Latent Class Analysis of the Short and Long Forms of the Chronic Pain Acceptance Questionnaire: Further Examination of Patient Subgroups

An Observational Study of Outcomes Associated With Virtual Pain Management Programs Based on Acceptance and Commitment Therapy Implemented During the COVID-19 Pandemic

OBJECTIVE

In response to COVID-19, virtual, group-based interdisciplinary pain management programs (PMPs) were rapidly implemented. This included implementing different intensities and formats of virtual PMPs to address a range of patient needs and complexity. This observational study investigated outcomes associated with virtual high and low-intensity and pre-neuromodulation PMPs based on acceptance and commitment therapy as part of routine care during the pandemic.

METHODS

Depending on patients' needs, participants completed a virtual high-intensity or low-intensity PMP, or a virtual PMP in preparation for neuromodulation, from June 2020 to June 2022. Participants completed standardized measures of pain intensity and interference, work and social adjustment, depression, and pain acceptance before and after treatment. Data from 2018 to 2019 for in-person residential ( n= 561), outpatient ( n =123), and pre-neuromodulation ( n =207) PMPs were also examined to provide a historical benchmark of performance.

RESULTS

The virtual high-intensity PMP ( n =294) showed significant improvements in all variables, with small effects. There were significant improvements with small effects for pain interference, depression, and acceptance for the virtual pre-neuromodulation PMP ( n =129). No statistically significant improvements were observed for the virtual low-intensity PMP ( n =90). The improvements associated with prepandemic in-person PMPs were generally larger relative to the virtual PMPs of comparable intensity delivered during the pandemic.

DISCUSSION

These data provide preliminary support for the potential benefits of high, but not low, intensity virtual acceptance and commitment therapy-based PMPs, including in the context of neuromodulation. Research is needed to maximize the impact of virtual PMPs and match patients with the most appropriate delivery format.

Assessment of suitable referral, effectiveness and long-term outcomes of standard vs intensive pain management programmes for people with chronic pain

Background

Chronic pain is a leading cause of disability, often requiring multidisciplinary management. 2021 NICE guidance has questioned the quality of the evidence surrounding the efficacy of pain management programmes (PMPs), with only minor benefit demonstrated in psychological and physical outcomes. There is need for further high-quality evidence for the efficacy of PMPs for a range of chronic pain conditions and to identify barriers to successful management of chronic pain.

Objective

This service evaluation utilised routinely collected outcome data of 508 PMP attendees to investigate change in pain- and patient-related outcomes across two distinct PMPs; a standard and an intensive PMP, and establish their longer-term efficacy and appropriateness for patients with differing degrees of need.

Results

More people with chronic widespread pain, fibromyalgia, and osteoarthritis were referred to the intensive PMP (reflecting greater disability and distress in these conditions). Those referred to the intensive PMP demonstrated greater distress (such as more severe depression and anxiety), lower pain acceptance and poorer physical function. Improvements were observed in all outcomes across both PMPs (including physical function, pain catastrophising and pain acceptance). Depression and disability demonstrated clinically meaningful improvements in the intensive PMP, and pain severity showed clinically meaningful improvement in both PMPs. However, depression severity, disability, pain severity, and pain interference significantly deteriorated at 6-month follow-up for those on the intensive PMP, with pain severity increasing to a clinically meaningful degree (by more than 10%), though these outcomes remained better than at baseline.

Conclusion

This evaluation identified that people with chronic pain most at risk of deterioration in physical and psychological wellbeing after completing a PMP require early identification to mitigate such deterioration. Established and emerging PMPs need to be tailored to the needs of this group, particularly at follow-up to reduce risks of pain severity increasing, alongside establishing/reinforcing safeguards against deterioration post-PMP.

Cultural dimensions of individualism and collectivism and risk of opioid misuse: A test of Social Cognitive Theory

BACKGROUND

Despite the critical role social and cultural contexts play in pain experience, limited theoretical and empirical attention has been devoted to the interplay between social, cognitive, cultural, and psychological factors in chronic pain management and the risk of opioid misuse.

METHODS

Using structural equation modeling, the present study tested the Social Cognitive Theory (SCT) of chronic pain management and risk of opioid misuse in the context of intraindividual cultural dimensions of individualism and collectivism among 316 ethnically diverse adults with chronic pain in the United States.

RESULTS

Social cognitive predictors account for a significant amount of variance in pain dysfunction and risk of opioid misuse in adults with chronic pain. Satisfaction with pain support was positively associated with both greater pain acceptance and greater pain self-efficacy. Individualism was found to be positively associated with satisfaction with pain support, pain self-efficacy, and pain acceptance but negatively associated with the risk of opioid misuse. Collectivism was positively associated with the risk of opioid misuse.

