BACKGROUND

Vaginismus is known as a type of sexual pain disorder. Regarding the multifactorial nature of vaginismus, the biopsychosocial model is one of the best models to describe this sexual disorder.

AIM

The present research was conducted to study the determinants of sexual function in women with and without vaginismus based on the biopsychosocial model.

METHODS

This case-control study was conducted in Iran on 420 women with and without primary vaginismus who met the inclusion criteria. All eligible people were included in the research once their eligibility was verified and their informed permission was acquired; convenience and purposive sampling techniques were used continually. Data collection tools included the demographic and obstetric information form and multiple published scales and questionnaires. Structural equation modeling with LISREL 9.2 software (Scientific Software International) was used to evaluate the determinants of the sexual function of vaginismus.

OUTCOMES

Participants rated their determinants of sexual function based on the biopsychosocial model.

RESULTS

The mean ages of the case and control groups were 27.67 and 28.44 years, respectively. The direct, indirect, and total effects of the dimensions of sexual health on sexual function and the diagnostic score of vaginismus of the women with vaginismus were significant (P < .001). Furthermore, based on the results, the diagnostic score of vaginismus in women with vaginismus was significantly affected by the direct, indirect, and cumulative impacts of vaginal penetration cognition and fear of sex (P = .016, P = .005). Women with and without vaginismus were able to accept the models' excellent fit.

CLINICAL IMPLICATIONS

This study helps inform health planners and policy makers about the sexual function of women with vaginismus, the factors related to this disorder, and the multidimensional nature of this sexual problem.

STRENGTHS AND LIMITATIONS

This study attempted to offer a more comprehensive and complete view of present knowledge via surveying different aspects of sexual health and by means of valid and reliable tools and path analysis. The study's merits include the use of the biopsychosocial model to evaluate sexual function in women with vaginismus, the use of a variety of questionnaires to compare women with and without vaginismus, and the size of the sample. The research was limited by the fact that electronic sampling was conducted because of the COVID-19 epidemic.

CONCLUSION

Based on the findings of the present study for the group of women with vaginismus, the direct, indirect, and overall effects of the majority of dimensions of sexual health were significantly correlated with sexual function and vaginismus.

Denying the Truth Does Not Change the Facts: A Systematic Analysis of Pseudoscientific Denial of Complex Regional Pain Syndrome

Purpose

Several articles have claimed that complex regional pain syndrome (CRPS) does not exist. Although a minority view, it is important to understand the arguments presented in these articles. We conducted a systematic literature search to evaluate the methodological quality of articles that claim CRPS does not exist. We then examined and refuted the arguments supporting this claim using up-to-date scientific literature on CRPS.

Methods

A systematic search was conducted in MEDLINE, EMBASE and Cochrane CENTRAL databases. Inclusion criteria for articles were (a) a claim made that CRPS does not exist or that CRPS is not a distinct diagnostic entity and (b) support of these claims with subsequent argument(s). The methodological quality of articles was assessed if possible.

Results

Nine articles were included for analysis: 4 narrative reviews, 2 personal views, 1 letter, 1 editorial and 1 case report. Seven points of controversy were used in these articles to argue that CRPS does not exist: 1) disagreement with the label “CRPS”; 2) the “unclear” pathophysiology; 3) the validity of the diagnostic criteria; 4) CRPS as a normal consequence of immobilization; 5) the role of psychological factors; 6) other identifiable causes for CRPS symptoms; and 7) the methodological quality of CRPS research.

Conclusion

The level of evidence for the claim that CRPS does not exist is very weak. Published accounts concluding that CRPS does not exist, in the absence of primary evidence to underpin them, can harm patients by encouraging dismissal of patients’ signs and symptoms.

Can Central Sensitization after injury persist as an autonomous pain generator? - A comprehensive search for evidence

OBJECTIVE

To conduct a comprehensive search for evidence whether Central Sensitization following an injury can act as a persistent autonomous pain generator after the inducing injury has healed.

METHODS

We searched Medline on PubMed and the Cochrane Library, screening 3,572 abstracts, from which 937 full text articles were obtained, with 186 of these discarded as irrelevant to the question being posed. The remaining 751 articles were studied for evidence.

RESULTS

Fourteen publications were judged to provide weak evidence for the hypothesis of central sensitization as a persisting autonomous pain generator, but none addressed the question directly. No strong evidence for the affirmative answer was found.Sixty-two publications were judged to provide weak evidence for a negative answer, and nine judged to provide strong evidence.Unexpectedly, serious weaknesses were discovered in the literature underpinning the validity of the clinical diagnosis of Central Sensitization in man:(i)  Inappropriate extrapolation, in many publications, of laboratory animal data to humans.(ii) Failure to demonstrate the absence of peripheral pain generators which might be perpetuating Central Sensitization.(iii) Many factors now shown to confound what is being measured by quantitative sensory testing, conditioned pain modulation, and Central Sensitization Inventory.

CONCLUSIONS

We found no evidence proving that central sensitization can persist as an autonomous pain generator after the initiating injury has healed.Our review has also shown that the evidential basis for the diagnosis of CS in individual patients is seriously in question.

