Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process

Mind over chronic pain: A meta-analysis of cognitive restructuring in chronically ill adults

OBJECTIVE

This meta-analysis synthesizes research on the impact of cognitive restructuring on chronic pain intensity, aiming to integrate diverse methodologies and findings while evaluating potential moderators.

METHODS

Following PRISMA guidelines, we systematically searched multiple databases (PubMed, Web of Science, JSTOR, Sage, Social Science Research Network, PsycArticles, ScienceDirect, and Education Resources Information Center) until July 2023. Studies involving adults (≥18 years) diagnosed with chronic conditions who underwent cognitive restructuring to reduce chronic pain intensity, were included. Eligible studies compared this intervention with a control group. We excluded studies incorporating cognitive restructuring within broader interventions, lacking statistical data, or not written in English. Study quality was assessed using the Cochrane Risk of Bias tool (RoB 2).

RESULTS

After reviewing 18,312 studies, we selected 11 studies published between 1991 and 2022, involving 693 participants with chronic conditions. A significant large overall effect size was found (d = 0.94, 95% CI 0.48 to 1.40). Moderation analyses revealed significant differences based on sex and study quality, with effects less pronounced among females and more substantial in higher-quality studies.

CONCLUSION

Despite limitations such as statistical instability due to a small number of studies in certain moderator categories and methodological variability, this meta-analysis highlights the robust effects of cognitive restructuring on chronic pain intensity. The findings are valuable for guiding power calculations and future research expectations. Clinically, these results support the significant effect of cognitive restructuring in both individual and group settings, regardless of age, particularly when facilitated by teams that include psychologists.

Evaluation of Pain Catastrophizing Scale for surgical referral to pain psychology in patients undergoing spinal surgery

Background

Chronic pain is an issue that affects over 100 million Americans daily. Acceptance and Commitment Therapy (ACT) has been found to be beneficial for patients with chronic pain by focusing provider efforts on teaching coping mechanisms for pain instead of eliminating the pain entirely. Current studies demonstrate that ACT significantly improves post-operative chronic pain scores and outcomes.

Methods

The 200 patients chosen via random generator were collected and presented to (institution) orthopedic spine surgeons along with additional information such as the patients' history of present illness, Visual Analog Scale (VAS) scores, PROMIS-CAT Pain Interference scores, and status of opiate usage. Surgeons were blinded to the PCS cutoff scores. The (institution) orthopedic spine surgeons then identified which patients they would indicate for ACT and their reasoning. Pre-determined PCS score cut-offs were separately used to determine if a patient was indicated for ACT.

Results

The effectiveness of this screening tool was based on the frequency at which the surgeons and PCS scores were complimentary. A department epidemiologist assisted in the analysis of the data with the use of a ROC curve. ROC Curve demonstrated an area under the curve of 0.7784 with a Sensitivity of 0.68 and a Specificity of 0.79. The cut point according to Youden's index is 35. The data showed that the PCS is moderately accurate in its ability to distinguish coinciding patients that the [institution] orthopedic spine surgeons referred for ACT. The adjusted cut-point indicates that patients above a PCS of 35 would be referred to ACT by the orthopedic spine surgeons while those below a PCS score of 35 would not be referred.

Conclusions

Using the PCS, a referral with the department pain psychologist would occur by [institution] orthopedic spinal surgeons for patients that are deemed at-risk with a score of at least 35. The goal following this study is to perform future investigations regarding PCS and ACT with patients regarding chronic opioid use and postoperative outcomes. Patients who would be referred for help with chronic pain would be compared to PCS-referred patients and non-referred patients. Pre-operative ACT would be compared to patient outcomes post-operatively. The future aim is to use the cut-offs established in this study for experimental design to evaluate if PCS-referred patients have better pain management post-operatively as compared to the control and previously referred patients.

Level of Evidence

Level III diagnostic study.

Immediate Effects of Mindful Awareness in Body-oriented Therapy as an Adjunct to Medication for Opioid Use Disorder

Objective

While effective, medication for opioid use disorder (MOUD) treatment outcomes can be limited by co-occurring polysubstance use, mental health and chronic pain conditions. Interoceptive training may facilitate well-being and support medication treatment for MOUD. This study examined the pre-post effects of the mindfulness-based intervention Mindful Awareness in Body-oriented Therapy (MABT) as an adjunct to MOUD. MABT teaches interoceptive awareness skills to promote self-care and emotion regulation.

Methods

People stabilized on medication for OUD (N = 303) from 6 community clinics in Northwestern United States were recruited and randomly assigned to MABT plus MOUD or MOUD only. In a mixed-methods study, we used an intent-to-treat approach to examine the proportion of days abstinent from non-prescribed opioids, and other substance use (primary outcomes) at baseline and 3 months post-intervention. Secondary outcomes included symptoms of mental health distress; emotional regulation difficulties; pain and physical symptom indicators; interoceptive awareness and mindfulness skills. Participant experience of MABT was collected through post-intervention surveys. Changes in outcomes were assessed using linear mixed models; content analysis was used to analyze the qualitative data.

Results

Levels of overall substance use were low and did not differ between groups. Significant improvements in PTSD symptoms, interoceptive awareness, pain severity, pain activity interference, and physical symptom frequency were found for those who received MABT compared to MOUD only.

Conclusion

In this stable MOUD population, substance use outcomes were not improved, however MABT demonstrated significant positive changes across multiple health outcomes critical for improving MOUD treatment. Clinical Trials Registration: NCT04082637 on 9/3/2019.

Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans: A Randomized Clinical Trial

Importance

Chronic pain is common and disabling in older adults, and psychological interventions are indicated. However, the gold standard approach, cognitive-behavioral therapy (CBT), produces only modest benefits, and more powerful options are needed.

Objectives

To evaluate whether emotional awareness and expression therapy (EAET) is superior to CBT for treatment of chronic pain among predominantly male older veterans and whether higher baseline depression, anxiety, or posttraumatic stress disorder (PTSD) symptoms-key targets of EAET-moderate treatment response.

Design, Setting, and Participants

This 2-arm randomized clinical trial was conducted from May 16, 2019, to September 14, 2023, in the US Department of Veterans Affairs Greater Los Angeles Healthcare System. The trial included a racially and ethnically diverse group of veterans aged 60 to 95 years with at least 3 months of musculoskeletal pain.

Interventions

Emotional awareness and expression therapy or CBT, conducted concurrently, each presented as one 90-minute individual session followed by eight 90-minute group sessions.