CONCLUSIONS

The study findings not only empirically support using SCT for adults with chronic pain, but also provide a more thorough conceptual framework that highlights the intracultural diversity and interplay among social, cognitive, and psychological factors that affect pain experience and the risk of opioid misuse among adults with chronic pain.

Profiles of Pain Acceptance and Values-Based Action in the Assessment and Treatment of Chronic Pain

Pain acceptance and values-based action are relevant to treatment outcomes in those with chronic pain. It is unclear if patterns of responding in these two behavioral processes can be used to classify patients into distinct classes at treatment onset and used to predict treatment response. This observational cohort study had two distinct goals. First, it sought to classify patients at assessment based on pain acceptance and values-based action (N = 1746). Second, it sought to examine treatment outcomes based on class membership in a sub-set of patients completing an interdisciplinary pain rehabilitation program of Acceptance and Commitment Therapy for chronic pain (N = 343). Latent profile analysis was used in the larger sample to identify three distinct patient classes: low acceptance and values-based (AV) action (Low AV; n = 424), moderate acceptance and values-based action (Moderate AV; n = 983) and high acceptance and values-based action (High AV; n = 339). In the smaller treated sample, participants in the Low AV and Moderate AV class demonstrated improvements across all outcome variables, whereas those in the High AV class did not. These findings support the role of pain acceptance and values-based action in those with chronic pain.

Predictors of Outcomes Following Interdisciplinary Acceptance and Commitment Therapy for Chronic Pain: Profiling Psychological Flexibility

Background

Growing evidence demonstrates the benefit of acceptance and commitment therapy (ACT) for people with chronic pain. However, there remain people with chronic pain who do not benefit from ACT, and predicting treatment response is difficult.

Aims

This aim of this study was to investigate if baseline psychological flexibility (PF) profiles predict responses to an ACT‐based pain management programme.

Methods

Data from 415 participants attending an interdisciplinary pain management programme were included. Participants completed measures of PF processes and outcomes pre‐ and post‐treatment. Latent profile analysis was used to identify subgroups of participants based on their baseline PF scores. ANOVAs were conducted to compare subgroups of participants on outcome variables at baseline, and changes from pre‐ to post‐treatment.

Results

Three subgroups of participants were identified: (a) low PF, (b) low openness and (c) high awareness and action. The three subgroups significantly differed on all outcome measures at pre‐treatment, supporting the clinical relevance of these PF profiles. However, participants with different baseline PF profiles did not appear to differ in terms of changes in outcome variables.

Conclusions

People with chronic pain demonstrate different PF profiles, but appear to respond to ACT similarly regardless of these profiles. Future studies with a more individualized focus are needed to further understand which components of ACT work for whom on which outcome and how.

Significance

There remain people with chronic pain who do not benefit from acceptance and commitment therapy (ACT), and predicting treatment response is difficult. This is the first study to identify psychological flexibility (PF) profiles along multiple PF processes using latent class analysis, and the first longitudinal study to investigate PF profiles in relation to outcomes in ACT for chronic pain. The findings contribute to the understanding of theoretically consistent predictors of outcomes in ACT, which in turn can inform treatment development.

Establishing Central Sensitization-Related Symptom Severity Subgroups: A Multicountry Study Using the Central Sensitization Inventory

OBJECTIVES

The goal of this study was to identify central sensitization-related symptom severity subgroups in a large multicountry sample composed of patients with chronic pain and pain-free individuals using the Central Sensitization Inventory (CSI).

METHODS

A large, pooled international (N = 8 countries) sample of chronic pain patients plus healthy subjects (total N = 2,620) was randomly divided into two subsamples for cross-validation purposes. First, a hierarchical cluster analysis (HCA) was performed using CSI item-level data as clustering variables (test sample; N = 1,312). Second, a latent profile analysis (LPA) was conducted to confirm the optimal number of CSI clusters (validation sample; N = 1,308). Finally, to promote implementation in real-world clinical practice, we built a free online Central Sensitization Inventory Symptom Severity Calculator.

RESULTS

In both HCA (N = 1,219 valid cases) and LPA (N = 1,245 valid cases) analyses, a three-cluster and three-profile solution, respectively, emerged as the most statistically optimal and clinically meaningful. Clusters were labeled as follows: (i) Low Level of CS-Related Symptom Severity, (ii) Medium Level of CS-Related Symptom Severity, and (iii) High Level of CS-Related Symptom Severity.