Exploring the relationships among social support, patient activation, and pain-related outcomes

OBJECTIVE

Social support has been linked to more effective pain adaptation. The relationship between social support and other relevant constructs is less well-understood. Chief among these is patient activation, which has robust links to effective self-management, yet has not been well-studied in chronic pain. We sought to better understand these relationships in an effort to inform future intervention strategies for patients with chronic pain.

METHODS

Using baseline data from a clinical trial with patients with chronic pain (N = 213), we analyzed the relationships among perceived social support and patient activation, depression, anxiety, general health perceptions, pain centrality, pain catastrophizing, and pain intensity and interference. Multiple linear regression was used to examine the effect of social support on outcomes. Patient activation was explored as a mediator of the effect of social support on outcomes.

RESULTS

Social support was significantly associated with all outcomes except pain. Social support explained the greatest variance in patient activation (squared semi-partial correlation =0.081), followed by depression (0.073) and general health perceptions (0.072). Patient activation was not found to be a significant mediator of the effect of social support on pain-related outcomes.

CONCLUSIONS

Findings provide insight into the roles of patient activation and social support in chronic pain management. Although patient activation did not mediate the relationship between social support and outcomes, this study is an important step toward gaining a more complete understanding of constructs thought to be related to pain self-management and points to the need to advance theory in this area to guide future research. Such work is needed to optimize interventions for patients with chronic pain.

How Do I Help My Partner in Pain? Partners' Helping Behaviors Are Linked to Lower Pain and Greater Perceived Validation During an Experimental Pain Task

BACKGROUND

Observers' responses to people with illness are important predictors of quality of life, yet findings are mixed regarding the types of responses that affect illness-related suffering.

PURPOSE

The purpose of this study was to examine whether perspective taking positively affects observers' responses to their romantic partner experiencing experimentally induced pain and whether responses based in Self-Determination Theory and communication models of illness are related to perceived validation and pain outcomes.

METHODS

Undergraduate romantic couples (N = 122) completed baseline questionnaires; then one partner was randomly assigned to complete the cold pressor task, whereas the other partner observed. Couples were randomly assigned to one of two groups: a perspective-taking group in which observers were privately instructed to take the perspective of the pain participant or a control group. Afterward, both partners completed surveys, and pain participants completed a video recall task in which they recalled partner behaviors that were coded by trained raters using a theoretically derived manual.

RESULTS

Pain participants in the perspective-taking group identified significantly less invalidating communication from their partners, fewer behaviors that thwarted their competence, and more behaviors that supported their autonomy. Across groups, pain participants who received more normalizing communication that supported their competence felt more validated by their partners, had lower pain intensity, and exhibited greater pain tolerance, whereas those who received more invalidation showed worse outcomes.

CONCLUSIONS

The results from this study suggest that attention to different types of partner behaviors is essential when developing behavioral medicine treatments for pain and illness.

Patient Satisfaction With Chronic Pain Management: Patient Perspectives of Improvement

Integrating satisfaction measures with pain-related variables can highlight global change and improvement from the patients' perspective. This study examined patient satisfaction in an interdisciplinary chronic pain management program. Nine hundred and twenty-seven (n = 927) participants completed pre- and post-treatment measures of pain, depression, catastrophizing, anxiety, stages of change, and pain acceptance. Multiple regression was used to examine these variables at admission and discharge as predictors of patient satisfaction. Pain-related variables explained 50.6% of the variance (R2 = .506, F 22,639 = 29.79, P < .001) for general satisfaction, and 38.9% of the variance (R2 = 0.389, F 22,639 = 18.49, P < .001) for goal accomplishment. Significant predictors of general satisfaction included depression (β = -0.188, P < .001) and the maintenance stage of change (β = 0.272, P < .001). The latter was also a significant predictor of goal accomplishment (β = 0.300, P < .001). Discharge pain-related measures are more influential than admission measures for predicting patient satisfaction. Patient satisfaction is significantly related to establishing a self-management approach to pain.

Predictors and mediators of outcome in cognitive behavioral therapy for chronic pain: the contributions of psychological flexibility

There is now a consensus in the literature that future improvements in outcomes obtained from cognitive behavioral therapy (CBT) for chronic pain will require research to identify patient and treatment variables that help explain outcomes. The first aim of this study was to assess whether pre-treatment scores on measures of psychological (in)flexibility, acceptance, committed action, cognitive (de)fusion, and values-based action predict outcomes in a multidisciplinary, multicomponent, group-based CBT program for adults with chronic pain. The second aim was to assess whether change scores on these same measures mediate outcomes in the treatment program. Participants were 232 people attending treatment for chronic pain. Of the psychological flexibility measures, only pre-treatment scores on the psychological inflexibility scale predicted outcomes; higher scores on this measure were associated with worse outcomes. However, change scores on each of the psychological flexibility measures separately mediated outcomes. The efficacy of CBT for chronic pain may be improved with a greater focus on methods that increase psychological flexibility.

