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Johannesson C, Nehlin C, Gordh T, Hysing EB, Bothelius K. Patients' experiences of treatment-relevant processes in multimodal pain rehabilitation for severe complex regional pain syndrome - a qualitative study. Disabil Rehabil 2024; 46:1862-1869. [PMID: 37191973 DOI: 10.1080/09638288.2023.2209744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 04/28/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Complex regional pain syndrome (CRPS) is a longstanding condition with spontaneous and evoked pain, that usually occurs in an upper or lower extremity. Although it often resolves within the first year, it may for a minority progress to a chronic and occasionally severely disabling condition. The aim of this study was to explore patients' experiences and perceived effects of a specific treatment, designed for patients with severe and highly disabling CRPS, in order to identify possible treatment-relevant processes. METHODS The method used was a qualitative design, using semi-structured interviews with open-ended questions to capture participants' experiences and perceptions. Ten interviews were analyzed using applied thematic analysis. RESULTS Despite the fact that participants had a severe conditions, including nerve damage and a long duration of illness, they reported having been helped to increase flexible persistence, reduce fear and avoidance, and improve connections. This helped participants to significant improvements in daily life functioning. CONCLUSIONS The participants described distinct possible treatment-relevant processes leading to a substantial improvement in everyday life. The results imply that there is hope for this group that has been severely disabled for many years. This may help guide future clinical treatment trials.
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Affiliation(s)
| | - Christina Nehlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Torsten Gordh
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Eva-Britt Hysing
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Farzad M, MacDermid J, Packham T. Fear of Movement in People With CRPS: A Psychometric Evaluation of the Tampa Scale-11 for Kinesiophobia. Clin J Pain 2024; 40:26-34. [PMID: 37867330 DOI: 10.1097/ajp.0000000000001169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/13/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND People with complex regional pain syndrome (CRPS) commonly report a fear of movement that can worsen symptoms and increase disability. The Tampa Scale of Kinesiophobia (TSK) is used to evaluate fear of movement and (re)injury, but findings have been inconsistent in different populations. OBJECTIVE To evaluate the psychometric properties of the Persian version of TSK-11 in individuals with upper limb CRPS. Specifically, to determine whether the factor structure aligns with the original 2-factor model, consisting of "activity avoidance" and "somatic focus." MATERIALS AND METHODS People with CRPS (n=142, mean age=42, 54% female) completed the TSK. The psychometric testing included internal consistency, test-retest reliability (intraclass correlation coefficient), and convergent construct validity. Confirmatory and exploratory factor analyses were performed to evaluate the structural validity. RESULTS The TSK-11 showed acceptable internal consistency (Cronbach alpha 0.93) and excellent test-retest reliability (intraclass correlation coefficient=0.93, 95% CI: 0.92-0.94). The Standard Error of Measurement and Minimal Detectable Change were 4.3 and 11.7, respectively. The results also demonstrated excellent criterion validity ( r =0.81). Confirmatory factor analysis demonstrated that the original 2-factor model did not fit. Exploratory factor analysis derived a 2-factor solution with different items. The factor structure accounted for 64.91% of the variance, and the internal consistency of the factors was acceptable (>0.90). Expert consensus suggested naming these 2 factors as fear avoidance and magnification and helplessness. DISCUSSION The TSK-11 demonstrates excellent retest reliability in people with CRPS. The original 2-factor structure was not confirmed, and a new 2-factor structure of the TSK-11 was proposed consisting of subscales for Fear Avoidance Beliefs and Magnification/Helplessness. Given the overlap between these constructs and the construct of pain catastrophizing, further study is needed to clarify both measures' content validity and relative uniqueness.
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Affiliation(s)
- Maryam Farzad
- Occupational Therapy, Department of Health and Rehabilitation Sciences, Hand and Upper Limb Center, St. Joseph's Health Center, School of Physical Therapy, University of Western Ontario, London, ON, Canada
| | - Joy MacDermid
- Physical Therapy and Surgery, Western University, London, ON, Canada
- Hand and Upper Limb Center, St. Joseph's Health Center, London, ON, Canada
- Rehabilitation Science McMaster University, Hamilton, ON, Canada
| | - Tara Packham
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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Vowles KE, Kruger ES, Bailey RW, Ashworth J, Hickman J, Sowden G, McCracken LM. The Pain Anxiety Symptom Scale: Initial Development and Evaluation of 4 and 8 Item Short Forms. THE JOURNAL OF PAIN 2024; 25:176-186. [PMID: 37574179 DOI: 10.1016/j.jpain.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/30/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023]
Abstract
Elevated levels of anxiety in relation to chronic pain have been consistently associated with greater distress and disability. Thus, accurate measurement of pain-related anxiety is an important requirement in modern pain services. The Pain Anxiety Symptom Scale (PASS) was introduced over 30 years ago, with a shortened 20-item version introduced 10 years later. Both versions of the PASS were derived using Principal Components Analysis, an established method of measure development with roots in classical test theory. Item Response Theory (IRT) is a complementary approach to measure development that can reduce the number of items needed and maximize item utility with minimal loss of statistical and clinical information. The present study used IRT to shorten the 20-item PASS (PASS-20) in a large sample of people with chronic pain (N = 2,669). Two shortened versions were evaluated, 1 composed of the single best-performing item from each of its 4 subscales (PASS-4) and the other with the 2 best-performing items from each subscale (PASS-8). Several supplementary analyses were performed, including comparative item convergence evaluations based on sample characteristics (ie, female or male sex; clinical or online sample), factor invariance testing, and criterion validity evaluation of the 4, 8, and 20-item versions of the PASS in hierarchical regression models predicting pain-related distress and interference. Overall, both shortened PASS versions performed adequately across these supplemental tests, although the PASS-4 had more consistent item convergence between samples, stronger evidence for factor invariance, and accounted for 83% of the variance accounted for by the PASS-20% and 92% of the variance accounted for by the PASS-8 in criterion variables. Consequently, the PASS-4 is recommended for use in situations where a briefer evaluation of pain-related anxiety is appropriate. PERSPECTIVE: The Pain Anxiety Symptom Scale (PASS) is an established measure of pain-related fear. This study derived 4 and 8-item versions of the PASS using IRT. Both versions showed strong psychometric properties, stability of factor structure, and relation to important aspects of pain-related functioning.
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Affiliation(s)
- Kevin E Vowles
- School of Psychology, Queen's University Belfast and Belfast Centre for Pain Rehabilitation, Belfast City Hospital, National Health Service (NHS), Belfast, Northern Ireland, UK
| | - Eric S Kruger
- Division of Physical Therapy, University of New Mexico, Albuquerque, New Mexico
| | - Robert W Bailey
- VA Puget Sound Health Care System, Seattle Division, Seattle, Washington
| | - Julie Ashworth
- Midlands Partnership NHS Foundation Trust, Staffordshire, UK; School of Medicine, Keele University, Keele, UK
| | - Jayne Hickman
- UK Pain Service, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Gail Sowden
- School of Medicine, Keele University, Keele, UK; Connect Health, Newcastle upon Tyne, UK
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Ee JS, Dogbey GY, Fitzpatrick JK, Agnello RN, Skelly SK, Chang MH, Frost LS. Factors Associated With Chronic Pain Intensity in U.S. Army Soldiers. Mil Med 2023; 188:340-345. [PMID: 37948252 DOI: 10.1093/milmed/usad137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/17/2023] [Accepted: 04/27/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Chronic pain is prevalent among U.S. military personnel and veterans. The effectiveness of evidence-based pain treatments can be boosted with knowledge of factors associated with chronic pain perception. This study examined the factors that influence soldiers' self-rating of their chronic pain intensity. MATERIALS AND METHODS The study design was a retrospective review of the intake questionnaire from 203 soldiers seen at an Interdisciplinary Pain Management Center. The intake covered various aspects of soldiers' chronic pain experience, including pain intensity, interference in functioning, emotional sequelae, and pain-related catastrophic thinking. Pain intensity and impact were measured using the Defense and Veterans Pain Rating Scale. The mood was measured using the depression (Patient Health Questionnaire [PHQ]-9) and the anxiety (Generalized Anxiety Disorder-7) scales from the PHQ. Pain-related catastrophic thinking was measured using the Pain Catastrophizing Scale (PCS). Pain interference was assessed using a five-item scale that inquired about concentration, life and recreation enjoyment, task performance, and socializing. Data were analyzed using descriptive statistics and linear regression analyses. RESULTS The mean duration of pain was 34.73 ± 38.66 months. Regression analysis using scores from the PHQ-9, Generalized Anxiety Disorder-7, three PCS subscales (rumination, magnification, and helplessness), and pain interference scale as predictors showed that pain interference and PCS helplessness factors were significant predictors of average pain rating (R2 = 24%, P < .001). CONCLUSIONS Pain interference in functioning and pain-related thoughts of helplessness accounted for a significant degree of the variance in soldiers' self-rating of their chronic pain. The findings suggest that added attention should be directed at helping patients boost their self-efficacy in using pain-coping methods to improve their functioning and address the perception of helplessness about their pain.
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Affiliation(s)
- Juliana S Ee
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Godwin Y Dogbey
- Department of Research and Medical Education, Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - John K Fitzpatrick
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Robert N Agnello
- Department of Family Medicine, Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - Stephanie K Skelly
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Min Ho Chang
- Department of Medicine, Womack Army Medical Center, Fort Bragg, NC 28310, USA
| | - Landon S Frost
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
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Shai K, Lebelo SL, Ng'ambi JW, Mabelebele M, Sebola NA. A review of the possibilities of utilising medicinal plants in improving the reproductive performance of male ruminants. ALL LIFE 2022. [DOI: 10.1080/26895293.2022.2147225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- K. Shai
- Department of Agricultural Economics and Animal Production, University of Limpopo, Sovenga, South Africa
| | - S. L. Lebelo
- Department of Life and Consumer Sciences, College of Agriculture and Environmental Sciences, University of South Africa, Pretoria, South Africa
| | - J. W. Ng'ambi
- Department of Agricultural Economics and Animal Production, University of Limpopo, Sovenga, South Africa
| | - M. Mabelebele
- Department of Agriculture and Animal Health, College of Agriculture and Environmental Sciences, University of South Africa, Pretoria, South Africa
| | - N. A. Sebola
- Department of Agriculture and Animal Health, College of Agriculture and Environmental Sciences, University of South Africa, Pretoria, South Africa
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Melf-Marzi A, Böhringer B, Wiehle M, Hausteiner-Wiehle C. Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:879-886. [PMID: 36482756 PMCID: PMC10011717 DOI: 10.3238/arztebl.m2022.0358] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system. METHODS Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS. RESULTS Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence. CONCLUSION Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.