CONCLUSIONS

Our results indicated that a three-cluster solution clearly captured the heterogeneity of the CSI data. The calculator might provide an efficient way of classifying subjects into the cluster groups. Future studies should analyze the extent to which the CSI cluster classification correlates with other patient-reported and objective signs and symptoms of CS in patients with chronic pain, their associations with clinical outcomes, health-related costs, biomarkers, (etc.), and responsiveness to treatment.

Initial evaluation of the Chronic Pain Acceptance Questionnaire - 2

Greater acceptance of chronic pain is associated with lesser levels of pain-related distress and disability and better overall functioning. Pain acceptance is most often assessed using the Chronic Pain Acceptance Questionnaire (CPAQ), which includes both an eight-item short form (CPAQ-8) and a twenty item parent measure (CPAQ-20). This study derived a two-item CPAQ for use in busy clinical settings and for repeated measurement during treatment, the CPAQ-2. An Item Response Theory (IRT) approach was used to identify the strongest items from the CPAQ-20, one from each of its two subscales. Next, regression analyses were conducted to evaluate the utility of the CPAQ-2 by examining variance accounted for in the CPAQ-8, CPAQ-20, and in measures of depression, pain-related fear, physical disability, and psychosocial disability. Four clinical databases were combined (N = 1,776) for the analyses. Items 9 and 14 were identified as the strongest CPAQ-20 items in the IRT analyses. The sum score of these two items accounted for over 60% of the variance in the CPAQ-8 and CPAQ-20. Furthermore, this score accounted for significant variance in measures of depression, pain-related fear, physical disability, and psychosocial disability after controlling for data collection method (i.e. in clinic or online), participant age, education, pain duration and usual pain. Finally, the amount of variance accounted for by the CPAQ-2 was comparable to that accounted for by both the CPAQ-8 and CPAQ-20. These results provide initial support for the CPAQ-2 and suggest that it is well-suited as a brief assessment of chronic pain acceptance. SIGNIFICANCE: The most frequently used measure of pain acceptance is the CPAQ, which includes both an eight-item short form, the CPAQ-8, and a longer twenty item parent measure, the CPAQ-20. The present study sought to derive a two-item measure of the CPAQ for use in busy clinical settings and for repeated measurement during treatment, the CPAQ-2. An IRT approach was used to identify the strongest items from the CPAQ-20, one from each of its two subscales in a large sample of 1,776 individuals with chronic pain. The two item measure accounted for significant variance in measures of depression, pain-related fear, physical disability, and psychosocial disability. The brief measure will be useful in assessing pain acceptance in busy clinical setting and longitudinal designs.

The importance of emotional distress, cognitive behavioural factors and pain for life impact at baseline and for outcomes after rehabilitation – a SQRP study of more than 20,000 chronic pain patients

Background and aims

Although literature concerning chronic pain patients indicates that cognitive behavioural variables, specifically acceptance and fear of movement/(re)injury, are related to life impact, the relative roles of these factors in relation to pain characteristics (e.g. intensity and spreading) and emotional distress are unclear. Moreover, how these variables affect rehabilitation outcomes in different subgroups is insufficiently understood. This study has two aims: (1) to investigate how pain, cognitive behavioural, and emotional distress variables intercorrelate and whether these variables can regress aspects of life impact and (2) to analyse whether these variables can be used to identify clinically meaningful subgroups at baseline and which subgroups benefit most from multimodal rehabilitation programs (MMRP) immediately after and at 12-month follow-up.

Methods

Pain aspects, background variables, psychological distress, cognitive behavioural variables, and two life impact variables were obtained from the Swedish Quality Registry for Pain Rehabilitation (SQRP) for chronic pain patients. These data were analysed mainly using advanced multivariate methods.

Results

The study includes 22,406 chronic pain patients. Many variables, including acceptance variables, showed important contributions to the variation in clinical presentations and in life impacts. Based on the statistically important variables considering the clinical presentation, three clusters/subgroups of patients were identified at baseline; from the worst clinical situation to the relatively good situation. These clusters showed significant differences in outcomes after participating in MMRP; the subgroup with the worst situation at baseline showed the most significant improvements.

Conclusions

Pain intensity/severity, emotional distress, acceptance, and life impacts were important for the clinical presentation and were used to identify three clusters with marked differences at baseline (i.e. before MMRP). Life impacts showed complex relationships with acceptance, pain intensity/severity, and emotional distress. The most significant improvements after MMRP were seen in the subgroup with the lowest level of functioning before treatment, indicating that patients with complex problems should be offered MMRP.