Pain Catastrophizing Thoughts Explain the Link Between Perceived Caregiver Responses and Pain Behaviors of Patients With Chronic Musculoskeletal Pain

PURPOSE

Caregivers' responses to pain behaviors of patients with chronic pain have an essential role in how patients perceive their pain condition. The current study investigated the mediating role of pain catastrophizing on the link between perceived caregiver responses and patient pain behaviors.

MATERIALS AND METHODS

The sample of this cross-sectional study consisted of 200 patients with chronic pain (mean of age = 44.6; 71.5% were female). Participants responded to measures assessing their perception of their caregiver responses to their pain, their pain catastrophizing thoughts, and their pain behaviors.

RESULTS

The mediation analyses showed that perceived distracting responses were negatively related to pain catastrophizing level in patients, which in turn was positively associated with expressing pain behaviors. Besides, perceived caregiver negative responses were positively associated with catastrophizing thoughts, which in turn was positively related to expressing pain behaviors.

CONCLUSION

Patients' perceptions regarding how their caregiver responds to their pain condition can be related to their thoughts about their pain and how they react to their pain situation. Investigating the external sources that might have an impact on patients' reactions to their pain, especially when those external sources are caregivers who, in most situations, are with the patients for a prolonged duration, is essential.

Health social workers' assessments as part of a specialized pain rehabilitation: a clinical data-mining study

This study examines how health social workers (HSWs) assess the rehabilitation needs of patients with long-term pain. Data were extracted from 66 patient assessments through a retrieval form based on the International Classification of Functioning, Disability, and Health. The assessments included information about relations, work, and recreation. Stress management, problem solving, self-care, participation in community life, and providing personal care were missing in parts of or all assessments. Differences in assessments suggest that information was registered based on traditional gender roles and age. Therefore, HSWs need standardized assessment tools to ensure that assessments are relevant for all patients with long-term pain irrespective of gender or age.

Couple Interventions for Chronic Pain: A Systematic Review

OBJECTIVE

Couple interventions for chronic pain have been shown to more effectively reduce pain intensity for individuals with chronic pain (ICPs) than individual behavioral interventions or usual care. This systematic review identified randomized controlled trials of couple interventions to highlight strategies that could be incorporated into psychotherapy with ICPs and their romantic partners.

METHODS

The authors identified articles reporting randomized controlled trials of couple interventions for chronic pain. Three databases were searched (ie, PubMed, Embase, and PsycInfo), resulting in 18 studies and 22 articles.

RESULTS

Couple interventions resulted in statistically significant improvements in pain intensity compared with other conditions in 8% to 40% of the studies depending on the comparator group (i.e., control, individual intervention, another couple intervention), and in statistically significant improvements on a pain-related outcome compared with other conditions in 31% to 50% of the studies depending on the comparator group (ie, control, individual intervention, another couple intervention). Educating couples about pain was the most common strategy (83%). Jointly administered relaxation or meditation skills were included in nearly half of the interventions (48%). Many interventions taught cognitive-behavioral skills jointly to couples (39%) or to the ICP with partner encouragement (30%). Teaching couples how to request and provide assistance (30%), and encouraging partners to avoid reinforcing pain behaviors (39%), occurred frequently. ICPs and their partners were often asked to set goals (30%).

DISCUSSION

This review outlined strategies included in couple interventions for chronic pain that are derived from the cognitive-behavioral therapy, acceptance and commitment therapy, and operant behavioral traditions, but delivered relationally. Therapists working with ICPs and their partners may integrate these strategies into their practice to help couples who are managing chronic pain.

Partners' Overestimation of Patients' Pain Severity: Relationships with Partners' Interpersonal Responses

Objectives

The present study examined whether concordance between patients' and their partners' reports of patient pain severity relates to partners' social support and behavioral responses in couples coping with chronic pain.

Methods

Fifty-two couples completed questionnaires about the patient's pain severity. Both dyad members also rated the partner's social support and negative, solicitous, and distracting responses toward the patient when in pain.

Results

Bivariate correlations showed moderate correspondence between patient and partner ratings of pain severity (r = 0.55) and negative (r = 0.46), solicitous (r = 0.47), and distracting responses (r = 0.53), but lower correspondence for social support (r = 0.28). Twenty-eight couples (54%) were concordant in their perceptions of patient pain; partners overestimated pain in 14 couples (27%), and partners underestimated pain in 10 couples (19%). Couple concordance in pain perceptions was not related to patients' reports; however, it significantly predicted partners' reports: Partners who overestimated pain reported giving more social support (β = 0.383, P = 0.016), fewer negative responses (β = -0.332, P = 0.029), and more solicitous responses (β = 0.438, P = 0.016) than partners who were in agreement or who underestimated pain.

Discussion

Partner overestimation of pain severity is associated with partner-reported but not with patient-reported support-related responses. This finding has important clinical implications for couple interventions in chronic pain.

Solicitous and invalidating responses are associated with health-care visits in fibromyalgia

Objectives

Health-care use in FM is substantial. Besides the severity of the disease and psychological factors, previous research suggests that the social environment can influence patients’ health-care use. In this study, we describe health-care use in patients with FM and investigate the relationship of social responses of the partner and family with health-care use.