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Affiliation(s)
- Alexandra Melf-Marzi
- Department for BG Rehabilitation; Outpatient CRPS Clinic; BG Trauma Center Murnau; Department for Anesthesiology, Intensive Care Medicine and Pain Therapy; Multimodal Pain Therapy; BG Trauma Center Murnau; Department for Neurology, Clinical Neurophysiology and Stroke Unit; BG Trauma Center Murnau; Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich
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Leung T, Hess CW, Choate ES, Van Orden AR, Tremblay-McGaw AG, Menendez M, Boothroyd DB, Parvathinathan G, Griffin A, Caruso TJ, Stinson J, Weisman A, Liu T, Koeppen K, Koeppen K. Virtual Reality-Augmented Physiotherapy for Chronic Pain in Youth: Protocol for a Randomized Controlled Trial Enhanced With a Single-Case Experimental Design. JMIR Res Protoc 2022; 11:e40705. [PMID: 36508251 PMCID: PMC9793297 DOI: 10.2196/40705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/13/2022] [Accepted: 09/21/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain. OBJECTIVE This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design. METHODS This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice. RESULTS The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024. CONCLUSIONS Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR. TRIAL REGISTRATION ClinicalTrials.gov NCT04636177; https://clinicaltrials.gov/ct2/show/NCT04636177. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/40705.
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Affiliation(s)
| | - Courtney W Hess
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Ellison S Choate
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Amanda R Van Orden
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Alexandra G Tremblay-McGaw
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Maria Menendez
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Derek B Boothroyd
- Quantitative Statistical Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Gomathy Parvathinathan
- Quantitative Statistical Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Anya Griffin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Thomas J Caruso
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Jennifer Stinson
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,The Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Amy Weisman
- Department of Rehabilitation, Lucile Packard Children's Hospital, Stanford, CA, United States
| | - Timothy Liu
- Department of Rehabilitation, Lucile Packard Children's Hospital, Stanford, CA, United States
| | - Kurt Koeppen
- California Rehabilitation & Sports Therapy, Palo Alto, CA, United States
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Kelly KJ, Fisher BL, Rosen NO, Hamilton LD. Anxiety and Anticipated Pain Levels of Women With Self-Reported Penetration-Related Genito-Pelvic Pain are Elevated in Response to Pain-related Images. J Sex Med 2022; 19:1281-1289. [DOI: 10.1016/j.jsxm.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 04/20/2022] [Accepted: 04/28/2022] [Indexed: 12/01/2022]
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Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, Bruehl S. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S1-S53. [PMID: 35687369 PMCID: PMC9186375 DOI: 10.1093/pm/pnac046] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/23/2022]
Abstract
There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.
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Affiliation(s)
- R Norman Harden
- Departments of PM&R and Physical Therapy and Human Movement Sciences, Northwestern University
| | - Candida S McCabe
- University of the West of England, Stapleton, Bristol, UK
- Dorothy House Hospice, Bradford-on-Avon, Wilts, UK
| | - Andreas Goebel
- Pain Research Institute, Faculty of Health and Life Science, University of Liverpool, Liverpool, UK
| | - Michael Massey
- CentraCare Neurosciences Pain Center, CentraCare, St. Cloud, Minnesota, USA
| | - Tolga Suvar
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Grieve
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Centers, Nashville, Tennessee, USA
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Moore E, Braithwaite FA, Stanton TR, Bellan V, Moseley GL, Berryman C. What do I need to know? Essential educational concepts for complex regional pain syndrome. Eur J Pain 2022; 26:1481-1498. [PMID: 35598314 PMCID: PMC9542775 DOI: 10.1002/ejp.1976] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/01/2022] [Accepted: 05/07/2022] [Indexed: 11/12/2022]
Abstract
Background Methods Results Conclusion Significance
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Affiliation(s)
- E. Moore
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - F. A. Braithwaite
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - T. R. Stanton
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - V. Bellan
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - G. L. Moseley
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
- Neuroscience Research Australia, Randwick Sydney Australia
| | - C. Berryman
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
- Brain Stimulation, Imaging and Cognition Group School of Medicine The University of Adelaide, Kaurna Country Adelaide Australia
- Corresponding author. Carolyn Berryman, Level 7 Centenary Building University of South Australia Kaurna Country, Adelaide, Australia, 5005
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11
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Individual Patterns and Temporal Trajectories of Changes in Fear and Pain during Exposure In Vivo: A Multiple Single-Case Experimental Design in Patients with Chronic Pain. J Clin Med 2022; 11:jcm11051360. [PMID: 35268453 PMCID: PMC8911417 DOI: 10.3390/jcm11051360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Exposure in vivo (EXP) is an effective treatment to reduce pain-related fear and disability in chronic pain populations. Yet, it remains unclear how reductions in fear and pain relate to each other. This single-case experimental design study attempted to identify patterns in the individual responses to EXP and to unravel temporal trajectories of fear and pain. Daily diaries were completed before, during and after EXP. Multilevel modelling analyses were performed to evaluate the overall effect. Temporal effects were scrutinized by individual regression analyses and determination of the time to reach a minimal clinically important difference. Furthermore, individual graphs were visually inspected for potential patterns. Twenty patients with chronic low back pain and complex regional pain syndrome type I were included. On a group level, both fear and pain were reduced following EXP. Individually, fear was significantly reduced in 65% of the patients, while pain in only 20%. A decrease in fear was seen mostly in the first weeks, while pain levels reduced later or remained unchanged. Daily measurements provided rich data on temporal trajectories of reductions in fear and pain. Overall, reductions in fear preceded pain relief and seemed to be essential to achieve pain reductions.
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12
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Culture and musculoskeletal pain: strategies, challenges, and future directions to develop culturally sensitive physical therapy care. Braz J Phys Ther 2022; 26:100442. [PMID: 36209626 PMCID: PMC9550611 DOI: 10.1016/j.bjpt.2022.100442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 07/13/2022] [Accepted: 08/25/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Pain experience has a multidimensional nature. Assessment and treatment recommendations for pain conditions suggest clinicians use biopsychosocial approaches to treat pain and disability. The current pain research is overwhelmingly skewed towards the study of biological and psychological factors including interventions, whereas, cultural factors are often ignored. OBJECTIVE The aims of this Masterclass is threefold: (1) to discuss cultural influences on pain, (2) to provide strategies for delivering appropriate pain education and exercises in culturally diverse people with chronic pain, and (3) to present challenges and future directions to clinicians and researchers. DISCUSSION Cultural factors have a relevant influence on the way individuals experience and manage health and illness. Thus, people with different cultural experience perceive, respond, communicate and manage their pain in different ways. In this aspect, the contents of pain education should be presented using different culturally appropriate examples, metaphors, images, and delivery methods that may enhance the impact of the message. Efforts should be made to produce and spread culturally adapted evidence-based materials and resources. In addition, a culturally sensitive approach may help to introduce patients to graded activities, so that they can apply these strategies in culturally acceptable and meaningful ways. Future studies should investigate the effectiveness of culturally-adapted interventions in pain-related outcomes in different pain conditions in patients with different cultural backgrounds.
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Boersma EZ, Meent HV, Klomp FP, Frölke JM, Nijhuis-van der Sanden MWG, Edwards MJR. Treatment of Distal Radius Fracture: Does Early Activity Postinjury Lead to a Lower Incidence of Complex Regional Pain Syndrome? Hand (N Y) 2022; 17:119-127. [PMID: 31916452 PMCID: PMC8721542 DOI: 10.1177/1558944719895782] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The optimal treatment for a distal radius fracture (DRF) remains an ongoing discussion. This study observed whether early activity postinjury can lead to the prevention of type 1 complex regional pain syndrome (CRPS-1). Method: Patients who underwent nonoperative treatment for a DRF were invited to participate in this study. Patients followed an exercise program with progressive loading exercises at home immediately after cast removal. After a minimum of 3 months, patients were interviewed by telephone to determine the presence of disproportionate pain. If present, the patients were seen during a clinical consultation to determine whether they had CRPS-1, using the Budapest Diagnostic Criteria. Results: Of the 129 patients included in this study, 12 reported disproportionate pain, and none were diagnosed with CRPS-1. The incidence of CRPS-1 was zero in this study. Conclusion: A more active treatment approach seems to lower the incidence of CRPS-1. A larger randomized study is necessary to strengthen the evidence.
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Affiliation(s)
- Emily Z. Boersma
- Radboud University Medical Center, Nijmegen, The Netherlands,Emily Z. Boersma, Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, 618, P.O. Box 9101, NL-6500 HB Nijmegen, The Netherlands.
| | - Henk vd Meent
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank P. Klomp
- Radboud University Medical Center, Nijmegen, The Netherlands
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A Scoping Review of the Evidence regarding Assessment and Management of Psychological Features of Shoulder Pain. Rehabil Res Pract 2021; 2021:7211201. [PMID: 34631168 PMCID: PMC8497138 DOI: 10.1155/2021/7211201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/10/2021] [Accepted: 09/04/2021] [Indexed: 11/17/2022] Open
Abstract
Methods A scoping review of research studies identified through PubMed, EMBASE, and CINAHL and graduate theses identified using Google Scholar was conducted to determine studies and systematic reviews that addressed the management of psychological aspects of shoulder pain with or without neck pain. The search terms included psychological factors, anxiety, depression, catastrophic thinking, fear of movement, and psychological treatments. Two investigators screened study titles and abstracts. Data extraction, content analysis, and thematic coding focused on the dimensions of pain addressed (emotional, behavioural, and cognitive) and treatment approaches used (dimensions targeted, specific treatment parameters) and the linkage between treatment targets/rationale with interventions/outcomes measured. Results Ten studies (seven randomized trials and three cohorts) were identified that addressed the psychological aspects of shoulder pain. Out of seven RCTs, four compared psychological interventions with usual care. Eight studies used cognitive approaches, including emotional freedom techniques (EFT), pain coping strategies (PCS), physical-cognitive-mindfulness training (PCMT), psychological flexibility, face-to-face cognitive-behavioural treatment (CBT), and cognitive therapy using virtual reality (V.R.). Three studies used the behavioural approaches as their intervention, including behavioural therapy and Graded Exercise Therapy (GET). Pain intensity was addressed as the primary outcome in two studies and as a secondary outcome in five studies. Cognitive factors were evaluated in 50% of the articles using nine different measures. Emotional factors were evaluated in 80% of articles using ten different measures. Reduction of pain intensity and catastrophic thinking concerning pain was achieved in most studies using a biopsychosocial approach (70%). Applying a behavioural approach was associated with reductions in kinesiophobia and pain catastrophizing. Cognitive approaches had a positive association with reductions in the emotional aspect of pain. Only one study specifically linked rationale or specific physical and psychosocial treatment targets with the treatments provided and outcomes measured. Conclusions Small pools of studies indicate that the rationale and treatment targeting are poorly defined in biopsychosocial interventions for shoulder pain. However, these benefits have been demonstrated when cognitive or behavioural components are added to the standard physical treatment of shoulder pain. A better definition of treatment targets, description of intervention components, and linkage of outcomes to targets are needed to advance our understanding of optimizing bio-psychosocial approaches.