Main Outcomes and Measures

The primary outcome was Brief Pain Inventory pain severity (range, 0 to 10) from baseline to posttreatment (week 10, primary end point) and 6-month follow-up. Secondary outcomes included Patient Reported Outcomes Institute Measurement System Anxiety, Depression, Fatigue, General Life Satisfaction (NIH Toolbox), Pain Interference, and Sleep Disturbance Short Forms, Patient Global Impression of Change (PGIC), and Satisfaction with Therapy and Therapist Scale-Revised. A subset of participants completed the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). All analyses were for the intention-to-treat population and included all randomized participants.

Results

Among 126 randomized participants (66 in the EAET group and 60 in the CBT group; mean [SD] age, 71.9 [5.9] years; 116 [92%] male), 111 (88%) completed posttreatment, and 104 (82%) completed the 6-month follow-up. The EAET was superior to CBT for the primary outcome of reduction in pain severity at posttreatment (estimate, -1.59 [95% CI, -2.35 to -0.83]; P < .001) and follow-up (estimate, -1.01 [95% CI, -1.78 to -0.24]; P = .01). A greater percentage of participants in EAET vs CBT had clinically significant (at least 30%) pain reduction (63% vs 17%; odds ratio, 21.54 [95% CI, 4.66-99.56]; P < .001) at posttreatment. In addition, EAET was superior to CBT on 50% pain reduction (35% vs 7%; odds ratio, 11.77 [95% CI, 2.38-58.25]; P = .002), anxiety (estimate, -2.49 [95% CI, -4.30 to -0.68]; P = .006), depression (estimate, -3.06 [95% CI, -5.88 to -0.25]; P = .03), general life satisfaction (estimate, 1.23 [95% CI, 0.36-2.10]; P = .005), PTSD symptoms (estimate, -4.39 [95% CI, -8.44 to -0.34]; P = .03), PGIC score (estimate, 1.46 [95% CI, 0.77-2.15]; P < .001), and global treatment satisfaction (estimate, 0.28 [95% CI, 0.12-0.45]; P < .001) at posttreatment. Higher baseline depression (estimate, -1.55 [95% CI, -0.37 to 2.73]; P < .001), anxiety (estimate, -1.53 [95% CI, -2.19 to -0.88]; P < .001), and PTSD symptoms (estimate, -1.69 [95% CI, -2.96 to -0.42]; P = .009) moderated greater reduction in pain severity after EAET but not CBT.

Conclusions and Relevance

The results of this randomized clinical trial suggest that EAET may be a preferred intervention for medically and psychiatrically complex patients with pain. The societal burden of chronic pain could be improved by further incorporating the principles of EAET into mainstream clinical pain medicine.

Trial Registration

ClinicalTrials.gov Identifier: NCT03918642.

The effect of emotion regulation on the emotional modulation of pain and nociceptive flexion reflex

ABSTRACT

Positive emotions inhibit pain, whereas negative emotions facilitate pain. Thus, many psychosocial interventions capitalize on this emotion-pain relationship to improve patients' abilities to regulate emotion (ie, reduce negative emotion, increase positive emotion), influence nociception, and manage pain. This study extended the existing literature to examine whether emotion regulation procedures could influence emotional modulation of the nociceptive flexion reflex (NFR), a marker of spinal nociception. To elicit emotion, 2 blocks of pleasant, neutral, and unpleasant pictures were presented. In block 1, participants were asked to passively view pictures during which painful electric stimulations were delivered to evoke pain and the NFR. Valence, arousal, corrugator electromyogram, and skin conductance response were used to measure emotional responses to pictures. To manipulate emotion regulation, participants were randomized to either suppress (downregulate) or enhance (upregulate) their emotion during block 2 (other procedures same as block 1). Instructions to suppress decreased subjective and physiological responding to emotional pictures, reduced emotional modulation of pain, and generally decreased NFR magnitude (regardless of picture content). Instructions to enhance emotion increased subjective responding to emotional pictures but did not alter physiological responding to pictures or emotional modulation of pain/NFR in predictable ways. Results imply that downregulation/suppression of negative emotions may work best to reduce pain facilitation. Furthermore, this study contributes to the existing literature that shows that pain and pain signaling is tightly coupled with emotional states and that emotion regulation can impact pain perception.

Patients' experiences of treatment-relevant processes in multimodal pain rehabilitation for severe complex regional pain syndrome - a qualitative study

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.

Improvement in functional outcome 1 year after nonsurgical multidisciplinary treatment for chronic pain after total knee arthroplasty: A prospective cohort study

PURPOSE

The purpose of this study was to evaluate a multidisciplinary intervention developed for patients with debilitating chronic pain after total knee arthroplasty (TKA) unresponsive to existing treatment options.

METHODS

A treatment-based prospective cohort study was caried out in 30 TKA patients with debilitating chronic pain at least 1 year after TKA. The treatment was a multidisciplinary intervention. Main inclusion criteria: no indication for surgery. Primary outcome was function measured by KOOS-PS, OKS, OKS-APQ and WORQ. Secondary outcome measures were pain, fear of movement, self-efficacy, quality of life (QoL), health care and pain medication use, work rehabilitation and patient satisfaction. The assessments took place pre- and directly posttreatment, at 1, 3 and 12 months follow-up. The clinical relevance was assessed by predefined minimal important clinical change (MCIC).

RESULTS

At baseline patients were on average 64.7 (±7.9) years old, 67% were female, and they had knee pain for 42 (10-360) months. The results at 12-month follow-up: first, a significant improvement was shown in function, pain, fear of movement, self-efficacy and QoL. Second, in 38.5%-69.2% of patients clinical relevant improvement was shown for functional outcome, 31% for pain, and 50% for self-efficacy. Third, 42% of patients reported 'no healthcare use in the past three months'.

CONCLUSION

One year after a multidisciplinary treatment a clinically relevant improvement was shown in terms of function, pain, self-efficacy and QoL. It seems to be a promising treatment option in this difficult-to-treat patient group with debilitating chronic pain after TKA. Future research should examine the effect of the treatment in a larger study population, considering a control group, and focusing on the working population and evaluating cost-efficacy.

LEVEL OF EVIDENCE

Level II.

Implications of Preoperative Depression for Lumbar Spine Surgery Outcomes: A Systematic Review and Meta-Analysis

Importance

Comorbid depression is common among patients with degenerative lumbar spine disease. Although a well-researched topic, the evidence of the role of depression in spine surgery outcomes remains inconclusive.

Objective

To investigate the association between preoperative depression and patient-reported outcome measures (PROMs) after lumbar spine surgery.