Methods

Cross-sectional data of 280 patients with FM were analysed. Sociodemographic variables, health-status variables, health-care use, partner’s solicitous and punishing responses, and invalidation (i.e. discounting and lack of understanding) by family were assessed. Heath-care use was defined as the number of visits to physicians and health professionals. Associations of independent variables with health-care use were examined using univariate and hierarchical regression analyses.

Results

In the preceding 6 months, 99% of the patients visited at least one physician and 66% visited at least one health professional. The mean (s.d.) total health-care visits and the number of different disciplines consulted were 18.5 (17.7) and 3.6 (1.7), respectively. Being female, paid employment, having a co-morbid condition, a higher severity of FM, more partner’s solicitous responses and more invalidating responses by family were univariately associated with visits to a physician. Having a co-morbid condition, severity of FM and invalidation by family were uniquely associated with visits to a physician. No other associations were found.

Conclusion

Therapeutic attention to patients’ close social environment might be a useful approach to improve health-related outcomes, including health-care use, in patients with FM.

Influence of significant others on work participation of individuals with chronic diseases: a systematic review

OBJECTIVE

It is widely recognised that significant others (SOs), such as a partner, family member or friend, can influence health outcomes of individuals with a chronic disease. However, not much is known about which specific cognitions (ie, illness perceptions and expectation of work ability) and behaviours (eg, emotional and practical support) of SOs influence work participation. Therefore, we aimed to identify cognitions and behaviours of SOs that are related to work participation of individuals with a chronic disease.

DESIGN

A systematic review and thematic synthesis.

DATA SOURCES

PubMed, Embase, PsycINFO, SocINDEX and Web of Science were searched until 28 March 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies reporting on cognitions and behaviours of SOs related to work participation in populations with various chronic diseases.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the data and performed a quality assessment using the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project 2007 and a checklist for assessment of qualitative studies derived from the Cochrane Supplemental Handbook Guidance. Evidence was thematically synthesised.

RESULTS

Out of 5168 articles, 18 were included (15 qualitative and 3 quantitative) of moderate to high quality. Studies were on cancer, chronic pain, brain injuries and mental health disorders. After thematic synthesis 27 factors could be distinguished. Consistent evidence was found that SOs' positive and encouraging attitudes regarding work participation, encouragement and motivating behaviour and open communication with patients are facilitators for work participation. Consistently reported barriers were SOs' positive attitudes towards sickness absence and advise, encouragement or pressure to refrain from work.

CONCLUSIONS

Our findings show that several cognitions and behaviours of SOs can facilitate or hinder work participation of individuals with a chronic disease. Intervening on these factors by involving SOs in disability prevention and return to work intervention strategies may be beneficial. More prognostic studies are needed, as the current evidence is mostly based on qualitative studies.

Social Influences on Peer Judgments about Chronic Pain and Disability

Chronic pain is a leading cause of work absenteeism and disability compensation. Previous work demonstrates that patients with chronic illness often seek advice, such as whether or not to pursue disability benefits, from peers with similar health conditions. The current study examined the extent that social factors influence patients with chronic pain ("peers") when making disability judgments and recommendations for other patients with chronic pain. Participants (N = 71) made pain-related and disability ratings for fictional vignette patients that varied in weight (normal vs obese), fault of accident, and physical work demands. Results of repeated measures analyses of variance indicated that participants rated patients with obesity, who were not at fault, and who held a physically demanding job as experiencing more severe pain symptoms and disability and were more likely to recommend they seek disability benefits. Participants who had applied for disability benefits themselves rated patients as more disabled than participants who had not applied for disability. These data suggest that patients with chronic pain are influenced by patient and contextual factors when making pain-related and disability judgments for peers. These judgments may impact patient decision making via peer support programs and online forums. PERSPECTIVE: This study suggests that patients with chronic pain are influenced by patient weight, fault of accident, and physical work demands when making judgments about pain and disability for peers. Future studies should examine the extent such peer-to-peer recommendations influence actual disability-seeking behaviors for pain.

Spousal Support for Patients With Rheumatoid Arthritis: Getting the Wrong Kind Is a Pain

Research indicates that perceived support availability is beneficial, with support available from the spouse particularly important for well-being. However, actual support mobilization has shown mixed associations with recipient well-being. The primary goal of the present study was to go beyond examining the effects of global perceptions of support on recipient outcomes. Instead, we examined the effects of several specific types of support that have been found to be important in the clinical literature. In this study, we followed both members of couples in which one partner was diagnosed with rheumatoid arthritis. Patients provided reports on pain for both mornings and evenings across 1 week. Both partners also reported esteem, solicitous, and negative support mobilization received by the patient. We found that patient pain tended to increase across the day following increases in patient reports of negative support receipt and partner reports of solicitous support provision. We also found that patient pain tended to decrease across the day when partners reported increased levels of esteem support provision. Reverse causation analyses indicated higher levels of patient pain may lead partners to increase solicitous support mobilization to the patient. Findings underscore the importance of examining both partners' reports of support within a dyadic coping framework. They further suggest that not all forms of support are equally beneficial, calling for a finer grained assessment of specific support transactions.