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Abstract
BACKGROUND Pain is a complex and highly subjective phenomenon that can be modulated by several factors. On the basis of results from experimental and clinical studies, the existence of endogenous pain modulatory mechanisms that can increase or diminish the experience of pain is now accepted. METHODS In this narrative review, the pain modulatory effects of exercise, stress, and cognitions in humans are assessed. RESULTS Experimental studies on the effect of exercise have revealed that pain-free participants show a hypoalgesic response after exercise. However, in some patients with chronic pain, this response is reduced or even hyperalgesic in nature. These findings will be discussed from a mechanistic point of view. Stress is another modulator of the pain experience. Although acute stress may induce hypoalgesia, ongoing clinical stress has detrimental effects on pain in many patients with chronic pain conditions, which have implications for the understanding, assessment, and treatment of stress in patients with pain. Finally, cognitive strategies play differing roles in pain inhibition. Two intuitive strategies, thought suppression and focused distraction, will be reviewed as regards experimental, acute, and chronic pain. CONCLUSION On the basis of current knowledge on the role of exercise, stress, and cognitive pain control strategies on the modulation of pain, implications for treatment will be discussed.
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16
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Liu H, Huang L, Yang Z, Li H, Wang Z, Peng L. Fear of Movement/(Re)Injury: An Update to Descriptive Review of the Related Measures. Front Psychol 2021; 12:696762. [PMID: 34305755 PMCID: PMC8292789 DOI: 10.3389/fpsyg.2021.696762] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/14/2021] [Indexed: 11/15/2022] Open
Abstract
The prevalence of fear of movement (kinesiophobia) in persistent pain ranges from 50 to 70%, and it may hinder the subsequent rehabilitation interventions. Therefore, the evaluation of fear of movement/(re)injury plays a crucial role in making clinical treatment decisions conducive to the promotion of rehabilitation and prognosis. In the decision-making process of pain treatment, the assessment of fear of movement/(re)injury is mainly completed by scale/questionnaire. Scale/questionnaire is the most widely used instrument for measuring fear of movement/(re)injury in the decision-making process of pain treatment. At present, the most commonly used scale/questionnaire are the Tampa Scale for Kinesiophobia (TSK), the Fear-Avoidance Beliefs Questionnaire (FABQ), the Kinesiophobia Causes Scale (KCS), the Athlete Fear-Avoidance Questionnaire (AFAQ), and the Fear-Avoidance Components Scale (FACS). In order to provide necessary tools and references for related research and rehabilitation treatment, this descriptive review is designed as an introduction to the background and content, score system, available language versions, variants of the original questionnaire, and psychometric properties of these scales/questionnaries.
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Affiliation(s)
- Haowei Liu
- College of Physical Education, Southwest University, Chongqing, China
| | - Li Huang
- College of Physical Education, Southwest University, Chongqing, China
| | - Zongqian Yang
- College of Physical Education, Southwest University, Chongqing, China
| | - Hansen Li
- College of Physical Education, Southwest University, Chongqing, China
| | - Zhenhuan Wang
- College of Physical Education, Southwest University, Chongqing, China
| | - Li Peng
- College of Physical Education, Southwest University, Chongqing, China.,Key Lab of Physical Fitness Evaluation and Motor Function Monitoring, Southwest University, Chongqing, China
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Lavefjord A, Sundström FT, Buhrman M, McCracken LM. Assessment methods in single case design studies of psychological treatments for chronic pain: A scoping review. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2021. [DOI: 10.1016/j.jcbs.2021.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Occupational therapy, as a rehabilitative treatment is an essential part of multimodal therapy for complex regional pain syndrome (CRPS). The goals of the treatment and the methods vary greatly for this condition, because they are subject to the changing symptomatology. In some cases there are overlapping and synergistic treatment strategies with physiotherapy. For a positive treatment result it is important to implement occupational therapy early on and continuously during the course of the disease. This allows treatment methods, such as mental exercises or sensory exercises to improve the processing of pain-triggering perceptual stimuli at an early stage. Alongside the classical movement exercises and advice on aids, special treatment methods, such as mirror therapy, neurocognitive rehabilitation according to Perfetti or the graded exposure concept can also be beneficial for CRPS patients.
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Timmers I, van de Ven VG, Vlaeyen JW, Smeets RJ, Verbunt JA, de Jong JR, Kaas AL. Corticolimbic Circuitry in Chronic Pain Tracks Pain Intensity Relief Following Exposure In Vivo. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2021; 1:28-36. [PMID: 36324433 PMCID: PMC9616294 DOI: 10.1016/j.bpsgos.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 12/28/2022] Open
Abstract
Background A subset of patients with chronic pain who receive exposure in vivo (EXP) treatment experience clinically relevant relief of pain intensity. Although pain relief is not an explicit therapeutic target, it is important to understand how and why this concomitant effect occurs in some patients but not others. This longitudinal study therefore aimed to characterize brain plasticity as well as to explore pretreatment factors related to pain relief. Methods Resting-state functional magnetic resonance imaging data were acquired in 30 patients with chronic pain. Twenty-three patients completed EXP, and 6-month follow-up data were available in 20 patients (magnetic resonance imaging data in 17 patients). Pain-free control data were acquired at two time points (n = 29, n = 21). Seed-based resting-state functional connectivity (rsFC) analyses were performed, with seeds in the amygdala, hippocampus, and nucleus accumbens. Results Pain relief after EXP was highly variable, with 60% of patients reporting a clinically relevant improvement. Amygdala rsFC with the middle frontal gyrus decreased significantly over time in patients but was not associated with pain relief. In contrast, greater pain relief was associated with greater decreases over time in hippocampus rsFC with the precuneus, which was related to reductions in catastrophizing (EXP therapeutic target) as well. Greater pain relief was also associated with lower pretreatment rsFC between nucleus accumbens and postcentral gyrus. Conclusions While changes in hippocampus rsFC were associated with pain relief after EXP, pretreatment nucleus accumbens rsFC showed potential prognostic value. Our findings further support the importance of corticolimbic circuitry in chronic pain, emphasizing its relation to pain relief and identifying potential underlying mechanisms and prognostic factors, warranting further testing in independent samples.
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20
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Optimizing Long-term Outcomes of Exposure for Chronic Primary Pain from the Lens of Learning Theory. THE JOURNAL OF PAIN 2021; 22:1315-1327. [PMID: 34029684 DOI: 10.1016/j.jpain.2021.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 01/04/2023]
Abstract
Exposure in vivo is a theory-driven and widely used treatment to tackle functional disability in people with chronic primary pain. Exposure is quite effective; yet, in line with exposure outcomes for anxiety disorders, a number of patients may not profit from it, or relapse. In this focus article, we critically reflect on the current exposure protocols in chronic primary pain, and provide recommendations on how to optimize them. We propose several adaptations that are expected to strengthen inhibitory learning and/or retrieval of the extinction memory, thus likely decreasing relapse. We summarize the limited, but emerging experimental data in the pain domain, and draw parallels with experimental evidence in the anxiety literature. Our reflections and suggestions pertain to the use of the fear hierarchy, reassurance, positive psychology interventions, exposure with a range of stimuli and within different contexts, and the use of safety behaviors during treatment, as well as associating the fear-inducing stimuli with novel outcomes. In addition, we reflect on the importance of specifically tackling (the return of) pain-related avoidance behavior with techniques such as disentangling fear from avoidance and reinforcing approach behaviors. Finally, we discuss challenges in the clinical application of exposure to improve functioning in chronic primary pain and possible avenues for future research. Perspectives: Inspired by recent advances in learning theory and its applications on the treatment of anxiety disorders, we reflect on the delivery of exposure treatment for chronic primary pain and propose strategies to improve its long-term outcomes.
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21
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Buvanendran A, Sremac AC, Merriman PA, Della Valle CJ, Burns JW, McCarthy RJ. Preoperative cognitive-behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial. Reg Anesth Pain Med 2021; 46:313-321. [PMID: 33452201 DOI: 10.1136/rapm-2020-102258] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/28/2020] [Accepted: 12/30/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Cognitive-behavioral therapy (CBT) can reduce preoperative pain catastrophizing and may improve postsurgical pain outcomes. We hypothesized that CBT would reduce pain catastrophizing more than no-CBT controls and result in improved pain outcomes. METHODS The study was a randomized controlled trial of patients undergoing elective total knee arthroplasty between January 2013 and March 2020. In phase 1, the change in pain catastrophizing scores (PCS) among 4-week or 8-week telehealth, 4-week in person and no-CBT sessions was compared in 80 patients with a PCS >16. In phase 2, the proportion of subjects that achieved a 3-month decrease in Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain subscale >4 following 4-week telehealth CBT with no-CBT controls were compared in 80 subjects. RESULTS In phase 1, 4-week telehealth CBT had the highest completion rate 17/20 (85%), demonstrated an adjusted median reduction in PCS of -9 (95% CI -1 to -14, p<0.01) compared with no-CBT and was non-inferior to 8-week telehealth CBT at a margin of 2 (p=0.02). In phase 2, 29 of 35 (83%) in the 4-week telehealth CBT and 26 of 33 (79%) subjects in the no-CBT demonstrated a decrease in the WOMAC pain subscale >4 at 3 months, difference 4% (95% CI -18% to 26%, p=0.48), despite a median decrease in the PCS for the 4-week CBT and no-CBT group of -6 (-10 to -2, p=0.02). CONCLUSIONS Our findings demonstrate that CBT interventions delivered prior to surgery in person or via telehealth can reduced PCS scores; however, this reduction did not lead to improved 3-month pain outcomes. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT01772329, registration date 21 January 2013).