Data Sources

A systematic search of PubMed, Cochrane Database of Systematic Reviews, Embase, Scopus, PsychInfo, Web of Science, and ClinicalTrials.gov was performed from database inception to September 14, 2023.

Study Selection

Included studies involved adults undergoing lumbar spine surgery and compared PROMs in patients with vs those without depression. Studies evaluating the correlation between preoperative depression and disease severity were also included.

Data Extraction and Synthesis

All data were independently extracted by 2 authors and independently verified by a third author. Study quality was assessed using Newcastle-Ottawa Scale. Random-effects meta-analysis was used to synthesize data, and I2 was used to assess heterogeneity. Metaregression was performed to identify factors explaining the heterogeneity.

Main Outcomes and Measures

The primary outcome was the standardized mean difference (SMD) of change from preoperative baseline to postoperative follow-up in PROMs of disability, pain, and physical function for patients with vs without depression. Secondary outcomes were preoperative and postoperative differences in absolute disease severity for these 2 patient populations.

Results

Of the 8459 articles identified, 44 were included in the analysis. These studies involved 21 452 patients with a mean (SD) age of 57 (8) years and included 11 747 females (55%). Among these studies, the median (range) follow-up duration was 12 (6-120) months. The pooled estimates of disability, pain, and physical function showed that patients with depression experienced a greater magnitude of improvement compared with patients without depression, but this difference was not significant (SMD, 0.04 [95% CI, -0.02 to 0.10]; I2 = 75%; P = .21). Nonetheless, patients with depression presented with worse preoperative disease severity in disability, pain, and physical function (SMD, -0.52 [95% CI, -0.62 to -0.41]; I2 = 89%; P < .001), which remained worse postoperatively (SMD, -0.52 [95% CI, -0.75 to -0.28]; I2 = 98%; P < .001). There was no significant correlation between depression severity and the primary outcome. A multivariable metaregression analysis suggested that age, sex (male to female ratio), percentage of comorbidities, and follow-up attrition were significant sources of variance.

Conclusions and Relevance

Results of this systematic review and meta-analysis suggested that, although patients with depression had worse disease severity both before and after surgery compared with patients without depression, they had significant potential for recovery in disability, pain, and physical function. Further investigations are needed to examine the association between spine-related disability and depression as well as the role of perioperative mental health treatments.

The relationship between kinesiophobia severity and clinical parameters in patients with mechanical low back pain

BACKGROUND

Low back pain is an important widespread health problem that can occur at any age, causing serious socioeconomic losses.

OBJECTIVE

The objective of this study is to investigate the relationship between kinesiophobia severity and pain severity, depression, and quality of life in patients with mechanical low back pain.

METHODS

The study sample consisted of 155 patients, of whom 72 were female and 83 were male, aged between 18 and 75 years with mechanical low back pain. Quality of life was assessed with the 36-Item Short Form Health Survey (SF-36), pain intensity with the Visual Analogue Scale (VAS), kinesiophobia with the Tampa Kinesiophobia Scale (TKS), and depression with the Beck Depression Inventory (BDI). Patients were divided into the low (TKS ⩽ 37) and high kinesiophobia (TKS > 37) groups according to the scores they obtained from TKS.

RESULTS

VAS-pain severity and BDI scores were significantly higher in the high kinesiophobia group than in the low kinesiophobia group (p< 0.001). On the other hand, the SF-36 subscale scores were significantly higher in the low kinesiophobia group than in the high kinesiophobia group (p< 0.001). The TKS scores were moderately correlated with VAS-pain severity (r= 0.470; p< 0.001) and BDI scores (r= 0.584; p< 0.001) in the positive direction, and strongly correlated with all sub-parameters of quality of life in the negative direction (p< 0.001).

CONCLUSION

The results indicated that the severity of kinesiophobia in patients with non-inflammatory low back pain is associated with pain severity, depression, and poor quality of life.

Evaluation of a therapist-guided virtual psychological pain management program when provided as routine care: a prospective pragmatic cohort study

INTRODUCTION

Numerous randomized controlled trials have evaluated the outcomes of internet-delivered psychological pain management programs (PMPs) as a way of increasing access to care for people with chronic pain. However, there are few reports of the effectiveness of these PMPs when provided as part of routine care.

METHODS

The present study sought to report the clinical and demographic characteristics of users (n = 1367) and examine the effectiveness of an established internet-delivered psychological PMP program in improving several pain-related outcomes, when offered at a national digital mental health service over a 5-year period. It also sought to comprehensively explore predictors of treatment commencement, treatment completion, and clinical improvement.

RESULTS

Evidence of clinical improvements (% improvement; Hedges g) were found for all outcomes, including pain interference (18.9%; 0.55), depression (26.1%; 0.50), anxiety (23.9%; 0.39), pain intensity (12.8%; 0.41), pain self-efficacy (-23.8%; -0.46) and pain-catastrophizing (26.3%; 0.56). A small proportion of users enrolled but did not commence treatment (13%), however high levels of treatment completion (whole treatment = 63%; majority of the treatment = 75%) and satisfaction (very satisfied = 45%; satisfied = 37%) were observed among those who commenced treatment. There were a number of demographic and clinical factors associated with commencement, completion and improvement, but no decisive or dominant predictors were observed.

DISCUSSION

These findings highlight the effectiveness and acceptability of internet-delivered psychological PMPs in routine care and point to the need to consider how best to integrate these interventions into the pathways of care for people with chronic pain.

Predictors of treatment outcome in cognitive behavioural therapy for chronic pain: a systematic review

PURPOSE

The aim of this systematic review was to synthesise the research identifying possible influences on CBT outcomes in chronic pain. Variations in the effectiveness of psychological therapies, such as CBT, in chronic pain have led to research investigating predictors of improved treatment outcomes.

MATERIALS AND METHODS

We identified randomised controlled and cohort studies of CBT for chronic pain, published between 1974 to 2nd August 2023, which identified predictors of CBT outcomes.

RESULTS

Nineteen studies were included in the review. Baseline sociodemographic, physical and emotional factors that influence the outcomes of CBT for chronic pain were identified. The most commonly reported predictors of CBT outcome, with medium to large effect sizes, were anxiety, depression and negative cognitions about pain and coping. Sociodemographic predictors of outcomes demonstrated small effects and lacked replicability.

CONCLUSIONS

There was variability across study designs, CBT delivery and outcomes measures. Further research is needed in chronic pain to identify the predictive factors which influence treatment outcomes, and consistency across study designs and outcome variables is needed to reduce heterogeneity.