Do Pain-Related Support Preferences Moderate Relationships Between Chronic Pain Patients' Reports of Support Received and Psychosocial Functioning?

Objective

The operant theory of chronic pain and related research suggest pain-related solicitous support promotes disability. The current study investigated the hypotheses that solicitous support is positively associated with both disability and relationship satisfaction and that these relationships are moderated by the level of desire for this type of support.

Methods

Patients with chronic pain (N = 147) and in a relationship were recruited from a multidisciplinary pain treatment center. They provided self-reports of the amount of three types of pain-related support wanted and received (i.e., solicitous, encouragement, and suppression), disability, and relationship satisfaction.

Results

A hierarchical regression analysis indicated that solicitous support received was not significantly associated with disability. However, a moderation effect was found regarding encouragement. Encouragement received was negatively associated with disability, and this relationship was strongest at lower levels of interest in encouragement. Solicitous support received had a large positive association with relationship satisfaction.

Conclusions

The findings suggest the influence of pain-related support is more complex than suggested by the operant conditioning model of chronic pain, which emphasizes the possible detrimental impact of solicitous support. Further research is warranted regarding the potential relationship enhancing effects of solicitous support and the influence of encouragement on disability experienced by those with chronic pain.

Why and when social support predicts older adults' pain-related disability: a longitudinal study

Pain-related social support has been shown to be directly associated with pain-related disability, depending on whether it promotes functional autonomy or dependence. However, previous studies mostly relied on cross-sectional methods, precluding conclusions on the temporal relationship between pain-related social support and disability. Also, research on the behavioral and psychological processes that account for such a relationship is scarce. Therefore, this study aimed at investigating the following longitudinally: (1) direct effects of social support for functional autonomy/dependence on pain-related disability, (2) mediating role of physical functioning, pain-related self-efficacy, and fear, and (3) whether pain duration and pain intensity moderate such mediating processes. A total of 168 older adults (Mage = 78.3; SDage = 8.7) participated in a 3-month prospective design, with 3 moments of measurement, with a 6-week lag between them. Participants completed the Formal Social Support for Autonomy and Dependence in Pain Inventory, the Brief Pain Inventory, the 36-SF Health Survey, behavioral tasks from the Senior Fitness Test, the Pain Self-Efficacy Questionnaire, and the Tampa Scale for Kinesiophobia. Moderated mediation analyses showed that formal social support for functional dependence (T1) predicted an increase in pain-related disability (T3), that was mediated by self-reported physical functioning (T2) and by pain-related self-efficacy (T2) at short to moderate pain duration and at low to moderate pain intensity, but not at higher levels. Findings emphasized that social support for functional dependence is a risk factor for pain-related disability and uncovered the "why" and "when" of this relationship. Implications for the design of social support interventions aiming at promoting older adults' healthy aging despite chronic pain are drawn.

Do Pain Coping and Pain Beliefs Associate With Outcome Measures Before Knee Arthroplasty in Patients Who Catastrophize About Pain? A Cross-sectional Analysis From a Randomized Clinical Trial

BACKGROUND

Pain-coping strategies and appraisals are responses to the pain experience. They can influence patient-reported and physical performance outcome measures in a variety of disorders, but the associations between a comprehensive profile of pain-coping responses and preoperative pain/function and physical performance measures in patients scheduled for knee arthroplasty have not been examined. Patients with moderate to high pain catastrophizing (a pain appraisal approach associated with an exaggerated focus on the threat value of pain) may represent an excellent study population in which to address this knowledge gap.

QUESTIONS/PURPOSES

We asked the following questions among patients with high levels of pain catastrophizing who were scheduled for TKA: (1) Do maladaptive pain responses correlate with worse self-reported pain intensity and function and physical performance? (2) Do adaptive pain-coping responses show the opposite pattern? As an exploratory hypothesis, we also asked: (3) Do maladaptive responses show more consistent associations with measures of pain, function, and performance as compared with adaptive responses?

METHODS

A total of 384 persons identified with moderate to high levels of pain catastrophizing and who consented to have knee arthroplasty were recruited. The sample was 67% (257 of 384) women and the mean age was 63 years. Subjects were consented between 1 and 8 weeks before scheduled surgery. All subjects completed the WOMAC pain and function scales in addition to a comprehensive profile of pain coping and appraisal measures and psychologic health measures. Subjects also completed the Short Physical Performance Battery and the 6-minute walk test. For the current study, all measures were obtained at a single point in time at the preoperative visit with no followup. Multilevel multivariate multiple regression was used to test the hypotheses and potential confounders were adjusted for in the models.

RESULTS

Maladaptive pain responses were associated with worse preoperative pain and function measures. For example, the maladaptive pain-coping strategy of guarding and the pain catastrophizing appraisal measures were associated with WOMAC pain scores such that higher guarding scores (β = 0.12, p = 0.007) and higher pain catastrophizing (β = 0.31, p < 0.001) were associated with worse WOMAC pain; no adaptive responses were associated with better WOMAC pain or physical performance scores. Maladaptive responses were also more consistently associated with worse self-reported and performance-based measure scores (six of 16 associations were significant in the hypothesized direction), whereas adaptive responses did not associate with better scores (zero of 16 scores were significant in the hypothesized direction).