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Affiliation(s)
| | - Amanda C Sremac
- Anesthesiology, Rush Medical College of Rush University, Chicago, Illinois, USA
| | - Patricia A Merriman
- Anesthesiology, Rush Medical College of Rush University, Chicago, Illinois, USA
| | - Craig J Della Valle
- Orthopedic Surgery, Rush Medical College of Rush University, Chicago, Illinois, USA
| | - John W Burns
- Behavioral Sciences, Rush Medical College of Rush University, Chicago, Illinois, USA
| | - Robert J McCarthy
- Anesthesiology, Rush Medical College of Rush University, Chicago, Illinois, USA
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Functional Disability in Adolescents with Chronic Pain: Comparing an Interdisciplinary Exposure Program to Usual Care. CHILDREN-BASEL 2020; 7:children7120288. [PMID: 33322504 PMCID: PMC7763849 DOI: 10.3390/children7120288] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 01/09/2023]
Abstract
(1) Background: Chronic musculoskeletal pain (CMP) in adolescents can negatively affect physical, psychological, and social functioning, resulting in functional disability. This randomized controlled trial (RCT) aimed to evaluate the effectiveness of an outpatient rehabilitation program based on graded exposure in vivo (EP) compared with care as usual (CAU: interdisciplinary outpatient rehabilitation care). Both EP and CAU aim to improve functional ability in adolescents with CMP. (2) Methods: Pragmatic multicenter RCT with 12-month follow-up. Adolescents (12-21 years) with CMP were invited to participate. Primary outcome: functional disability; secondary outcomes: perceived harmfulness; pain catastrophizing; pain intensity. Data analysis: intention-to-treat linear mixed model. (3) Results: Sixty adolescents (mean 16 years) were randomized; data for 53 were analyzed. Adolescents in EP showed relevant and significant decreases in functional disability (estimated mean difference at least -8.81, p ≤ 0.01) compared with CAU at all times. Significant differences in favor of EP were found for perceived harmfulness at all times (p ≤ 0.002), for pain catastrophizing at 2 months (p = 0.039) and for pain intensity at 4 and 10 months (p ≤ 0.028). (4) Conclusion: EP leads to a significant and clinically relevant decrease in functional disability compared with usual care.
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Körfer K, Schemer L, Kube T, Glombiewski JA. An Experimental Analogue Study on the "Dose-Response Relationship" of Different Therapeutic Instructions for Pain Exposures: The More, The Better? J Pain Res 2020; 13:3181-3193. [PMID: 33293855 PMCID: PMC7719044 DOI: 10.2147/jpr.s265709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/20/2020] [Indexed: 01/05/2023] Open
Abstract
Objective Novel suggestions derived from the inhibitory learning model on how to optimize exposure therapy have been debated with enthusiasm in the last few years, particularly with respect to the focus on expectancy violations. However, little is known about how this new approach directly compares to the traditional habituation rationale of exposure therapy. In the present study, we examined these two competing therapeutic instructions among healthy female participants in an experimental heat pain paradigm. Design and Methods Participants (N= 116) received a therapeutic instruction derived from either a habituation-based approach or the inhibitory learning model (expectation violation). Participants were repeatedly exposed to painful thermal stimulations until a predefined exposure goal was reached. Results The expectation violation instruction led to faster goal attainment and higher response rates than the habituation instruction. Both instructions led to increased pain tolerance in the short and long term (one-week follow-up). Conclusion Our results suggest that exposure treatments using an expectation violation instruction are especially time-effective. Although the findings from this analogue design cannot be directly generalized to populations with clinically relevant levels of chronic pain, they do point to some important theoretical and clinical implications for the treatment of pain.
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Affiliation(s)
- Karoline Körfer
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Lea Schemer
- Department of Clinical Psychology and Psychotherapy, University of Koblenz - Landau, Landau, Germany
| | - Tobias Kube
- Department of Clinical Psychology and Psychotherapy, University of Koblenz - Landau, Landau, Germany
| | - Julia A Glombiewski
- Department of Clinical Psychology and Psychotherapy, University of Koblenz - Landau, Landau, Germany
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Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, White P. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-490. [PMID: 32975190 PMCID: PMC7548871 DOI: 10.3310/hta24460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms. OBJECTIVES An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis. DATA SOURCES Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019. PARTICIPANTS Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes. INTERVENTIONS Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes. RESULTS Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000. LIMITATIONS Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points. CONCLUSIONS Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study). STUDY REGISTRATION This study is registered as PROSPERO CRD42015025520. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Peter White
- Barts and The London School of Medicine and Dentistry, London, UK
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25
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Meulders A. Fear in the context of pain: Lessons learned from 100 years of fear conditioning research. Behav Res Ther 2020; 131:103635. [DOI: 10.1016/j.brat.2020.103635] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023]
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26
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Biggs EE, Meulders A, Kaas AL, Goebel R, Vlaeyen JWS. The acquisition and generalization of fear of touch. Scand J Pain 2020; 20:809-819. [PMID: 32712594 DOI: 10.1515/sjpain-2019-0177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/01/2020] [Indexed: 12/17/2022]
Abstract
Objectives Contemporary fear-avoidance models of chronic pain posit that fear of pain, and overgeneralization of fear to non-threatening stimuli is a potential pathway to chronic pain. While increasing experimental evidence supports this hypothesis, a comprehensive investigation requires testing in multiple modalities due to the diversity of symptomatology among individuals with chronic pain. In the present study we used an established tactile fear conditioning paradigm as an experimental model of allodynia and spontaneous pain fluctuations, to investigate whether stimulus generalization occurs resulting in fear of touch spreading to new locations. Methods In our paradigm, innocuous touch is presented either paired (predictable context) or unpaired (unpredictable context) with a painful electrocutaneous stimulus (pain-US). In the predictable context, vibrotactile stimulation to the index or little finger was paired with the pain-US (CS+), whilst stimulation of the other finger was never paired with pain (CS-). In the unpredictable context, vibrotactile stimulation to the index and little fingers of the opposite hand (CS1 and CS2) was unpaired with pain, but pain-USs occurred unpredictable during the intertrial interval. During the subsequent generalization phase, we tested the spreading of conditioned responses (self-reported fear of touch and pain expectancy) to the (middle and ring) fingers between the CS+ and CS-, and between the CS1 and CS2. Results Differential fear acquisition was evident in the predictable context from increased self-reported pain expectancy and self-reported fear for the CS + compared to the CS-. However, expectancy and fear ratings to the novel generalization stimuli (GS+ and GS-) were comparable to the responses elicited by the CS-. Participants reported equal levels of pain expectancy and fear to the CS1 and CS2 in the unpredictable context. However, the acquired fear did not spread in this context either: participants reported less pain expectancy and fear to the GS1 and GS2 than to the CS1 and CS2. As in our previous study, we did not observe differential acquisition in the startle responses. Conclusions Whilst our findings for the acquisition of fear of touch replicate the results from our previous study (Biggs et al., 2017), there was no evidence of fear generalization. We discuss the limitations of the present study, with a primary focus on procedural issues that were further investigated with post-hoc analyses, concluding that the present results do not show support for the hypothesis that stimulus generalization underlies spreading of fear of touch to new locations, and discuss how this may be the consequence of a context change that prevented transfer of acquisition.
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Affiliation(s)
- Emma E Biggs
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Ann Meulders
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Amanda L Kaas
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Rainer Goebel
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Johan W S Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
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Baadjou VA, Hollander MD, Meulenbroek TV, Verbunt JA, Timmers I. Clinicians' Initial Experiences of Transition to Online Interdisciplinary Pain Rehabilitation During the Covid-19 Pandemic. JOURNAL OF REHABILITATION MEDICINE - CLINICAL COMMUNICATIONS 2020; 3:1000036. [PMID: 33884138 PMCID: PMC8008721 DOI: 10.2340/20030711-1000036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 12/23/2022]
Abstract
Objective Public health legislation during the CO-VID-19 pandemic has resulted in forced transitioning to the use of remote care in order to continue the provision of pain rehabilitation worldwide. The objective of this study was to gain insight into clinicians’ initial experiences with the provision of interdisciplinary pain rehabilitation via videoconferencing. Design Observational, cross-sectional design. Participants Twelve team members (specialists in rehabilitation medicine -MD-, psychologists, physiotherapists and occupational therapists) from a tertiary expertise centre in pain rehabilitation. Methods Quantitative and qualitative data were collected via a digital survey. Theme-based content analysis was performed for qualitative data. Results The themes that emerged were: the compulsory context; prerequisites for proper use of videoconferencing methods, which are strongly associated with the clinicians’ experiences; changes experienced in specific components of pain rehabilitation; and overarching changes experienced, including opportunities and limitations (sub-themes: therapeutic relationship, system involvement, efficiency, hands-on possibilities, interdisciplinary teamwork, and formalities). Overall, clinicians expressed moderate agreement with the statements that the quality of the pain rehabilitation programme can be maintained using videoconferencing, and that the COVID-19 pandemic offers opportunities for growth and innovation in telehealth. Conclusion It is feasible to provide valid and satisfactory pain rehabilitation via videoconferencing. This study identified facilitators and barriers to the use of videoconferencing, and great potential for integrating aspects of telehealth into standard care after the pandemic.