Virtual transitional pain service delivered via telehealth is effective in preventing new and persistent opioid use amongst post-surgical spine patients

Opioid dependence is a national crisis, with 30 million patients annually at risk of becoming persistent opioid users after receiving opioids for post-surgical pain management. Translational Pain Services (TPS) demonstrate effectiveness for behavioral health improvements but its effectiveness in preventing persistent opioid use is less established, especially amongst opioid exposed patients. Prohibitive costs and accessibility challenges have hindered TPS program adoption. To address these limitations, we designed and implemented a remote telehealth TPS protocol focusing on preventing continued opioid use while improving behavioral health. Licensed therapists trained in the opioid-tapering CBT protocol delivered sessions reimbursed through standard payer reimbursement. Our prospective study evaluated the protocol's effectiveness on preventing persistent opioid use and behavioral health outcomes amongst both opioid naïve and exposed patients. In an opioid-naive patient cohort (n=67), 100% completely tapered off opioids, while in an opioid-exposed cohort (n =19) 52% completely tapered off opioids, demonstrating promising results. In both cohorts, we observed significant improvements in behavioral health scores, including pain. This opioid-tapering digital TPS is effective, adoptable, and incurs no out-of-pocket cost for healthcare systems. We provide the opioid-tapering CBT protocol in the supplement to facilitate adoption. Trial Registration Impact of Daily, Digital and Behavioral Tele-health Tapering Program for Perioperative Surgical Patients Exposed to Opioids and Benzodiazepines registered at clinicaltrials.gov, NCT04787692. https://clinicaltrials.gov/ct2/show/NCT04787692?term=NCT04787692&draw=2&rank=1.

Relations between PTSD symptom clusters and pain in three trauma-exposed samples with pain

OBJECTIVES

Little is known about how the individual PTSD symptom clusters relate to intensity and interference of pain and whether these relationships differ across clinical groups. The present study examines relations between PTSD symptom clusters and pain in three trauma-exposed, unique clinical groups: 1) adults seeking treatment for chronic pain with current symptoms of PTSD, 2) trauma affected refugees seeking treatment for PTSD and chronic pain; and 3) individuals identified at admission to the emergency ward after whiplash injury.

METHODS

Network analysis was used to assess unique relations between pain intensity, pain interference, re-experiencing, avoidance, numbing, hyperarousal, depression, and anxiety separately in each sample. Links between PTSD clusters and pain were then compared within and between samples.

RESULTS

No within-group differences were identified for the links between pain and any of PTSD clusters in the chronic pain and refugee groups. In the whiplash group, hyperarousal was more strongly related to pain than re-experiencing, avoidance, and numbing. Between group comparisons revealed a more pronounced relationship between hyperarousal and pain in the whiplash group, with no between-group differences between the chronic pain and refugee groups.

CONCLUSIONS

The findings suggest that when depression and anxiety are accounted for, few unique associations are found between pain and the PTSD symptom clusters in trauma-exposed samples with pain, with the exception of a link between pain and hyperarousal in individuals with whiplash-related PTSD symptoms.

Pain education and pain management skills in virtual reality in the treatment of chronic low back pain: A multiple baseline single-case experimental design

Chronic lower back pain is a major health problem and current treatments do not always lead to adequate pain control. Virtual reality (VR) is an upcoming technology that has shown to be effective in reducing acute pain. However, the value of VR in reducing chronic pain is still unknown. Therefore, the current study focuses on the effects of a recently developed VR application 'Reducept' using a multiple baseline single-case experimental design in 8 patients (N = 8). Reducept is a VR-training program aiming to improve pain management skills and providing pain education in patients with (chronic lower) back pain. Results based on visual and statistical analyses indicated that Reducept has the potential to reduce chronic lower back pain, although its clinical relevance was small. This study is one of the first that focuses on the possible effects of Reducept using sophisticated visual and statistical analyses. Our study shows a detailed overview of individual changes in pain intensity over time. Further research is necessary to investigate the working mechanism of Reducept and its impact on chronic pain conditions.

Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain

Both mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) are effective for chronic low back pain (CLBP), but little is known regarding who might benefit more from one than the other. Using data from a randomized trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with CLBP (N = 297), we examined baseline characteristics that moderated treatment effects or were associated with improvement regardless of treatment. Outcomes included 8-week function (modified Roland Disability Questionnaire), pain bothersomeness (0-10 numerical rating scale), and depression (Patient Health Questionnaire-8). There were differences in the effects of CBT versus MBSR on pain based on participant gender (P = .03) and baseline depressive symptoms (P = .01), but the only statistically significant moderator after Bonferroni correction was the nonjudging dimension of mindfulness. Scores on this measure moderated the effects of CBT versus MBSR on both function (P = .001) and pain (P = .04). Pain control beliefs (P <.001) and lower anxiety (P < .001) predicted improvement regardless of treatment. Replication of these findings is needed to guide treatment decision-making for CLBP. TRIAL REGISTRATION: The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT01467843). PERSPECTIVE: Although few potential moderators and nonspecific predictors of benefits from CBT or MBSR for CLBP were statistically significant after adjustment for multiple comparisons, these findings suggest potentially fruitful directions for confirmatory research while providing reassurance that patients could reasonably expect to benefit from either treatment.

Time since onset might be of essence: A recommendation to assess the effects of combination of non-pharmacological neuromodulatory approaches at early stage since symptoms onset

In the past decade researchers began to assess the potential beneficial effects of non-invasive brain stimulation (NIBS) combined with a behavioral task as a treatment approach for various medical conditions. Transcranial direct current stimulation (tDCS) applied to the motor cortex combined with another treatment approach has been assessed as analgesic treatment in neuropathic and non-neuropathic pain conditions, and was found to exert only modest pain relief. Our group results show that combined tDCS and mirror therapy dramatically reduced acute phantom limb pain intensity with long-lasting effects, potentially preventing pain chronification. A review of the scientific literature indicates that our approach differs from that of others: We applied the intervention at the acute stage of the disease, whereas other studies applied the intervention in patients whose disease had already been established. We suggest that the timing of administration of the combined intervention is critical. Unlike in patients with chronic painful condition, in which the maladaptive plasticity associated with pain chronification and chronicity is well-consolidated, early treatment at the acute pain stage may be more successful in counterbalancing the not-yet consolidated maladaptive plasticity. We encourage the research community to test our hypothesis, both in the treatment of pain, and beyond.

