A SMART design to determine the optimal treatment of chronic pain among military personnel

Role of Pain Catastrophizing in the Effects of Cognitive Behavioral Therapy for Chronic Pain in Different Subgroups: An Exploratory Secondary Data Analysis Using Finite Mixture Models

INTRODUCTION

Providing effective treatment for debilitating chronic pain is a challenge among many populations including military service members. Cognitive behavioral therapy for chronic pain (CBT-CP) is a leading psychological pain treatment. Pain catastrophizing is a pivotal mediator of pain-related outcomes. The purpose of this study was (1) to identify patient subgroups who differ in response to CBT-CP and (2) to explore the characteristics that define these patient subgroups. The overall goal was to obtain a better understanding of factors that may influence response to CBT-CP.

MATERIALS AND METHODS

This study was a secondary analysis of data from a clinical trial of 149 U.S. active duty service members with chronic pain. Participants underwent group-based CBT-CP for 6 weeks and completed pre- and posttreatment assessments. Finite mixture models were employed to identify subgroups in treatment response, with pain impact score as the primary outcome measure.

RESULTS

We identified two classes of nearly equal size with distinct pain impact responses. One class reported improved pain impact scores following CBT-CP. This improvement was significantly associated with lower (better) baseline depression scores and greater improvement in posttreatment pain catastrophizing. In contrast, the other class reported slightly worse mean pain impact scores following CBT-CP treatment; this response was not related to baseline depression or change in pain catastrophizing.

CONCLUSIONS

Our findings demonstrate that a sizable proportion of individuals with chronic pain may not respond to group-based CBT-CP and may require a more individualized treatment approach.

Lifestyle factors and psychological factors are associated with central pain processing in service members with persistent low-back pain: A cross-sectional exploratory study

Persistent low-back pain (LBP) is highly prevalent in the military. Altered central pain processing is one of the mechanisms found to underlie persistent LBP. Our aim was to explore which factors are associated with altered pain processing in Dutch service members with persistent LBP. This knowledge may guide clinicians in what factors to address in the treatment of dysfunctional pain processing in service members with persistent LBP. Twenty-one service members with persistent LBP (mean age 34.0 years, 18 males) were included in this cross-sectional exploratory study. Participants completed questionnaires regarding lifestyle and psychological factors. Altered central pain processing was measured by temporal summation of pain to examine the function of the pain facilitatory system and by conditioned pain modulation to examine the pain inhibitory function. Univariable and multivariable linear regression analyses were performed. A higher local temporal summation of pain was associated with a longer sitting time, a higher level of physical activity and a higher level of pain catastrophizing. A higher local conditioned pain modulation was associated with a higher level of pain catastrophizing, anxiety and depression symptoms, and with a lower sleep quality. A higher remote conditioned pain modulation effect was associated with a higher level of physical activity, a higher body mass index and a shorter sitting time. This study succeeded in identifying lifestyle and psychological factors associated with altered pain processing in service members with persistent LBP. Prospective studies are needed to examine causality in these relationships.

Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement

ABSTRACT

Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions.

Sequential multiple assignment randomized trial studies should report all key components: a systematic review

OBJECTIVE

Sequential Multiple Assignment Randomised Trial (SMART) designs allow multiple randomisations of participants; this allows assessment of stage-specific questions (individual randomisations) and adaptive interventions (i.e. treatment strategies). We assessed the quality of reporting of the information required to design SMART studies.

STUDY DESIGN AND SETTING

We systematically searched four databases (PubMed, Ovid, Web of Science and Scopus) for all trial reports, protocols, reviews, and methodological papers which mentioned SMART designs up to June 15, 2020.

RESULTS

Of the 157 selected records, 12 (7.64%) were trial reports, 24 (15.29%) were study protocols, 91 (58%) were methodological papers, and 30 (19.1%) were review papers. All these trials were powered using stage-specific aims. Only four (33.33%) of these trials reported parameters required for sample size calculations. A small number of the trials (16.67 %) were interested in determining the best embedded adaptive interventions. Most of the trials did not report information about multiple testing adjustment. Furthermore, most of records reported designs that were mainly focused on stage-specific aims.

CONCLUSIONS

Some features of SMART designs are seldomly reported and/or used. Furthermore, studies using this design tend to not adequately report information about all the design parameters, limiting their transparency and interpretability.

Optimal allocation to treatments in a sequential multiple assignment randomized trial

One of the main questions in the design of a trial is how many subjects should be assigned to each treatment condition. Previous research has shown that equal randomization is not necessarily the best choice. We study the optimal allocation for a novel trial design, the sequential multiple assignment randomized trial, where subjects receive a sequence of treatments across various stages. A subject's randomization probabilities to treatments in the next stage depend on whether he or she responded to treatment in the current stage. We consider a prototypical sequential multiple assignment randomized trial design with two stages. Within such a design, many pairwise comparisons of treatment sequences can be made, and a multiple-objective optimal design strategy is proposed to consider all such comparisons simultaneously. The optimal design is sought under either a fixed total sample size or a fixed budget. A Shiny App is made available to find the optimal allocations and to evaluate the efficiency of competing designs. As the optimal design depends on the response rates to first-stage treatments, maximin optimal design methodology is used to find robust optimal designs. The proposed methodology is illustrated using a sequential multiple assignment randomized trial example on weight loss management.