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Affiliation(s)
- Vera A Baadjou
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Marlies Den Hollander
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Thijs Van Meulenbroek
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Jeanine A Verbunt
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Inge Timmers
- Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Nijs J, Wijma AJ, Willaert W, Huysmans E, Mintken P, Smeets R, Goossens M, van Wilgen CP, Van Bogaert W, Louw A, Cleland J, Donaldson M. Integrating Motivational Interviewing in Pain Neuroscience Education for People With Chronic Pain: A Practical Guide for Clinicians. Phys Ther 2020; 100:846-859. [PMID: 31995191 DOI: 10.1093/ptj/pzaa021] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 07/07/2019] [Accepted: 10/06/2019] [Indexed: 12/28/2022]
Abstract
Pain neuroscience education (PNE) and motivational interviewing (MI) have been widely implemented and tested in the field of chronic pain management, and both strategies have been shown to be effective in the short term (small effect sizes) for the management of chronic pain. PNE uses contemporary pain science to educate patients about the biopsychosocial nature of the chronicity of their pain experience. The goal of PNE is to optimize patients' pain beliefs/perceptions to facilitate the acquisition of adaptive pain-coping strategies. MI, on the other hand, is a patient-centered communication style for eliciting and enhancing motivation for behavior change by shifting the patient away from a state of indecision or uncertainty. Conceptually, PNE and MI appear to be complementary interventions, with complementary rather than overlapping effects; MI primarily improves cognitive and behavioral awareness and, potentially, adherence to treatment principles, whereas PNE potentially increases pain knowledge/beliefs, awareness, and willingness to explore psychological factors that are potentially associated with pain. Therefore, combining PNE with MI might lead to improved outcomes with larger and longer-lasting effect sizes. The combined use of PNE and MI in patients having chronic pain is introduced here, along with a description of how clinicians might be able to integrate PNE and MI in the treatment of patients experiencing chronic pain. Clinical trials are needed to examine whether combining PNE with MI is superior to PNE or MI alone for improving pain and quality of life in patients having chronic pain.
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Affiliation(s)
- Jo Nijs
- Department of Physiotherapy, Faculty of Physical Education and Physiotherapy, Pain in Motion International Research Group, Vrije Universiteit Brussel, Building F-KIMA, Laarbeeklaan 103, BE-1090 Brussels, Belgium; and Department of Physical Medicine and Physiotherapy, Chronic Pain Rehabilitation, University Hospital Brussels, Brussels, Belgium
| | - Amarins J Wijma
- Department of Physiotherapy, Faculty of Physical Education and Physiotherapy, Pain in Motion International Research Group, Vrije Universiteit Brussel; Department of Physical Medicine and Physiotherapy, Chronic Pain Rehabilitation, University Hospital Brussels; and Transcare Pain, Transdisciplinary Treatment Center, Groningen, the Netherlands
| | - Ward Willaert
- Department of Physiotherapy, Faculty of Physical Education and Physiotherapy, Pain in Motion International Research Group,Vrije Universiteit Brussel; Department of Physical Medicine and Physiotherapy, Chronic Pain Rehabilitation, University Hospital Brussels; and Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Eva Huysmans
- Department of Physiotherapy, Faculty of Physical Education and Physiotherapy, Pain in Motion International Research Group, Vrije Universiteit Brussel; Department of Physical Medicine and Physiotherapy, Chronic Pain Rehabilitation, University Hospital Brussels; Research Foundation-Flanders (FWO); and Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel
| | - Paul Mintken
- Department of Physical Therapy, School of Medicine, University of Colorado, Aurora, Colorado, and Wardenburg Health Center, University of Colorado, Boulder, Colorado
| | - Rob Smeets
- Research School CAPHRI, Maastricht University, Maastricht, the Netherlands, and CIR Revalidatie Eindhoven/Zwolle, Eindhoven/Zwolle, the Netherlands
| | - Mariëlle Goossens
- Research School CAPHRI, Maastricht University, and CIR Revalidatie Eindhoven/Zwolle
| | - C Paul van Wilgen
- Department of Physiotherapy, Faculty of Physical Education and Physiotherapy, Pain in Motion International Research Group, Vrije Universiteit Brussel; and Transcare Pain, Transdisciplinary Treatment Center
| | - Wouter Van Bogaert
- Department of Physiotherapy, Faculty of Physical Education and Physiotherapy, Pain in Motion International Research Group, Vrije Universiteit Brussel
| | - Adriaan Louw
- Department of Physical Therapy, International Spine and Pain Institute, Louisville, Kentucky
| | - Josh Cleland
- Department of Physical Therapy, Franklin Pierce University, Manchester, New Hampshire
| | - Megan Donaldson
- Physical Therapy Program, School of Medicine, Tufts University, Boston, Massachusetts
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29
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Abstract
Pain is considered a hardwired signal of bodily disturbance belonging to a basic motivational system that urges the individual to act and to restore the body's integrity, rather than just a sensory and emotional experience. Given its eminent survival value, pain is a strong motivator for learning. Response to repeated pain increases when harm risks are high (sensitization) and decreases in the absence of such risks (habituation). Discovering relations between pain and other events provides the possibility to predict (Pavlovian conditioning) and control (operant conditioning) harmful events. Avoidance is adaptive in the short term but paradoxically may have detrimental long-term effects. Pain and pain-related responses compete with other demands in the environment. Exposure-based treatments share the aim of facilitating or restoring the pursuit of individual valued life goals in the face of persistent pain, and further improvements in pain treatment may require a paradigm shift toward more personalized approaches.
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Affiliation(s)
- Johan W S Vlaeyen
- Research Group on Health Psychology, Faculty of Psychology and Educational Sciences, University of Leuven, 3000 Leuven, Belgium; .,Experimental Health Psychology, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Geert Crombez
- Department of Experimental-Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, Ghent University, 9000 Ghent, Belgium.,Centre for Pain Research, University of Bath, Bath BA2 7AY, United Kingdom
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30
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Dekker C, van Haastregt JCM, Verbunt JAMCF, de Jong JR, van Meulenbroek T, Pernot HFM, van Velzen AD, Bastiaenen CHG, Goossens MEJB. Pain-related fear in adolescents with chronic musculoskeletal pain: process evaluation of an interdisciplinary graded exposure program. BMC Health Serv Res 2020; 20:213. [PMID: 32171308 PMCID: PMC7071667 DOI: 10.1186/s12913-020-5053-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 02/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background For studying the effectiveness of treatment, it is important to check whether a new treatment is performed as originally described in the study-protocol. Objectives To evaluate whether an interdisciplinary graded exposure program, for adolescents with chronic musculoskeletal pain reporting pain-related fear, was performed according to protocol, and whether it is feasible to implement the program in rehabilitation care. Methods A process evaluation where quantitative and qualitative data on participant characteristics (adolescents, parents and therapists), attendance and participants’ opinion on the program were collected, by means of registration forms, questionnaires and group interviews. To evaluate treatment fidelity, audio and video recordings of program sessions were analyzed. Results Thirty adolescents were offered the program, of which 23 started the program. Adolescents attended on average 90% of the sessions. At least one parent per adolescent participated in the program. Analysis of 20 randomly selected recordings of treatment sessions revealed that treatment fidelity was high, since 81% of essential treatment elements were offered to the adolescents. The program was considered client-centered by adolescents and family-centered by parents. Treatment teams wished to continue offering the program in their center. Conclusion The interdisciplinary graded exposure program was performed largely according to protocol, and therapists, adolescents and their parents had a favorable opinion on the program. Implementation of the program in rehabilitation care is considered feasible. Trial registration Clinicaltrials.gov ID: NCT02181725 (7 February 2014).
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Affiliation(s)
- C Dekker
- Department of Rehabilitation Medicine, Care and Public Health Research Institute (CAPHRI), Functioning and Rehabilitation, Maastricht University, Universiteitssingel 40, 6229, ET, Maastricht, the Netherlands
| | - J C M van Haastregt
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - J A M C F Verbunt
- Department of Rehabilitation Medicine, Care and Public Health Research Institute (CAPHRI), Functioning and Rehabilitation, Maastricht University, Universiteitssingel 40, 6229, ET, Maastricht, the Netherlands. .,Adelante, Center of Expertise in Rehabilitation and Audiology, Hoensbroek, the Netherlands.
| | - J R de Jong
- Department of Rehabilitation Medicine, Care and Public Health Research Institute (CAPHRI), Functioning and Rehabilitation, Maastricht University, Universiteitssingel 40, 6229, ET, Maastricht, the Netherlands.,Adelante, Center of Expertise in Rehabilitation and Audiology, Hoensbroek, the Netherlands
| | - T van Meulenbroek
- Department of Rehabilitation Medicine, Care and Public Health Research Institute (CAPHRI), Functioning and Rehabilitation, Maastricht University, Universiteitssingel 40, 6229, ET, Maastricht, the Netherlands.,Adelante, Center of Expertise in Rehabilitation and Audiology, Hoensbroek, the Netherlands
| | - H F M Pernot
- Medicine, Laurentius Hospital Roermond, Roermond, the Netherlands
| | | | - C H G Bastiaenen
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Functioning and Rehabilitation, Maastricht University, Maastricht, the Netherlands
| | - M E J B Goossens
- Department of Rehabilitation Medicine, Care and Public Health Research Institute (CAPHRI), Functioning and Rehabilitation, Maastricht University, Universiteitssingel 40, 6229, ET, Maastricht, the Netherlands.,Department of Clinical Psychological Sciences, Experimental Psychopathology, Maastricht University, Maastricht, the Netherlands
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31
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Hollander MD, de Jong J, Onghena P, Vlaeyen JW. Generalization of exposure in vivo in Complex Regional Pain Syndrome type I. Behav Res Ther 2020; 124:103511. [DOI: 10.1016/j.brat.2019.103511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/24/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
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32
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Rand SE, Basu S, Khalid S. Complex Regional Pain Syndrome: Current Diagnostic and Treatment Considerations. Curr Sports Med Rep 2019; 18:325-329. [PMID: 31503044 DOI: 10.1249/jsr.0000000000000633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Complex Regional Pain Syndrome is a severe complication of extremity fracture or other injury. Patients who develop this show marked hyperalgesia and allodynia, altered vasomotor, sudomotor and trophic changes. The condition affects women more than men and is most common in those between the ages of 50 and 70 years but can be seen in younger athletes. The diagnosis is made clinically, and treatment is directed at functional recovery using medications, occupational and physical therapy, and psychological interventions. Prognosis for complete recovery is variable and unpredictable.