Effect of Cognitive-Behavioral Therapy or Mindfulness Therapy on Pain and Quality of Life in Patients with Diabetic Neuropathy: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aimed to evaluate the effectiveness of cognitive behavioral therapy (CBT) and mindfulness therapy (MT) for pain relief and quality of life (QOL) in patients with diabetic neuropathy.

REVIEW/ANALYSIS METHODS

Four databases were systematically searched from their respective inception dates to 29 June 2021. Relevant randomized controlled trials (RCTs) were screened and assessed for risk of bias. Eight RCTs evaluating CBT or MT were included. Statistical analysis was performed using Review Manager 5.4.

RESULTS

Eight RCTs involving 384 patients with painful diabetic neuropathy (PDN) tested psychological interventions, including three CBT and five MT studies. The results showed that patients' pain severity (standardized mean difference [SMD] = -0.60, 95% confidence interval [CI; -0.93 to -0.27], P = .0003) and QOL (SMD = -0.43, 95% CI [-0.83 to -0.04], p = .03) were improved immediately after treatment. Besides, the pain intensity (SMD = -0.67, 95% CI [-1.37 to 0.03], p = .06), pain interference (SMD = -0.75, 95% CI [-1.20 to -0.30], p = .001) and depressive symptoms (SMD = -0.62, 95% CI [-0.96 to -0.28], p = .0003) were superior to the control group after follow up. The subgroup analysis results of different intervention type showed that the CBT group could immediately improve pain (SMD = -0.44, 95% CI [-0.78 to -0.10], p = .01) after treatment. However, there was no statistically significant difference in the CBT group after follow-up (SMD = -0.15, 95% CI [-0.52 to 0.22], p = .42).

CONCLUSIONS

Cognitive behavioral therapy or MT is effective for treating pain in patients with diabetic peripheral neuropathy, improving the QOL, and reducing depressive symptoms. However, large-scale, multi-centre, rigorously designed RCTs are needed to further verify the long-term effects.

Can Internet-Delivered Pain Management Programs Reduce Psychological Distress in Chronic Pain? Exploring Relationships Between Anxiety and Depression, Pain Intensity, and Disability

Background

Adults with chronic pain who also report high pain intensity and disability are more likely to experience depression and anxiety symptoms. The present study examined changes in anxiety and depression symptoms after an Internet-delivered pain management program based on baseline pain intensity and disability severity categories.

Methods

We conducted a secondary analysis of data from four randomized controlled trials (N = 1,333).

Results

Greater pain intensity and disability were associated with increased odds of elevated anxiety or depression symptoms at baseline. Treatment led to greater reductions in anxiety and depression symptoms compared with a waitlist control, and these improvements occurred irrespective of baseline pain intensity or disability severity. Those individuals who reported ≥30% improvements in pain intensity or disability after treatment were more likely to also report ≥30% improvements in psychological symptoms. Importantly, most participants who achieved ≥30% improvements in depression and anxiety had not experienced such improvements in pain intensity or disability.

Conclusion

These findings suggest that emerging Internet-delivered pain management programs can lead to reductions in psychological distress even when pain intensity and disability are severe or do not improve with treatment. This indicates the value of such treatments in treating distress and improving mental health in people with chronic pain.

Lessons Learned from an Attempted Pragmatic Randomized Controlled Trial for Improvement of Chronic Pain-Associated Disability in Green Professions: Long-Term Effectiveness of a Guided Online-Based Acceptance and Commitment Therapy &nbsp;(PACT-A)

Musculoskeletal symptoms are increased in farmers, whereas the prevalence of chronified pain is unknown. Online interventions based on acceptance and commitment therapy (ACT) have shown encouraging results in the general population, representing a promising approach for reducing pain interference in green professions (i.e., farmers, foresters, gardeners). We conducted a pragmatic RCT comparing a guided ACT-based online intervention to enhanced treatment-as-usual in entrepreneurs, contributing spouses, family members and pensioners in green professions with chronic pain (CPG: ≥grade II, ≥6 months). Recruitment was terminated prematurely after 2.5 years at N = 89 (of planned N = 286). Assessments were conducted at 9 weeks (T1), 6 months (T2) and 12 months (T3) post-randomization. The primary outcome was pain interference (T1). The secondary outcomes encompassed pain-, health- and intervention-related variables. No treatment effect for reduction of pain interference was found at T1 (β = -0.16, 95%CI: -0.64-0.32, p = 0.256). Improvements in cognitive fusion, pain acceptance, anxiety, perceived stress and quality of life were found only at T3. Intervention satisfaction as well as therapeutic and technological alliances were moderate, and uptake and adherence were low. Results are restricted by low statistical power due to recruitment issues, high study attrition and low intervention adherence, standing in contrast to previous studies. Further research is warranted regarding the use of ACT-based online interventions for chronic pain in this occupational group. Trial registration: German Clinical Trial Registration: DRKS00014619. Registered: 16 April 2018.

Using clinical patient characteristics to predict treatment outcome of cognitive behavior therapies for individuals with medically unexplained symptoms: A systematic review and meta-analysis

OBJECTIVE

For individuals with medically unexplained symptoms (MUS), cognitive behavioral therapy (CBT) is the best-evaluated treatment. This systematic review and meta-analyses identify clinical patient characteristics associated with the treatment outcome of CBT for MUS.

METHODS

A systematic literature search (PubMed, PsycInfo, Web of Science) resulted in 53 eligible studies; of these 32 studies could be included in meta-analyses. Pooled correlation coefficients between predictors and treatment outcome were calculated with a random-effects model. Moderator analyses were conducted to examine differences between subgroups of MUS and different levels of methodological study quality.

RESULTS

Meta-analyses demonstrated that individuals with higher symptom intensity (r = 0.38; p < 0.001), lower physical functioning (r = -0.29; p < 0.001), lower emotional and social functioning (r = -0.37; p < 0.001), more potential symptom-related incentives (r = -0.15; p = 0.001), or longer symptom duration (r = 0.10; p = 0.033) at the beginning of treatment reported less change of symptom severity until the end of therapy or higher end-of-treatment symptom severity. The pooled effect sizes did not differ between certain subgroups of MUS or between different levels of methodological quality.

CONCLUSION

Our findings indicated that clinical characteristics of MUS patients are associated with treatment outcome of CBT. We discuss how the results can be used to optimize and personalize future treatments for MUS.