CONCLUSIONS

The maladaptive responses of guarding, resting, and pain catastrophizing were associated with worse scores on preoperative pain and performance measures. These are pain-related responses surgeons should consider when assessing patients before knee arthroplasty. TKA candidates found to have these pain responses may be targets for treatments that may improve postoperative outcome given that these responses are modifiable. Future intervention-based research should target this trio of maladaptive pain responses to determine if intervention leads to improvements in postsurgical health outcomes.

LEVEL OF EVIDENCE

Level I, prognostic study.

Sexual Assertiveness Mediates the Associations Between Partner Facilitative Responses and Sexual Outcomes in Women With Provoked Vestibulodynia

Provoked vestibulodynia (PVD) is a recurrent idiopathic vulvo-vaginal pain associated with negative sexual and psychological consequences. Facilitative partner responses to pain are currently receiving empirical attention because they are positively associated with women's sexual outcomes. However, the mechanisms through which facilitative responses to pain are associated with these outcomes have not been examined. One potential mechanism is sexual assertiveness, which has been found to be associated with better sexual function and satisfaction in women with PVD. The present study examined whether women's sexual assertiveness mediated the association between women's perception of facilitative partner responses and women's sexual function and satisfaction. Women (N = 140) with PVD symptomatology completed self-reported questionnaires evaluating their perception of their partners' facilitative responses, and their own sexual assertiveness, sexual function, and sexual satisfaction. Dependent measures were sexual function measured by the Female Sexual Function Index and sexual satisfaction assessed by the Global Measure of Sexual Satisfaction Scale. Results indicated that women's higher sexual assertiveness mediated the association between their greater perceived facilitative partner responses and their improved sexual function and satisfaction. Findings suggest a potential mechanism through which partner responses may be associated with women's sexual outcomes.

Couples coping with chronic pain: How do intercouple interactions relate to pain coping?

Background and aims

Pain is not merely an isolated experience occurring within the person. It takes place in a wider social context, including the immediate social relationships that the person is a part of. The aim of this paper is to provide an overview of how intercouple interactions might influence pain coping in couples coping with chronic pain.

Methods

Four different approaches to understanding the influence of intercouple interactions have been proposed in the literature. In this review, we present and discuss the empirical support for each of these models. A literature search on all studies published up until May 2017 (PubMed and PsycINFO) was performed. The search string consisted of 3 steps: Chronic pain AND couple interaction*/partner validation/marital interaction/chronic pain couple*/spouse response* AND coping/adjustment/disability/function/work participation/sick leave/sickness absence/work disability.

Results

The operant model views partner responses from the perspective of conditioned learning and focuses on how such responses might increase or decrease the occurrence of pain behaviour. The notion that partner responses can reinforce pain behaviour generally finds support in the literature. However, when it comes to negative partner responses results are mixed, and the model paints a limited picture of the range of interactions that takes place in a couple. The communal coping model focuses on one specific type of coping (i.e. catastrophizing), and emphasizes the interpersonal aspect of pain coping. There is some evidence that a tendency to catastrophize is related both to couple interactions and pain coping, but it has proved difficult to test this model empirically. The interpersonal process model of intimacy is concerned with patient disclosures of distress and subsequent validating and invalidating partner responses. There is some preliminary support that such mechanisms of validation and invalidation can be linked to pain coping. A dyadic approach focuses on processes where the couple negotiates a shared meaning of events and participates in mutual coping of a shared stressor. This approach has not been investigated explicitly, but preliminary support can be derived from studies conducted within other frameworks.

Conclusions

Each of the four approaches find some support in the research literature, yet none of them can explain the full range of couple interactions. We argue that the different approaches are complementary and that several of the approaches can be integrated in a dyadic understanding of pain coping.

Implications

All the models indicate that couple interactions can affect pain coping and that this should be taken into account when developing treatment programmes for chronic pain patients.

Validation of the Social support and Pain Questionnaire (SPQ) in patients with painful temporomandibular disorders

Background

The present study aimed to validate of Social support and Pain Questionnaire (SPQ) for use in Chinese patients with painful temporomandibular disorders (TMD).

Methods

The Chinese version of SPQ was produced by translation and cross-culturally adaptation of the original English version according to international guidelines. The Chinese version of SPQ was then distributed to a total of 118 patients with painful TMD. Reliability of the SPQ was evaluating using internal consistency and test-retest methods and validity of the SPQ was determined by construct validity and convergent validity. The exploratory factor analysis (EFA) was used to assess the construct validity of SPQ. And convergent validity was assessed by correlating the SPQ scores with the score of a global oral health question.

Results

The Chinese version of SPQ has a high internal consistency (Cronbach’s alpha value, 0.926) and good test-retest reliability ((intraclass correlation coefficient (ICC), 0.784). Construct validity was evaluated by EFA, extracting one factor, accounting for 74.8% of the variance. All factor loadings of the six items had exceeded 0.80. As regards convergent validity, the SPQ showed good correlation with the global oral health question.

Conclusion

These findings support that the Chinese version of SPQ can be used as a reliable and valid tool for Chinese patients with painful TMD.