Implications

This study emphasizes the need to adopt a biopsychosocial perspective when assessing patients with chronic pain. Patients with chronic pain referred to specialist clinics are not homogenous in their clinical presentation. Instead we identified three distinct subgroups of patients. The outcomes of MMRP appears to be related to the clinical presentation. Thus, patients with the most severe clinical presentation show the most prominent improvements. However, even though this group of patients improve they still after MMRP show a complex situation and there is thus a need for optimizing the content of MMRP for these patients. The subgroup of patients with a relatively good situation with respect to pain, psychological distress, coping and life impact only showed minor improvements after MMRP. Hence, there is a need to develop other complex interventions for them.

Vulnerability and Resilience in Patients with Chronic Pain in Occupational Healthcare: A Pilot Study with a Patient-Centered Approach

OBJECTIVES

The aim of this pilot study was to describe vulnerability and resilience and possible subgroups in patients with chronic work related musculoskeletal pain in occupational healthcare. A second aim was to evaluate a patient-centered approach.

METHODS

This study was based on consecutive patients with chronic pain, seen by the same physician and sick-listed full or part time three months or longer. They were included during a period of three months. Patient reported outcome measures (PROM) were administered at baseline and at follow-up after 8 months. A patient-centered approach was applied where the patient's whole situation was taken into account.

RESULTS

A dominance of an insecure dismissing attachment pattern and a subnormal sense of coherence (SOC) was reported both at baseline and at follow-up. The patients (n=38) reported significant improvement of pain severity (p=0.01), pain interference (p=0.001), life control (p=0.01), affective distress (p=0.02), and dysfunction (p=0.001) on the multidimensional pain inventory (MPI) and fewer patients were sick-listed full time at follow-up (13 patients versus 21). By means of multivariate data analyses this change in MPI was confirmed and was also correlated with a significant increase in health related quality of life (HRQoL). Moreover subgroups with different outcome at follow-up were identified according to attachment pattern and subgroups on MPI.

CONCLUSION

A patient-centered approach may be of value for patients with chronic pain in occupational healthcare, improving pain and dysfunction. Patients with chronic pain are a heterogeneous group where outcome of treatment might be influenced by individual resilience and/or vulnerability.

Alcohol and Opioid Use in Chronic Pain: A Cross-Sectional Examination of Differences in Functioning Based on Misuse Status

Opioid misuse is regularly associated with disrupted functioning in those with chronic pain. Less work has examined whether alcohol misuse may also interfere with functioning. This study examined frequency of opioid and alcohol misuse in 131 individuals (61.1% female) prescribed opioids for the treatment of chronic pain. Participants completed an anonymous survey online, consisting of measures of pain, functioning, and opioid and alcohol misuse. Cut scores were used to categorize individuals according to substance misuse status. Individuals were categorized as follows: 35.9% (n = 47) were not misusing either opioids or alcohol, 22.9% (n = 30) were misusing both opioids and alcohol, 38.2% (n = 50) were misusing opioids alone, and only 3.0% (n = 4) were misusing alcohol alone. A multivariate analysis of variance was performed to examine differences in pain and functioning between groups (after excluding individuals in the alcohol misuse group due to the small sample size). Group comparisons indicated that individuals who were not misusing either substance were less disabled and distressed in comparison to those who were misusing opioids alone or both opioids and alcohol. No differences were indicated between the latter 2 groups. Overall, the observed frequency of opioid misuse was somewhat higher in comparison to previous work (approximately 1 out of every 3 participants), and misuse of both alcohol and opioids was common (approximately 1 out of every 5 participants). While these data are preliminary, they do suggest that issues of substance misuse in those with chronic pain extends beyond opioids alone.

PERSPECTIVE

Opioid and alcohol misuse was examined in 131 individuals prescribed opioids for chronic pain. In total, 35.9% were not misusing either, 22.9% were misusing both, 38.2% were misusing opioids, and 3.1% were misusing alcohol. Individuals not misusing either were generally less disabled and distressed compared to those misusing opioids or both.

Do Correlates of Pain-Related Stoicism and Cautiousness Differ in Younger and Older People With Advanced Cancer?