Comparison the Effects of Physical Therapy on Chronic Pain in Active or Sedentary Military Personnel

BACKGROUND

Chronic pain (CP) is a debilitating condition in which pain persists for months or years beyond the expected duration seen in normal healing processes. Because of the social and economic burden of CP in military personnel, it is important to ascertain pain-related physical, mental and psychological conditions to improve pain management.

OBJECTIVE

The aim of the study was to evaluate the effectiveness of the physical therapy in active military personnel (AMP) with CP through self-reported questionnaires.

METHODS

Sixty male AMP outpatients suffering from CP were included and divided into two groups according to their exercise levels in daily life (30 patients exercised regularly, while the remaining 30 had a sedentary lifestyle). All participants completed the following forms and questionnaires: Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for pain, Neck Disability Index (NDI), Neck Bournemouth Questionnaire (NBQ), International Physical Activity Questionnaire (IPAQ), Hospital Anxiety-Depression Index (HADS), 36-item Short Form Survey (SF-36), Automatic Thoughts Questionnaire (ATQ), and Pain Belief Questionnaire (PBQ). Patients were given 10 sessions of a standardized physical therapy program, including hot pack applications, TENS, ultrasound therapy and also home-based physical exercise.

RESULTS

The median age of patients was 22 (min-max: 20-42) years. The HADS and PBQ-psychological scores were high and ATQ scores were low in both groups. After the treatment, ODI and VAS scores decreased in both groups; however, the group comprised of patients that exercised regularly at baseline also demonstrated a significant decrease in NBQ and NDI values.

CONCLUSION

We showed that three components of pain (physical, cognitive and emotional) are indeed effective on pain intensity and levels of disability. Our study showed that scales related with pain could improve by physical therapy in AMP, and that patients who normally exercised benefitted from physical therapy at a relatively higher degree. Chronic pain needs to be managed in the context of the patient's biological, psychological, social and also occupational characteristics; thus, individualized, patient-specific and multi-factorial treatments should be considered whenever possible.

The sequence of disease-modifying anti-rheumatic drugs: pathways to and predictors of tocilizumab monotherapy

BACKGROUND

There are numerous non-biologic and biologic disease-modifying anti-rheumatic drugs (bDMARDs) for rheumatoid arthritis (RA). Typical sequences of bDMARDs are not clear. Future treatment policies and trials should be informed by quantitative estimates of current treatment practice.

METHODS

We used data from Corrona, a large real-world RA registry, to develop a method for quantifying sequential patterns in treatment with bDMARDs. As a proof of concept, we study patients who eventually use tocilizumab monotherapy (TCZm), an IL-6 antagonist with similar benefits used as monotherapy or in combination. Patients starting a bDMARD were included and were followed using a discrete-state Markov model, observing changes in treatments every 6 months and determining whether they used TCZm. A supervised machine learning algorithm was then employed to determine longitudinal patient factors associated with TCZm use.

RESULTS

7300 patients starting a bDMARD were followed for up to 5 years. Their median age was 58 years, 78% were female, median disease duration was 5 years, and 57% were seropositive. During follow-up, 287 (3.9%) reported use of TCZm with median time until use of 25.6 (11.5, 56.0) months. Eighty-two percent of TCZm use began within 3 years of starting any bDMARD. Ninety-three percent of TCZm users switched from TCZ combination, a TNF inhibitor, or another bDMARD. Very few patients are given TCZm as their first DMARD (0.6%). Variables associated with the use of TCZm included prior use of TCZ combination therapy, older age, longer disease duration, seronegative, higher disease activity, and no prior use of a TNF inhibitor.

CONCLUSIONS

Improved understanding of treatment sequences in RA may help personalize care. These methods may help optimize treatment decisions using large-scale real-world data.

Pragmatic clinical trials: Increasing the rate of translating nursing research into practice†

AIM

Nursing research worldwide is committed to rigorous scientific inquiry that provides a significant body of knowledge to advance nursing practice. One way to advance nursing practice is to increase the rate at which nursing research findings are translated into clinical practice, and one way to do that is to use pragmatic clinical trial research designs. This article aims to describe and advocate for the increased use of pragmatic clinical trials in nursing research and to provide a summary of one nursing pragmatic clinical trial.

METHODS

A review and discussion of the features of pragmatic clinical trials.

RESULTS

This article describes the principles and benefits of pragmatic clinical trials. Nurse researchers who use these principles will generate results that are more actionable, patient-centered, and relevant in clinical practice. Focusing on research that provides practical evidence that can be translated into evidence-based practice is an important way to improve the environment for nursing research that leads more rapidly to improved nursing practice.

CONCLUSIONS

Embracing and increasing our use of pragmatic clinical trial design concepts in nursing research can enhance the significance of our findings and facilitate the translation of our research into practice.