A Brief Psychological Intervention for Chronic Pain in Primary Care: Examining Long-term Effects from a Pilot Randomized Clinical Trial

BACKGROUND

Despite the existence of evidence-based psychological interventions for pain management, there are barriers that interfere with treatment engagement. A brief intervention integrated into primary care reduced barriers and showed promising benefits from pre- to post-intervention. However, it is unknown whether a brief intervention can provide long-term effects. The purpose of this study was to examine whether a brief psychological intervention offered benefits in pain severity, pain interference, pain catastrophizing, and depressive symptoms at 1- and 6-month follow-ups.

METHODS

The majority of participants who enrolled in a pilot randomized clinical trial of a 5-session psychological intervention for chronic pain in primary care completed the 1-month (n= 54; 90%) and 6-month follow-ups (n= 50; 83.3%). Participants completed measures of pain severity, pain interference, pain catastrophizing, and depressive symptoms.

RESULTS

From baseline to the 6-month follow-up, those in the intervention group had significantly better outcomes for pain severity (p= .01) and pain catastrophizing (p= .003) compared to the control group. There were no significant differences between the intervention and control groups for pain interference and depression. The percentage of patients in the intervention experiencing clinically significant improvement across all outcomes was higher than the control group.

CONCLUSIONS

Findings suggest that a brief psychological intervention for chronic pain in primary care may offer longer-term benefits similar to that of lengthier interventions. Future studies should examine this through a randomized clinical trial with a larger sample size.

Development, evaluation and implementation of a digital behavioural health treatment for chronic pain: study protocol of the multiphase DAHLIA project

INTRODUCTION

Chronic pain affects about 20%-40% of the population and is linked to mental health outcomes and impaired daily functioning. Pharmacological interventions are commonly insufficient for producing relief and recovery of functioning. Behavioural health treatment is key to generate lasting benefits across outcome domains. However, most people with chronic pain cannot easily access evidence-based behavioural interventions. The overall aim of the DAHLIA project is to develop, evaluate and implement a widely accessible digital behavioural health treatment to improve well-being in individuals with chronic pain.

METHODS AND ANALYSIS

The project follows the four phases of the mHealth Agile Development and Evaluation Lifecycle: (1) development and pre-implementation surveillance using focus groups, stakeholder interviews and a business model; (2) iterative optimisation studies applying single case experimental design (SCED) method in 4-6 iterations with n=10 patients and their healthcare professionals per iteration; (3) a two-armed clinical randomised controlled trial enhanced with SCED (n=180 patients per arm) and (4) interview-based post-market surveillance. Data analyses include multilevel modelling, cost-utility and indicative analyses.In October 2021, inter-sectorial partners are engaged and funding is secured for four years. The treatment content is compiled and the first treatment prototype is in preparation. Clinical sites in three Swedish regions are informed and recruitment for phase 1 will start in autumn 2021. To facilitate long-term impact and accessibility, the treatment will be integrated into a Swedish health platform (www.1177.se), which is used on a national level as a hub for advice, information, guidance and e-services for health and healthcare.

ETHICS AND DISSEMINATION

The study plan has been reviewed and approved by Swedish ethical review authorities. Findings will be actively disseminated through peer-reviewed journals, conference presentations, social media and outreach activities for the wider public.

TRIAL REGISTRATION NUMBER

NCT05066087.

Brain circuits for pain and its treatment

[Figure: see text].

A Network Analysis of Clinical Variables in Chronic Pain: A Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

BACKGROUND

Efforts to identify specific variables that impact most on outcomes from interdisciplinary pain rehabilitation are challenged by the complexity of chronic pain. Methods to manage this complexity are needed. The purpose of the study was to determine the network structure entailed in a set of self-reported variables, examine change, and look at potential predictors of outcome, from a network perspective.

METHODS

In this study we apply network analysis to a large sample of people seeking interdisciplinary pain treatment (N = 2,241). Variables analyzed include pain intensity, pain interference, extent of pain, depression, anxiety, insomnia, and psychological variables from cognitive behavioral models of chronic pain.

RESULTS

We found that Acceptance, Pain Interference, and Depression were key, "central," variables in the pretreatment network. Interestingly, there were few changes in the overall network configuration following treatment, specifically with respect to which variables appear most central relative to each other. On the other hand, Catastrophizing, Depression, Anxiety, and Pain Interference each became less central over time. Changes in Life Control, Acceptance, and Anxiety were most strongly related to changes in the remainder of the network as a whole. Finally, no network differences were found between treatment responders and non-responders.

CONCLUSIONS

This study highlights potential future targets for pain treatment. Further application of a network approach to interdisciplinary pain rehabilitation data is recommended. Going forward, it may be better to next do this in a more comprehensive theoretically guided fashion, and ideographically, to detect unique individual differences in potential treatment processes.

Multidimensional health changes after a multimodal pain rehabilitation program: a registry-based study

Introduction

Chronic pain is treated with multimodal rehabilitation programs, targeting improvement in several health aspects. These treatments must be evaluated multidimensionally, which is a methodological challenge.

Objectives

This study investigated factors (demographic, pain-related, and individual- vs group-based treatment) predicting successful outcomes after multimodal pain rehabilitation programs.

Methods

Data from 3 outpatient clinics were retrieved from the Swedish Quality Registry for Pain Rehabilitation, for 314 patients (218 women). Outcome variables were dichotomized as binary change (improved or not improved) based on clinical thresholds. Total improvement grouped outcomes into 0 to 2, 3 to 4, and 5 to 6 improved variables. Binary logistic regression analyses investigated the association between the baseline predictors and change variables.

Results

Patients improving after treatment ranged from 34% (pain intensity) to 80% (depression) for women and 34% to 76% for men, respectively. Total improvement outcome was consistent (after treatment and 1 year) with 28% of patients improving on 5 to 6 outcomes. The baseline predictor related to most improved outcomes was pain intensity, with positive correlation to improvement in pain intensity (P < 0.001) and negative correlation with improvements in anxiety (P = 0.075) and depression (P = 0.002). Individual-based treatment, compared with group-based treatment, was associated with improvement in pain intensity (P = 0.008).

Conclusions

About a third of patients improved in several outcomes by the end of a multimodal program, with most improvement for depression and least for pain intensity. Generally, patients with more severe health status at baseline improve most directly after treatment, but these findings could not suggest treatment adjustments that would improve overall success rates.