Age differences are not evident in pain-related stoicism and cautiousness in people with cancer pain. Little is known about the factors associated with these pain-related attitudes or age-related patterns in these associations. The present cross-sectional study investigated the biopsychosocial correlates of the attitudes in younger and older patients with advanced cancer. Pain-related stoicism (fortitude, concealment, superiority) and cautiousness (self-doubt, reluctance) were assessed using the Pain Attitudes Questionnaire-Revised (PAQ-R). Participants, 155 younger (younger than 60 years old) and 114 older (60 years old or older) patients with advanced cancer completed the PAQ-R and measures of sociodemographic and medical characteristics, pain intensity, cognitive-affective pain-related responses, physical functioning, psychological distress and well-being, and psychosocial functioning. Backwards regression analyses identified correlates for each PAQ-R factor separately for younger and older patients. Activity engagement was a frequent correlate, but its relationship with concealment was the only association common to both age groups. Younger and older patients exhibited different avoidance-related constructs suggesting relational challenges in the former group (avoidant attachment) and intrapersonal fear in the latter (cognitive avoidance). Medical correlates also showed age differences: younger patients showed symptom-focused correlates, whereas older patients showed aging-related correlates. Findings support a biopsychosocial framework of cancer-pain adaptation incorporating a lifespan-developmental perspective.

PERSPECTIVE

To our knowledge, this article is the first to identify biopsychosocial correlates of stoic and cautious attitudes toward cancer pain in younger and older patients with advanced cancer. Findings highlight possible age-related motivations for greater pain-related stoicism or cautiousness and can potentially inform interventions addressing challenges in cancer-pain adaptation in advanced cancer.

Validation of a Chinese version of the Chronic Pain Acceptance Questionnaire (CAPQ) and CPAQ-8 in chronic pain patients

Acceptance of chronic pain has increasingly become a significant issue in the field of pain management. Many researchers have suggested that patients with better acceptance of pain are more likely to have better functioning both in physical and psychological status. In many countries, the Chronic Pain Acceptance Questionnaire (CPAQ) and CPAQ-8 have been validated and utilized frequently to measure the pain acceptance of patients with chronic pain. However, the CPAQ and CPAQ-8 yet have not been introduced and validated in Mainland China.In this study, we aimed to translate the English version of the CPAQ into simplified Chinese, make proper cross-cultural adaptations, and validate the psychometric properties of the Chinese version of the CPAQ and the CPAQ-8.The English version of the CPAQ was first linguistically translated and cross-culturally adapted to formulate a Chinese version. Then, we recruited 224 patients from a pain clinic and every participant was asked to finish a series of questionnaires. Finally, statistical analysis was performed to test the psychometric properties of the CPAQ and the CPAQ-8.Both confirmatory factor analysis (CFA) and principal component analysis (PCA) confirmed a 2-factor structure for the CPAQ and the CPAQ-8. Nine out of 10 of the hypotheses were validated for construct validity. The overall intraclass correlation coefficient (ICC) value for the CPAQ and CPAQ-8 were 0.92 and 0.89, respectively. In addition, the Cronbach α values for both the CPAQ and the CPAQ-8 showed excellent test-retest reliability.In conclusion, the original CPAQ was successfully developed into the Chinese version of the CPAQ and CPAQ-8 with excellent validity and reliability. The scores of the CPAQ or CPAQ-8 might be a strong predictor for the physical and psychological function of chronic pain patients. In addition, to improve the satisfaction of surgery patients, we recommend measuring patients' pain acceptance using the CPAQ or CPAQ-8 before and after the surgery. For patients with lower acceptance, psychological interventions may be more effective than treatment that simply reduces symptoms. Finally, we suggest that the Chinese version of the CPAQ and CPAQ-8 are appropriate for use in clinical settings or fundamental research in Mainland China.

Development and Preliminary Testing of a Screening Measure of Acceptance and Willingness in Relation to Pain, Fatigue, and Sadness in Chronic Pain

BACKGROUND

The manner in which one responds to the experience of chronic pain is a primary determinant of pain-related distress and disruptions in functioning. In particular, responses to pain that reflect substantial unwillingness, or a lack of acceptance, in relation to pain are reliably associated with greater difficulties in comparison with responses that reflect willingness and acceptance. To date, several multi-item self-report assessments have been developed to evaluate pain-related willingness and acceptance. The purpose of the present research was to develop and evaluate a single item measure, the Acceptance and Willingness screener (AWS).

METHODS

Participants included 172 individuals with chronic pain. The AWS consisted of 4 statements, reflecting various degrees of acceptance and willingness to experience pain, and participants were asked to endorse the statement that was most reflective of their views.

RESULTS

Overall, responses were fairly evenly distributed across the statements (range, 20% to 29%). Correlation and regression results indicated significant associations between AWS responses and measures of pain intensity, depression, pain interference, and engagement in activity. Furthermore, when individuals were grouped according to the statement endorsed, significant between-group differences were indicated across these same measures. Differences were particularly pronounced for groups endorsing the lowest levels of acceptance and willingness and those endorsing the highest.

CONCLUSIONS

These results correspond with previous work and provide initial support for the validity of a single item screening measure of acceptance and willingness in chronic pain.