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Affiliation(s)
- Scott E Rand
- Houston Methodist Willowbrook Hospital.,Houston Methodist Orthopedics and Sports Medicine, Houston, TX
| | - Sumana Basu
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX
| | - Shoaib Khalid
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX
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33
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Timmers I, Quaedflieg CWEM, Hsu C, Heathcote LC, Rovnaghi CR, Simons LE. The interaction between stress and chronic pain through the lens of threat learning. Neurosci Biobehav Rev 2019; 107:641-655. [PMID: 31622630 DOI: 10.1016/j.neubiorev.2019.10.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 02/06/2023]
Abstract
Stress and pain are interleaved at multiple levels - interacting and influencing each other. Both are modulated by psychosocial factors including fears, beliefs, and goals, and are served by overlapping neural substrates. One major contributing factor in the development and maintenance of chronic pain is threat learning, with pain as an emotionally-salient threat - or stressor. Here, we argue that threat learning is a central mechanism and contributor, mediating the relationship between stress and chronic pain. We review the state of the art on (mal)adaptive learning in chronic pain, and on effects of stress and particularly cortisol on learning. We then provide a theoretical integration of how stress may affect chronic pain through its effect on threat learning. Prolonged stress, as may be experienced by patients with chronic pain, and its resulting changes in key brain networks modulating stress responses and threat learning, may further exacerbate these impairing effects on threat learning. We provide testable hypotheses and suggestions for how this integration may guide future research and clinical approaches in chronic pain.
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Affiliation(s)
- Inge Timmers
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States.
| | - Conny W E M Quaedflieg
- Department of Clinical Psychological Science, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Connie Hsu
- Feinberg School of Medicine, Northwestern University, 420 E Superior St, Chicago, IL 60611, United States
| | - Lauren C Heathcote
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States
| | - Cynthia R Rovnaghi
- Department of Pediatrics, Stanford University School of Medicine, 770 Welch Road, Suite 435, Stanford, CA 94304, United States
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States
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34
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Nijs J, Wijma AJ, Leysen L, Pas R, Willaert W, Hoelen W, Ickmans K, Wilgen CPV. Explaining pain following cancer: a practical guide for clinicians. Braz J Phys Ther 2019; 23:367-377. [PMID: 30606621 PMCID: PMC6823686 DOI: 10.1016/j.bjpt.2018.12.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/04/2018] [Accepted: 12/10/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Pain is one of the most prevalent and debilitating symptom following cancer treatment. OBJECTIVES This paper entails a practical guide for clinicians willing to apply pain neuroscience education (PNE) in this specific population, or clinical researchers willing to examine the effects of PNE in patients suffering from pain following cancer. RESULTS Patient-specific information (i.e. beliefs, cognitions, pain memories, social factors) as well as identification of the dominant pain mechanism are needed to tailor the education to the specific needs and beliefs of the patient. Therapists require an in-depth understanding of pain mechanisms, the skills to explain to their patients various pain mechanisms, specific communication skills (e.g. Socratic-style dialogof education) and experience with current evidence-based biopsychosocially-driven pain management strategies for successful implementation of PNE in the clinic. Rather than purely focusing on the biomedical characteristics of pain following cancer (e.g., tissue damage due to past cancer treatment), PNE implies teaching patients about the underlying biopsychosocial mechanisms of pain. Its application is backed-up by mounting evidence supporting the effectiveness of PNE in non-cancer pain populations, and a pilot study in patients having pain following cancer. CONCLUSION PNE is a potential solution to improve pain outcome in cancer survivors. Further research using sufficiently powered and well-designed randomized clinical trials should be conducted to examine the potential of PNE in patients having pain following cancer.
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Affiliation(s)
- Jo Nijs
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Chronic Pain Rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium.
| | - Amarins J Wijma
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Transcare Transdisciplinary Pain Management Center, Groningen, The Netherlands
| | - Laurence Leysen
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Roselien Pas
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ward Willaert
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Wouter Hoelen
- De Berekuyl, Private Practice for Physiotherapy in Oncology & Lymphology, Hierden, The Netherlands; The Berekuyl Academy, Hierden, The Netherlands
| | - Kelly Ickmans
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Chronic Pain Rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
| | - C Paul van Wilgen
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Transcare Transdisciplinary Pain Management Center, Groningen, The Netherlands
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35
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Abstract
Exposure therapy is an economical and promising psychological method for the treatment of chronic back pain, although little research has been done and its evidence needs further clarification. Exposure therapy has so far been little used in practice, which is partly due to the few published studies on this topic and partly to the uncertainty of the practitioners as to whether exposure therapy can be carried out without risk. Exposure therapy can be classified as a "tailored treatment" approach, in which patients with certain profiles (here: increased fear of movement) receive specific treatments. In this review article, the theoretical principles of exposure therapy are presented. Subsequently, possibilities for the identification of those patients suitable for exposure treatment are explained. The practical procedure is presented using a case study. The four randomized controlled trials available to date are described in detail and discussed.
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Affiliation(s)
- J A Glombiewski
- Klinische Psychologie und Psychotherapie, Fachbereich Psychologie, Universität Koblenz-Landau, Ostbahnstr. 10, 76829, Landau, Deutschland.
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36
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Haramaki Y, Kabir RS, Abe K, Yoshitake T. Promoting Self-Regulatory Management of Chronic Pain Through Dohsa-hou: Single-Case Series of Low-Functioning Hemodialysis Patients. Front Psychol 2019; 10:1394. [PMID: 31281283 PMCID: PMC6596355 DOI: 10.3389/fpsyg.2019.01394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/28/2019] [Indexed: 01/06/2023] Open
Abstract
Hemodialysis patients suffer from long-term pain that drains their energy and contributes to behavioral interference and other negative effects on their daily lives that result in or exacerbate functional limitations. In addition, they deal with dietary restrictions, symptoms such as itching, lack of energy, and psychological stressors like the loss of self-concept and self-esteem. Self-regulation involves the capacity to notice, inform, and modulate responses and behavior, and research indicates that it promotes rehabilitation in chronic pain patients. Research on the aspects of self-regulation afforded by the Japanese psychotherapy Dohsa-hou correspond to psychological processes tied to the sense of self-control that clients realize over their body movements. This study pilot tested a hospital-integrated implementation of Dohsa-hou relaxation tasks as a chronic pain management behavioral intervention for five female hemodialysis patients between the ages of 59–62 years. We conducted an ABABABA single-case design to compare baseline A-phases (treatment-as-usual: TAU) taken at recurring 1 week intervals (three sessions per week for a total of 4 weeks, 12 total recordings) with an intervention of Dohsa-hou B-phases every 4 weeks (three sessions per week for 12 weeks, 36 total recordings) over the span of 4 months to compare effectiveness. Visual Analogue Scale (VAS) pain scores between phases were taken and self-regulatory progress was tracked and summarized from a series of semi-structured interviews. Visual analysis of scores for each participant as single cases indicated decreases for the Dohsa-hou phase compared to baseline treatment-as-usual. As a result, participants reported using Dohsa-hou to reduce pain and experienced improvements in quality of life associated with greater self-regulatory capacity to attend to personal care and domestic activities. These preliminary findings suggest that Dohsa-hou body movement relaxation tasks were feasible as a coping skill in a hospital-integrated setting and at home and show promise for promoting quality of life vis-a-vis the management of severe and chronic bodily pain associated with end-stage renal disease and its treatment, particularly by improving aspects of pain-mediated self-regulatory fatigue.
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Affiliation(s)
- Yutaka Haramaki
- Department of Clinical Psychology, Hiroshima University, Higashihiroshima, Japan
| | | | - Kazuaki Abe
- Department of Clinical Psychology, Hiroshima University, Higashihiroshima, Japan
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37
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Van Laake-Geelen CCM, Smeets RJEM, Van Meulenbroek T, Den Hollander M, Goossens MEJB, Verbunt JA. Biopsychosocial Rehabilitation Treatment "Exposure In Vivo" for Patients with Painful Diabetic Neuropathy: Development of a Treatment Protocol. JOURNAL OF REHABILITATION MEDICINE - CLINICAL COMMUNICATIONS 2019; 2:1000015. [PMID: 33884116 PMCID: PMC8008735 DOI: 10.2340/20030711-1000015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 03/06/2019] [Indexed: 11/16/2022]
Abstract
Objective Painful diabetic neuropathy is associated with low quality of life, depression and anxiety. Patients are limited in their performance of activities of daily living due to fears related to their condition. Treatment modalities are needed to help patients cope with their pain and pain-related disability. Exposure in vivo is an effective treatment in other chronic pain syndromes, increasing patients’ functional ability and quality of life. This paper presents an Exposure in vivo treatment protocol for patients with painful diabetic neuropathy. Protocol An 8-week Exposure in vivo treatment protocol was specifically adapted to the needs and risks of patients with painful diabetic neuropathy. New screening tools were developed for patients with PDN; the Painful Diabetic Neuropathy Anxiety Rasch-Transformed Questionnaire (PART-Q30) identifies specific fears related to painful diabetic neuropathy (e.g. fear of hypoglycaemia); and a customized version of the Photograph-series Of Daily Activities (PHODA-PDN) detects fear-eliciting activities related to the condition in individual patients. During Exposure in vivo, catastrophic interpretations regarding painful stimuli are challenged and corrected, thereby diminishing pain-related fear and enabling the patient to re-engage in activities of daily living. An interdisciplinary team provides Exposure in vivo in 1-h sessions twice a week. Discussion To the best of our knowledge, this treatment protocol is the first intervention using Exposure in vivo specifically adapted to the needs and risks of patients with painful diabetic neuropathy.
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Affiliation(s)
- Charlotte C M Van Laake-Geelen
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands.,Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Rob J E M Smeets
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands.,Libra Rehabilitation and Audiology, Eindhoven/Weert
| | - Thijs Van Meulenbroek
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands.,Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Marlies Den Hollander
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands.,Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Marielle E J B Goossens
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands.,Research Group Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Jeanine A Verbunt
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands.,Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
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38
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Onghena P, Tanious R, De TK, Michiels B. Randomization tests for changing criterion designs. Behav Res Ther 2019; 117:18-27. [DOI: 10.1016/j.brat.2019.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 11/29/2022]
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39
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The effect of exercise therapy combined with psychological therapy on physical activity and quality of life in patients with painful diabetic neuropathy: a systematic review. Scand J Pain 2019; 19:433-439. [DOI: 10.1515/sjpain-2019-0001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/15/2019] [Indexed: 12/26/2022]
Abstract
Abstract
Background and aims
Approximately 25% of patients with diabetes mellitus type 2 (DMII) develop painful diabetic neuropathy (PDN). PDN is known to affect both mental and physical wellbeing, resulting in anxiety, depression, low quality of life and physical disability. Pharmacological treatment of PDN aims at pain relief and is often ineffective and/or has many side effects. Rehabilitation treatment modalities that are designed to help the patient deal with PDN related complaints, are mostly focussed on either physical (e.g. exercise therapy) or psychological aspects (e.g. cognitive behavioural therapy, CBT). There is emerging evidence that PDN can be approached from a biopsychosocial perspective, in which physical and psychosocial aspects are integrated. From this biopsychosocial approach it is plausible that integrated treatment modalities such as acceptance commitment therapy (ACT) or exposure in vivo (EXP) could be effective in patients with PDN. The objective of this review was to provide an overview of the current evidence on the effects of rehabilitation treatments that combine exercise therapies with psychological therapies in order to improve physical activity (PA) and quality of life (QoL) in patients with PDN.