Student Expectations of Peer and Teacher Reactions to Students With Chronic Pain: Implications for Improving Pain-related Functioning

OBJECTIVES

Social interactions can influence the experience and impact of chronic pain. Children and adolescents expectations of how others respond to them could therefore influence their adjustment to pain. This study examined how children and adolescents expected their peers and teachers would react to classmates with chronic pain.

METHODS

211 school children participated in this study. We presented each participant 1 of 4 vignettes that described a boy or a girl who did or did not have chronic pain. Participants were then asked to describe how they think other children and their teachers would react to the child depicted in the vignette with respect to solicitous, discouraging, and coping responses.

RESULTS

Discouraging responses from peers and teachers were viewed as being relatively unlikely. However, both coping and solicitous responses-the latter being a response known to be linked to increased pain and disability in children and adults-were viewed by the participating children as being relatively likely. Moreover, the expected likelihood of solicitous responses from teachers was thought to be even more probable for children and adolescents with chronic pain than for those without chronic pain.

DISCUSSION

The results of this study have important practical implications, given the well-known importance of significant other's responses to chronic pain problems. Further research is needed to understand how social interactions at school may influence functioning of children with chronic pain and their development. This information could provide an important empirical basis for determining how best to manage individuals with chronic pain problems in the school setting.

Social pain and physical pain: shared paths to resilience

Although clinical models have traditionally defined pain by its consequences for the behavior and internal states of the sufferer, recent evidence has highlighted the importance of examining pain in the context of the broader social environment. Neuroscience research has highlighted commonalities of neural pathways connecting the experience of physical and social pain, suggesting a substantial overlap between these phenomena. Further, interpersonal ties, support and aspects of the social environment can impair or promote effective adaptation to chronic pain through changes in pain perception, coping and emotional states. The current paper reviews the role of social factors in extant psychological interventions for chronic pain, and discusses how greater attention to these factors may inform future research and clinical care.

The effects of daily mood and couple interactions on the sleep quality of older adults with chronic pain

We examined the effect of daily negative and positive mood on the sleep quality of knee osteoarthritis (OA) patients (N = 152) and whether a partner's daily responses to a patient's pain behaviors moderated these associations. Patients and their partners completed a baseline interview and 22 daily diary assessments. After controlling for demographic characteristics, OA severity, comorbidities, medication use, relationship satisfaction, and depressed mood, multilevel modeling analyses demonstrated main effects of negative and positive mood on sleep quality indicators. Mood and partner responses interacted such that high solicitous and punishing responses strengthened the association between negative mood and worse sleep. Further, high solicitous responses increased the degree of association between low positive mood and poor sleep, and empathic responses combined with positive mood were associated with better sleep. Results demonstrate that daily negative and positive mood fluctuations can interact with partner responses to affect sleep quality among older adults with chronic pain.

'I think positivity breeds positivity': a qualitative exploration of the role of family members in supporting those with chronic musculoskeletal pain to stay at work

Background

It is proposed that family members are important sources of support in helping those with chronic musculoskeletal pain to remain at work, but the phenomenon remains largely unexplored. The aim of this study was to examine the extent and nature of support provided by family members in this respect.

Methods

Qualitative data were collected from workers and their ‘significant others’ (spouses/partners/close family members) in two un-related studies focused on working with pain; one conducted in the United Kingdom (n = 10 dyads) and one in the Netherlands (n = 21 dyads). Thematic analysis techniques were applied to both sets of data independently, and findings were then assimilated to establish common themes.

Results

Findings were broadly similar in both studies. Workers acknowledged significant other support in helping them to manage their pain and remain at work, and their descriptions of the type of support provided and required were echoed by their significant others. Three common themes were identified - ‘connectivity’, ‘activity’ and ‘positivity’. Worker and significant other responses were largely congruent, but significant others provided more in-depth information on the nature of their support, their concerns and the impact on their relationship.

Conclusions

This research presents novel insights about the specific contribution made by significant others in helping their relatives with chronic musculoskeletal pain to stay at work. These findings add to the under-represented ‘social’ dimension of the biopsychosocial model currently applied to our understanding and treatment of pain, and point to harnessing support from significant others as a potentially effective management strategy.

Cognitive mediators of treatment outcomes in pediatric functional abdominal pain

OBJECTIVES

Cognitive-behavioral (CB) interventions improve outcomes for many pediatric health conditions, but little is known about which mechanisms mediate these outcomes. The goal of this study was to identify whether changes in targeted process variables from baseline to 1 week posttreatment mediate improvement in outcomes in a randomized controlled trial of a brief CB intervention for idiopathic childhood abdominal pain.

MATERIALS AND METHODS

Two hundred children with persistent functional abdominal pain and their parents were randomly assigned to 1 of 2 conditions: a 3-session social learning and CB treatment (N=100), or a 3-session educational intervention controlling for time and attention (N=100). Outcomes were assessed at 3-, 6-, and 12-month follow-ups. The intervention focused on altering parental responses to pain and on increasing adaptive cognitions and coping strategies related to pain in both parents and children.