The Effect of Literacy-Adapted Psychosocial Treatments on Biomedical and Biopsychosocial Pain Conceptualization

This is a secondary data analysis of a subgroup of participants who received the Learning About My Pain (LAMP) intervention (clinicaltrials.gov identifier NCT01967342). We examined the effects of LAMP on pre-to-post changes in biomedical and biopsychosocial pain conceptualization and whether those changes in pain conceptualization were associated with physical and psychological functioning. Participants were randomized into three conditions: Cognitive Behavioral Therapy (CBT), Pain Psychoeducation (EDU), or Usual Medical Care (UC). Results based on 225 participants who completed the Pain Concepts Questionnaire (PCQ) showed a pre-to-post reduction in biomedical pain conceptualization (BM), an increase in biopsychosocial pain conceptualization (BPS), and an increase in BPS/BM ratio for CBT and EDU but not UC. There were no differences between CBT and EDU in post-treatment PCQ scores. Compared to those with lower BM pain beliefs scores at post-treatment, participants endorsing higher BM pain beliefs scores reported greater pain intensity and greater pain interference. Furthermore, higher BM pain beliefs scores at post-treatment and lower BPS/BM ratio were associated with higher levels of pain catastrophizing. Overall, results of this study suggest the need for targeting specific pain beliefs that influence pain-related outcomes. PERSPECTIVE: This article presents the potential benefits of providing literacy-adapted psychosocial treatments to expand pain conceptualization beyond a biomedical-only understanding and toward a biopsychosocial conceptualization of the experience of pain. Furthermore, the association of changes in pain conceptualization and pain-related functioning argues for its potential clinical relevance.

Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol

Objective. Evidence to date, while sparse, suggests that patients taking long-term opioids require special considerations and protections to prevent potential iatrogenic harms from opioid de-prescribing, such as increased pain or suffering. Following this study protocol, the EMPOWER study seeks to address multiple unmet needs of patients with chronic pain who desire to reduce long-term opioid therapy, and provide the clinical evidence on effective methodology. Methods. EMPOWER applies patient-centered methods for voluntary prescription opioid reduction conducted within a comprehensive, multi-state, 3-arm randomized controlled comparative effectiveness study of three study arms (1) group cognitive behavioral therapy for chronic pain; (2) group chronic pain self-management; and (3) usual care (taper only). Specialized electronic data capture systems collect patient reported symptoms and satisfaction data weekly and monthly during the taper, with real-time clinical alerts and electronic feedback loops informing, documenting, and steering needed care actions. Conclusion. The EMPOWER study seeks to provide granular evidence on patient response to voluntary opioid tapering, and will provide evidence to inform clinical systems changes, clinical care, patient satisfaction, and patient outcomes for opioid reduction.

Behavioral Test (BAT-Back): Preliminary Evidence for a Successful Predictor of Treatment Outcome After Exposure Treatment for Chronic Low Back Pain

OBJECTIVES

Although several questionnaires assessing fear of movement exist, it is still a challenge to identify individuals who might benefit more from exposure for chronic pain than from other psychological approaches and vice versa. Psychological approaches to chronic pain cannot advance toward the often called-for "tailored approaches" because of limited knowledge about treatment predictors. Our aim was to evaluate the additional predictive value of avoidance behavior based on behavioral observation.

METHODS

This study examined pretreatment self-report and behavioral measures as predictors of treatment outcome for n=43 patients experiencing disabling chronic low back pain, who took part in a randomized controlled trial in which they received 10 to 15 sessions of exposure treatment. Only patients with elevated fear avoidance based on self-report measures were included. Data were analyzed using regression analyses and classification and regression trees.

RESULTS

Regression analyses showed that higher avoidance behavior at pretreatment as measured by the Behavioral Avoidance Test-Back Pain (BAT-Back) significantly predicted reduction in global disability (with a small to medium effect), but not in specific disability. Self-report measures failed to predict treatment success for both outcome measures. Classification and regression trees divide subgroups who might benefit from exposure treatment through a BAT-Back score of >22 for Pain Disability Index.

DISCUSSION

There is some preliminary evidence that pretreatment avoidance behavior might be an indicator for reduction in global disability after exposure treatments in patients experiencing disabling chronic low back pain and elevated fear avoidance. We identified preliminary cutoff scores that need further investigation.

Is Helping Really Helping? Health-Related Quality of Life after TBI Predicting Caregiver Depression Symptom Trajectories in Latin America

Previous research connecting health-related quality of life (HRQoL) in people with traumatic brain injury (TBI) and caregiver mental health has primarily been conducted cross-sectionally in the U.S. and Western Europe. This study, therefore, examined how HRQoL in individuals immediately after their TBI predicts longitudinal caregiver depression symptom trajectories in Latin America. A sample of 109 patients with an acute TBI and 109 caregivers (total n = 218) was recruited from three hospitals in Mexico City, Mexico, and in Cali and Neiva, Colombia. TBI patients reported their HRQoL while they were still in hospital, and caregivers reported their depression symptoms at the same time and at 2 and 4 months later. Hierarchal linear models (HLM) found that caregiver depression symptom scores decreased over time, and lower patient mental health and pain-related quality of life at baseline (higher pain) predicted higher overall caregiver depression symptom trajectories across the three time points. These findings suggest that in Latin America, there is an identifiable relationship between psychological and pain-related symptoms after TBI and caregiver depression symptom outcomes. The results highlight the importance of early detection of caregiver mental health needs based in part upon patient HRQoL and a culturally informed approach to rehabilitation services for Latin American TBI caregivers.

Effects of an intervention program with health education and hatha yoga on the health of professionals with musculoskeletal symptoms

Introduction

Musculoskeletal and mental disorders are relevant in the workers' disease process, and ergonomic interventions that include guidance and physical exercise consist of strategies of health promotion. Integrative and complementary practices are presented as a possibility of promoting comprehensive care and yoga consists of a therapeutic alternative.

Objective

To evaluate the effects of an intervention including educational measures and hatha yoga in musculoskeletal pain, disability, and stress in professionals of a university hospital.

Methods

We selected 125 professionals with musculoskeletal symptoms of intensity ≥ 1 who did not practice yoga and randomly assigned them to intervention (n = 63) and control (n = 62) groups, requesting answers to the following questionnaires: initial characterization, the Nordic Musculoskeletal Questionnaire and a numeric scale, the Pain Disability Questionnaire, and the Perceived Stress Scale. The intervention group went through a 12-week program with educational measures and hatha yoga. At the end of the study period, both groups answered to the questionnaires once again. We compared data before and after the intervention and between groups.

Results

Both groups presented improvements after 12 weeks, but the difference between mean results obtained in the first and second data collections revealed that the levels of pain, disability, and stress decreased more strongly in the intervention group than in the control group. Considering that the intervention group began the program in worse clinical conditions, the program led to a reduction in the difference between groups, but this was not enough for the intervention group to reach better results than the control.