Methods
Systematic review of the current literature. EMBASE, MEDLINE, Medline In-Process citations and e-Pubs ahead-of-print, Pedro, Web of Science, PsycINFO, CENTRAL, PubMed and Google Scholar were searched. All studies on interventions combining exercise therapy with psychological interventions in patients with PDN, aged >18 years, were included. Outcome measures were PA, QoL.
Results
The search resulted in 1603 records after removing duplicates. After screening on titles and abstracts, 100 records remained. From these, not one study reported on interventions that combined exercise therapy with psychological interventions. Through a secondary hand search, a total of three reviews were identified that described a total of five studies regarding either physical or psychological interventions in patients with PDN. These studies reported moderate effects of (1) mindfulness meditation on QoL, (2) CBT on pain severity, (3) mindfulness-based stress reduction intervention on function, health-related QoL, pain catastrophizing and depression, (4) aerobic exercise on QoL and (5) Tai Chi on glucose control, balance, neuropathic symptoms, and some dimensions of QoL in patients with PDN. All studies were of a moderate quality, and results should be interpreted with caution.
Conclusions
Based on increasing knowledge in the domain of chronic pain, it could be assumed that integrated rehabilitation treatments for patients with PDN are beneficial. There is no literature to support this and more research should be done on integrated biopsychosocial interventions in patients with PDN.
Implications
This empty review highlights the importance that more research should be done on integrated biopsychosocial interventions in patients with PDN. Currently, our research group is performing a study on the effects of EXP treatment in patients with PDN.
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van Velzen GAJ, Huygen FJPM, van Kleef M, van Eijs FV, Marinus J, van Hilten JJ. Sex matters in complex regional pain syndrome. Eur J Pain 2019; 23:1108-1116. [PMID: 30735277 PMCID: PMC6617788 DOI: 10.1002/ejp.1375] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 01/30/2019] [Accepted: 02/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is much more prevalent in women than men but potential differences in clinical phenotype have not been thoroughly explored to date. Differences in the clinical presentation between sexes may point at new avenues for a more tailored management approach of CRPS. We therefore explored if in CRPS, the patient's sex is associated with differences in clinical and psychological characteristics. METHODS In this cross-sectional study of 698 CRPS patients (599 females) fulfilling the Budapest clinical or research criteria, CRPS signs and symptoms, CRPS severity, pain (average pain intensity in the previous week and McGill pain rating index), pain coping (Pain Coping Inventory), physical limitations (Radboud Skills Questionnaire (upper limb), Walking and Rising questionnaire (lower limb)), anxiety and depression (Hospital Anxiety and Depression scale) and kinesiophobia (Tampa scale for kinesiophobia) were evaluated. RESULTS Male CRPS patients used more often extreme words to describe the affective qualities of pain, used more passive pain coping strategies, and were more likely to suffer from depression and kinesiophobia. CONCLUSION Sex-related differences are present in CRPS, but the effect is generally small and mainly concerns psychological functioning. A greater awareness of sex-specific factors in the management of CRPS may contribute to achieving better outcomes. SIGNIFICANCE What is known? Nonsex-specific clinical data of CRPS patients. What is new? Male CRPS patients used more often extreme words to describe the affective qualities of pain, used more passive pain coping strategies, and were more likely to suffer from depression and kinesiophobia.
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Affiliation(s)
- Gijsbrecht A J van Velzen
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.,Knowledge Consortium TREND, Leiden, The Netherlands
| | - Frank J P M Huygen
- Knowledge Consortium TREND, Leiden, The Netherlands.,Department of Anaesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten van Kleef
- Knowledge Consortium TREND, Leiden, The Netherlands.,Department of Anaesthesiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frank V van Eijs
- Knowledge Consortium TREND, Leiden, The Netherlands.,Department of Anaesthesiology, Sint Elisabeth Hospital, Tilburg, The Netherlands
| | - Johan Marinus
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.,Knowledge Consortium TREND, Leiden, The Netherlands
| | - Jacobus J van Hilten
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.,Knowledge Consortium TREND, Leiden, The Netherlands
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Pavlov’s Pain: the Effect of Classical Conditioning on Pain Perception and its Clinical Implications. Curr Pain Headache Rep 2019; 23:19. [DOI: 10.1007/s11916-019-0766-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Okifuji A, Neikrug A. Update and future perspective of behavioral medicine in the treatment for chronic pain. Pain Manag 2019; 9:161-173. [PMID: 30785366 DOI: 10.2217/pmt-2017-0055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Chronic pain is a biopsychosocial condition, and behavioral medicine has made significant contributions to the understanding of the phenomenon and optimization of therapeutic outcomes. The objective of this article is to provide future perspectives of behavioral medicine in pain management based upon recent development in the field. We will briefly review the mainstream approach of cognitive-behavioral therapy, its variations and new and innovative approaches that are on the horizon. We also review strategies that address potential barriers to pain management. Behavioral medicine is a promising field in pain medicine. The future growth is likely to come from addressing how we incorporate the patient heterogeneity into our treatment approaches and a better understanding of its role in a multimodal treatment.
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Affiliation(s)
- Akiko Okifuji
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA 84108
| | - Ariel Neikrug
- Department of Psychiatry, University of California Irvine, CA 92868, USA 92868
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Tang NKY. Cognitive behavioural therapy in pain and psychological disorders: Towards a hybrid future. Prog Neuropsychopharmacol Biol Psychiatry 2018; 87:281-289. [PMID: 28284902 DOI: 10.1016/j.pnpbp.2017.02.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 11/16/2022]
Abstract
Cognitive Behavioural Therapy (CBT) is a form of evidence-based talking therapy that emphasises the importance of behaviour and conscious thoughts in shaping our emotional experiences. As pain becomes increasingly accepted as not only a sensory but also an emotional experience, success in using CBT to treat emotional disorders has resulted in the incorporation of cognitive-behavioural principles into the management of chronic pain. Outcomes of CBT-informed interdisciplinary pain management programmes are modest at best, despite rapid methodological improvements in trial design and implementation. Whilst the field searches for new treatment directions, a hybrid CBT approach that seeks to simultaneously tackle pain and its comorbidities shows promise in optimising treatment effectiveness and flexibility. This article provides a brief description of the core characteristics of CBT and the transformation this therapeutic model has brought to our understanding and management of chronic pain. Current evidence on efficacy of CBT for chronic pain is then reviewed, followed by a critical consideration of the advantages and disadvantages of the new hybrid treatment approach that conceptualises and treats chronic pain in connection with its comorbidities. Recent progress made in the area of pain and insomnia is highlighted as an example to project therapeutic innovations in the near future.
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Affiliation(s)
- Nicole K Y Tang
- Department of Psychology, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom.
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Pons T, Shipton EA, Williman J, Mulder RT. A proposed clinical conceptual model for the physiotherapy management of Complex Regional Pain Syndrome (CRPS). MUSCULOSKELETAL SCIENCE & PRACTICE 2018; 38:15-22. [PMID: 30216868 DOI: 10.1016/j.msksp.2018.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 08/22/2018] [Accepted: 08/31/2018] [Indexed: 10/28/2022]
Abstract
There are no validated clinical models to show a reliable pathway of guaranteeing an effective recovery for Complex Regional Pain Syndrome (CRPS) with physiotherapy management. An array of medical, psychological and physiotherapy intervention methods show weak benefit. Spearman correlations, with significance p < 0.05, from an observational, prospective, longitudinal, multi-centre study of regional standard physiotherapy CRPS management showed complete recovery to be potentially associated with baseline factors of: better mental health; better functional ability and quality of life; higher scores of extraversion personality trait; lower scores of intraversion personality trait; and interventions such as concurrent prescription of the anticonvulsant secondary analgesia group and a higher intensity of physiotherapy education intervention. These correlations were integrated with the literature evidence and the crux of previously suggested models to conceptualise a clinical model that can contribute to the broader knowledge of physiotherapy management in CRPS that should be tested with future research.
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Affiliation(s)
- Tracey Pons
- Department of Anaesthesia, University of Otago, Christchurch, Corner of Riccarton and Hagley Avenues, Christchurch 8042, New Zealand.
| | - Edward A Shipton
- Department of Anaesthesia, University of Otago, Christchurch, Corner of Riccarton and Hagley Avenues, Christchurch 8042, New Zealand.
| | - Jonathan Williman
- Biostatistics and Computation Biology Unit, University of Otago, Christchurch, Corner of Riccarton and Hagley Avenues, Christchurch 8042, New Zealand.
| | - Roger T Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, Corner of Riccarton and Hagley Avenues, Christchurch 8042, New Zealand.
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Shepherd M, Louw A, Podolak J. The clinical application of pain neuroscience, graded motor imagery, and graded activity with complex regional pain syndrome-A case report. Physiother Theory Pract 2018; 36:1043-1055. [PMID: 30499359 DOI: 10.1080/09593985.2018.1548047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic Regional Pain Syndrome (CRPS) is a condition that physical therapists may encounter in an outpatient orthopedic setting. In physical therapy (PT) treatment of CRPS addresses pain and the changes observed in the brain through the use of graded motor imagery (GMI). CASE DESCRIPTION A 57-year-old female presented to an outpatient PT clinic with CRPS type 1. Complicating psychosocial factors such as kinesiophobia and catastrophization were present. The patient engaged in a treatment plan including GMI: pain neuroscience education (PNE), laterality training, motor imagery, and mirror training. As symptoms improved, graded functional exposure and functional restoration occurred. OUTCOMES The patient was seen for a total of 26 visits over a 9-month period. FAAM measures exceeded reported clinically important change that was sustained at two-year follow-up. Long term outcomes showed no functional deficits related to her foot or ankle and minimal to no catastrophizing and fear avoidance behaviors. DISCUSSION This case report showcases the use of GMI with a patient with CRPS type 1 in an outpatient orthopedic clinic. Clinicians may consider the use of GMI to progress a patient toward maximal functional gains.