RESULTS

Multiple mediation analyses were applied to examine the extent to which the effects of the social learning and CB treatment condition on child gastrointestinal (GI) symptom severity and pain as reported by children and their parents were mediated by changes in targeted cognitive process variables and parents' solicitous responses to their child's pain symptoms. Reductions in parents' perceived threat regarding their child's pain mediated reductions in both parent-reported and child-reported GI symptom severity and pain. Reductions in children's catastrophic cognitions mediated reductions in child-reported GI symptom severity but no other outcomes. Reductions in parental solicitousness did not mediate outcomes.

DISCUSSION

Results suggest that reductions in reports of children's pain and GI symptoms after a social learning and CB intervention were mediated at least in part by decreasing maladaptive parent and child cognitions.

Pain patients and who they live with: a correlational study of coresidence patterns and pain interference

BACKGROUND

Mixed associations have been observed between various aspects of 'social support' and patient pain experiences.

OBJECTIVE

To explore the possibility that more basic social factors, namely coresidence patterns, may be associated with variability in patient pain experiences.

METHODS

Relationships between coresidence partners and self-reported pain that interferes with activities were examined in a large representative sample of home health care patients (n=11,436; age range 18 to 107 years, mean [± SD] age 66.3±16.1 years; 55% females).

RESULTS

After controlling for sex, age and behavioural risks, compared with living alone, coresidence with an intimate affiliate (eg, spouse, relative) predicted greater pain interference (Cohen's d = 0.10 to 1.72), and coresidence with a less intimate type of affiliate (eg, friend, paid help) predicted lower pain interference (Cohen's d = -0.21 to -0.83). In general, however, coresidence patterns accounted for small proportions of variance in pain interference, and the magnitudes of these effects varied widely according to patients' sex, age and diagnosis.

DISCUSSION

The findings suggest that fundamental components of patient's home-living environment may be associated with potential costs and benefits related to clinically relevant pain functioning for some subgroups of patients.

CONCLUSION

Further research that incorporates quantitative and qualitative assessments of patient pain functioning is warranted to better understand how objective and subjective characteristics of patients' home-living environment may inform the development of more individualized pain treatment options for patients with differing social circumstances.

The Mediating Role of Acceptance in Multidisciplinary Cognitive-Behavioral Therapy for Chronic Pain

Cognitive-behavioral therapy (CBT) is the most frequently delivered psychological intervention for adults with chronic pain. The treatment yields modest effect sizes, and the mechanisms of action remain understudied and unclear. Efforts are needed to identify treatment mediators that could be used to refine CBT and improve outcomes. The primary aim of this study was to investigate whether pain-related acceptance, from the psychological flexibility model, mediates changes in outcome over time in a CBT-based treatment program. This includes comparing how this variable relates to 3 other variables posited as potential mediators in standard CBT: life control, affective distress, and social support. Participants attended a 5-week outpatient multidisciplinary program with self-report data collected at assessment, posttreatment, and 12-month follow-up. Multilevel structural equation modeling was used to test for mediation in relation to 3 outcomes: pain interference, pain intensity, and depression. Results indicate that effect sizes for the treatment were within the ranges reported in the CBT for pain literature. Pain-related acceptance was not related to pain intensity, which is in line with past empirical evidence and the treatment objectives in acceptance and commitment therapy. Otherwise, pain-related acceptance was the strongest mediator across the different indices of outcome. Accumulated results like these suggest that acceptance of pain may be a general mechanism by which CBT-based treatments achieve improvements in functioning. More specific targeting of pain-related acceptance in treatment may lead to further improvements in outcome.

PERSPECTIVE

Potential mediators of outcome in a CBT-based treatment for adult chronic pain were investigated using multilevel structural equation modeling. The results highlight the role of pain-related acceptance as an important treatment process even when not explicitly targeted during treatment. These data may help clinicians and researchers better understand processes of change and improve the choice and development of treatment methods.

Toward a theoretical model for mindfulness-based pain management

Mindfulness, as both a process and a practice, has received substantial research attention across a range of health conditions, including chronic pain. Previously proposed mechanisms underlying the potential health-related benefits of mindfulness and mindfulness-based interventions (MBIs) are based on a strong theoretical background. However, to date, an empirically grounded, integrated theoretical model of the mechanisms of MBIs within the context of chronic pain has yet to be proposed. This is a surprising gap in the literature given the exponential growth of studies reporting on the benefits of MBIs for heterogeneous chronic pain conditions. Moreover, given the importance of determining how, and for whom, psychological interventions for pain management are effective, it is imperative that this gap in the literature be addressed. The overarching aim of the current theoretical paper was to propose an initial integrated, theoretically driven, and empirically based model of the mechanisms of MBIs for chronic pain management. Theoretical and research implications of the model are discussed. The theoretical considerations proposed herein can be used to help organize and guide future research that will identify the mechanisms underlying the benefits of mindfulness-based treatments, and perhaps psychosocial treatments more broadly, for chronic pain management.

PERSPECTIVE

This focus article presents an initial framework for an empirically based, theoretical model of the mechanisms of MBIs for chronic pain management. Implications of the framework for refining theory and for future research are addressed.