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Affiliation(s)
- Mark Shepherd
- Department of Physical Therapy, South College , Knoxville, TN, USA.,Evidence in Motion Institute of Health Professions , Louisville, KY, USA
| | - Adriaan Louw
- International Spine and Pain Institute , Louisville, KY, USA
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Kanera IM, van Laake-Geelen CCM, Ruijgrok JM, Goossens MEJB, de Jong JR, Verbunt JA, Geerts M, Smeets RJEM, Kindermans HPJ. Living with painful diabetic neuropathy: insights from focus groups into fears and coping strategies. Psychol Health 2018; 34:84-105. [PMID: 30320508 DOI: 10.1080/08870446.2018.1518526] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Painful diabetic neuropathy (PDN) is known to negatively affect quality of life. Being physically active is a crucial part of successful diabetes self-management, but regimen adherence is often low. Coping strategies and fears have shown to be related to less physical activity (PA). The aim of the present study was to obtain more in-depth information on psychological risk factors leading to less PA in persons with PDN. DESIGN Three semi-structured focus group interviews were conducted with a representative sample of persons with PDN (N = 12). Data were transcribed verbatim and analysed using a hybrid method of thematic analyses and a grounded theory approach. MAIN OUTCOME MEASURES Fears and coping strategies related to PA in persons with PDN. RESULTS Several specific fears were identified; fear of hypoglycaemia, fear of pain increase, fear of total exhaustion, fear of physical injury, fear of falling, fear of loss of identity, and fear of negative evaluation by others. To cope with these fears, avoidance, remaining active, cognitive distraction, and acceptance strategies were described. CONCLUSION In persons with PDN, diabetes-related fears and pain-related fears play a role in less engagement in PA, indicating the need for new methods for improving self-management in persons with PDN.
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Affiliation(s)
- Iris M Kanera
- a Research Centre for Nutrition, Lifestyle, and Exercise, Faculty of Health , Zuyd University of Applied Sciences , Heerlen , The Netherlands.,b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands
| | - Charlotte C M van Laake-Geelen
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,c Department of Rehabilitation Medicine , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands.,d Adelante Centre of Expertise in Rehabilitation and Audiology , Hoensbroek , The Netherlands
| | - Joop M Ruijgrok
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,e Neurorehabilitation Centre , Klinik Bethesda Tschugg , Tschugg , Switzerland
| | - Marielle E J B Goossens
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands
| | - Jeroen R de Jong
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,c Department of Rehabilitation Medicine , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Jeanine A Verbunt
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,c Department of Rehabilitation Medicine , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands.,d Adelante Centre of Expertise in Rehabilitation and Audiology , Hoensbroek , The Netherlands
| | - Margot Geerts
- f Department of Neurology , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Rob J E M Smeets
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,g Libra Rehabilitation and Audiology , Eindhoven , The Netherlands
| | - Hanne P J Kindermans
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,h Department of Clinical Psychological Science , Maastricht University , Maastricht , The Netherlands
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Ariza-Mateos MJ, Cabrera-Martos I, Ortiz-Rubio A, Torres-Sánchez I, Rodríguez-Torres J, Valenza MC. Effects of a Patient-Centered Graded Exposure Intervention Added to Manual Therapy for Women With Chronic Pelvic Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil 2018; 100:9-16. [PMID: 30312595 DOI: 10.1016/j.apmr.2018.08.188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To explore the effects of a 6-week patient-centered graded exposure intervention added to manual therapy in women with chronic pelvic pain (CPP) and fear of movement/(re)injury. DESIGN Prospective 3-armed randomized controlled trial. SETTING Faculty of Health Sciences. PARTICIPANTS A total of 49 women with CPP and substantial fear of movement were randomly allocated to 1 of 3 groups: (1) patient-centered graded exposure intervention added to manual therapy; (2) manual therapy; (3) control group. INTERVENTIONS The 6-week intervention consisted of 12 sessions in the group receiving manual therapy and 6 additional sessions of graded exposure therapy in the group receiving both interventions. MAIN OUTCOME MEASURES Primary outcomes were fear-avoidance behavior assessed using the Fear-Avoidance Beliefs Questionnaire and pain interference and severity evaluated with the Brief Pain Inventory. The secondary outcome was disability evaluated with the Oswestry Disability Index. All the variables were assessed in a blinded manner at baseline, after the treatment, and at 3-month follow-up. RESULTS Our results show interaction effects (P<.05) for all the outcomes. Graded exposure added to manual therapy is distinctly superior to manual therapy alone in maintaining improvements for long-term fear-avoidance behavior and physical functioning. CONCLUSIONS Graded exposure added to manual therapy is a promising approach with long-term effects for women with CPP and fear of movement/(re)injury.
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Walston Z, Hernandez L, Yake D. Utilization of manual therapy to the lumbar spine in conjunction with traditional conservative care for individuals with bilateral lower extremity complex regional pain syndrome: A case series. Physiother Theory Pract 2018; 36:241-248. [PMID: 29873592 DOI: 10.1080/09593985.2018.1482392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Background and purpose: Conservative therapies for complex regional pain syndrome (CRPS) have traditionally focused on exercise and desensitization techniques targeted at the involved extremity. The primary purpose of this case series is to report on the potential benefit of utilizing manual therapy to the lumbar spine in conjunction with traditional conservative care when treating patients with lower extremity CRPS.Case description: Two patients with the diagnosis of lower extremity CRPS were treated with manual therapy to the lumbar spine in conjunction with education, exercise, desensitization, and soft tissue techniques for the extremity.Outcomes: Patient 1 received 13 sessions over 6 weeks resulting in a 34-point improvement in oswestry disability index (ODI) and 35-point improvement in lower extremity functional scale (LEFS). Patient 2 received 21 sessions over 12 weeks resulting in a 28-point improvement in ODI and a 41-point improvement in LEFS.Discussion: Both patients exhibited reductions in pain and clinically meaningful improvements in function. Manual therapies when applied to the lumbar spine in these patients as part of a comprehensive treatment plan resulted in improved spinal mobility, decreased pain, and reduction is distal referred symptoms. Although one cannot infer a cause and effect relationship from a case series, this report identifies meaningful clinical outcomes potentially associated with manual physical therapy to the lumbar spine for two patients with complex regional pain syndrome type 1.
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Affiliation(s)
| | | | - Dale Yake
- PT Solutions Physical Therapy, Atlanta, GA, USA
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49
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Maeda Y, Kan S, Fujino Y, Shibata M. Verbal Instruction Can Induce Extinction of Fear of Movement-Related Pain. THE JOURNAL OF PAIN 2018; 19:1063-1073. [PMID: 29702257 DOI: 10.1016/j.jpain.2018.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2018] [Accepted: 03/27/2018] [Indexed: 12/01/2022]
Abstract
The fear avoidance model of chronic musculoskeletal pain highlights the importance of pain-related fear in chronification of pain. Although several interventions have been developed on the basis of this model, the following issues remain unresolved: first, whether movement conditioned to pain can evoke fear responses particularly sympathetic activation, and second, whether verbal instructions can attenuate conditioned fear of movement-related pain as with direct experience. To investigate these issues, we induced proprioceptive conditioning (learning the relationship between proprioceptive sensations and an aversive event) and extinction learning in healthy volunteers, and we compared psychophysiological and subjective indices of fear between an instructed and a normal extinction group. Using paired presentation of painful heat stimuli as an unconditioned stimulus and flexion of the wrist as a conditioned stimulus, all participants acquired the conditioned fear response (skin potential response) to the conditioned stimulus. The instructed extinction group was then told that the movement was no longer followed by painful stimulus at the beginning of the extinction phase, and only this group showed significant decreases on both indices of fear. This finding indicates that verbal instruction can attenuate conditioned fear of movement-related pain, supporting the clinical importance of providing information regarding the relationship between movement and pain. PERSPECTIVE This article presents evidence that, in a laboratory setting, verbal instructions rapidly decrease conditioned fear of movement-related pain on psychophysiological as well as subjective indices. This result indicates that it is important for chronic musculoskeletal pain patients to precisely understand the relationship between movement and pain in clinical situations.
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Affiliation(s)
- Yoshiki Maeda
- Faculty of Health Science, Naragakuen University, Nara, Nara, Japan; Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shigeyuki Kan
- Department of Pain Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masahiko Shibata
- Department of Pain Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Demmelmaier I, Björk A, Dufour AB, Nordgren B, Opava CH. Trajectories of Fear-Avoidance Beliefs on Physical Activity Over Two Years in People With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2018; 70:695-702. [PMID: 28941003 PMCID: PMC5947112 DOI: 10.1002/acr.23419] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 09/12/2017] [Indexed: 12/19/2022]
Abstract
Objective To identify and describe 2‐year trajectories of fear‐avoidance beliefs on physical activity and to identify predictors of these trajectories in people with rheumatoid arthritis (RA). Methods We included 2,569 persons with RA (77% women, mean age 58 years). Data on fear‐avoidance beliefs (Fear‐Avoidance Beliefs Questionnaire physical activity subscale [FABQ‐PA]; range 0–24), sociodemographics, disease‐related variables, self‐efficacy, and health‐enhancing physical activity (HEPA) were collected from registers and by questionnaires at baseline, 14, and 26 months. K‐means cluster analysis was used to identify fear‐avoidance trajectories, and multinomial logistic regression was used to identify predictors of trajectory membership. Results Three trajectories of fear‐avoidance beliefs were identified: low (n = 1,060, mean FABQ‐PA = 3), moderate (n = 1,043, mean FABQ‐PA = 9), and high (n = 466, mean FABQ‐PA = 15). Consistent predictors of being in the high fear‐avoidance trajectory versus the other 2 trajectories were high activity limitation, male sex, income below average, not performing current HEPA, and elevated anxiety/depression. In addition, less consistent predictors such as shorter education, more pain, and low exercise self‐efficacy were also identified. Conclusion Stable trajectories of fear‐avoidance beliefs on physical activity exist among people with RA. Fear‐avoidance may be targeted more effectively by tailoring physical activity promotion to vulnerable socioeconomic groups, men, and those with high activity limitation and anxiety/depression.
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Affiliation(s)
| | | | - Alyssa B Dufour
- Karolinska Institutet, Stockholm, Sweden, and Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Birgitta Nordgren
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Christina H Opava
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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