Conclusions

The intervention promoted improvements in the intensity of pain, disability, and stress among the participants of the intervention group. Similar programs could be explored in the promotion of occupational health.

Efficacy of a Psychosocial Pain Management Intervention for Men and Women With Substance Use Disorders and Chronic Pain: A Randomized Clinical Trial

IMPORTANCE

Chronic pain is common in those with substance use disorders (SUDs) and predicts poorer addiction treatment outcomes. A critical challenge for addiction treatment is to develop effective methods to improve pain-related and substance use-related outcomes for those in treatment for SUDs.

OBJECTIVE

To examine the efficacy of an integrated behavioral pain management intervention (Improving Pain During Addiction Treatment [ImPAT]) for men and women with SUDs to treat pain, functioning, and substance use.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, 8 sessions of ImPAT were compared with 8 sessions of a supportive psychoeducational control (SPC) condition for adults with pain treated at a large residential SUD treatment program. Follow-up occurred at 3, 6, and 12 months postbaseline. A total of 1372 adults were screened, including 960 men and 412 women, and 510 adults were randomized, including 264 men and 246 women. The goal was to recruit approximately equal numbers of men and women to examine results separately in men and women. A total of 470 of 510 participants (92.2%) completed at least 1 follow-up assessment. Data were collected from October 3, 2011, to January 14, 2016. Data were analyzed from February 1, 2016, to May 1, 2020.

INTERVENTIONS

ImPAT focused on how a psychosocial model of pain was associated with functioning and relapse prevention and provides skills to manage pain. SPC served as the active control condition and involved discussions of topics like nutrition and the course of addiction, which were intended to be relevant to the patient population and to have face validity but be distinct from the content of ImPAT.

MAIN OUTCOMES AND MEASUREMENTS

The primary outcomes were pain intensity, pain-related functioning, and behavioral pain tolerance at 12 months. Secondary outcomes were frequency of alcohol and drug use over 12 months.

RESULTS

Of the 510 included participants, the mean (SD) age was 34.8 (10.3) years. A total of 133 men and 122 women were assigned to ImPAT, and a total of 131 men and 124 women were assigned to the SPC condition. Over 12 months of follow-up, randomization to the ImPAT intervention was associated with higher tolerance of pain among men, higher by a mean score of 0.11 (95% CI, 0.03 to 0.18; P = .004; Cohen d = 0.40) at 3 months and by 0.07 (95% CI, -0.01 to 0.19; P = .11; Cohen d = 0.25) at 12 months. Women receiving the ImPAT intervention experienced a reduction in pain intensity from 3 to 12 months, while women receiving the SPC condition experienced an increase in pain intensity, resulting in lower pain in the ImPAT condition by a mean score of 0.58 (95% CI, -0.07 to 1.22; P = .08; Cohen d = -0.22) at 12 months. No differences were found between the ImPAT and SPC conditions on alcohol or drug use.

CONCLUSIONS AND RELEVANCE

Behavioral pain management is not typically included in addiction treatment, but the present results indicate that this type of intervention was associated with better pain-related outcomes, including pain tolerance in men and pain intensity in women. Improvements in substance use-related outcomes beyond that achieved by treatment as usual were not observed. Treatment programs should consider providing psychosocial pain management services to augment standard addiction treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01372267.

Experiences From the Patient Perspective on Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Qualitatively Driven Mixed Method Analysis

INTRODUCTION

When neither pharmacological therapies nor alternative interventions provide sufficient pain relief, spinal cord stimulation (SCS) can be used to treat Failed Back Surgery Syndrome (FBSS). Although it seems reasonable that quality of life (QoL)- and psychosocial-related factors contribute to the outcome of SCS since pain is a multidimensional experience, few qualitative studies have explored the expectations of SCS and experiences on SCS to treat FBSS from the patient perspective.

OBJECTIVES

The aim of this study was to qualitatively and quantitatively map the FBSS patients' experiences with SCS and the effects of SCS on low back pain caused by FBSS.

MATERIALS AND METHODS

A qualitative study with in-depth semi-structured interviews, assisted by the Brief Pain Inventory (BPI)-questionnaire.

RESULTS

Seven themes regarding patients' experiences, subdivided into 15 categories, were identified, including an understudied theme within this field of research, Spiritual Well-Being. "Acceptance" and "coping" emerged as pre-eminent motifs throughout these themes. Moreover, the realization of patients' expectations were variable throughout the presented themes. According to the BPI Questionnaire, four out of 13 patients (31%) had significant pain relief (≥50%). Seven out of 13 (54%) reported a ≥50% increase regarding enjoyment of life.

CONCLUSION

Multiple QoL- and psychosocial-related themes are related to SCS-outcomes. In order to improve SCS-outcomes for both short- and long-term, these themes should be implemented as a multidimensional approach, both prior to implantation as during follow-up.

The Effectiveness of Acceptance and Commitment Therapy on Pain Acceptance and Pain Perception in Patients with Painful Diabetic Neuropathy: A Randomized Controlled Trial

INTRODUCTION

Neuropathic pain is a complex phenomenon in patients with diabetes. These patients have many problems, such as psychological problems, high-level pain perception, and pain acceptance. This study aimed to evaluate the effectiveness of acceptance and commitment therapy on pain acceptance and pain perception in patients with painful diabetic neuropathy.

METHODS

This study was performed according to the clinical trial method. The sample size was 50 participants. In this study, participants were divided into interventional and control groups. According to the diagnosis of neurologists, all participants received conventional medications to manage neuropathic pain. The intervention group received acceptance and commitment therapy for eight sessions. The results in the three phases of pre-test, post-test, and follow-up were evaluated. After completing the study, to comply with ethical standards, the control group received psycho-education. The tools used were the McGill Pain Questionnaire (MPQ) and the Chronic Pain Acceptance Questionnaire (CPAQ). Statistical analysis includes mean, standard deviation, and repeated-measures (ANOVA) conducted by SPSS software version 22.

RESULTS

The results demonstrated that in the post-test and follow-up phases, acceptance and commitment therapy could improve pain acceptance and reduce pain perception in the intervention group compared to the control group (P < 0.01).

CONCLUSION

The results indicated that acceptance and commitment therapy could be used as a psychological intervention besides pharmacotherapy to improve pain acceptance and reduce pain perception in patients with painful diabetic neuropathy.

CLINICAL TRAIL REGISTRATION

This study was registered at the Iranian Registry of Clinical Trials (IRCT20180205038630N4).

Low-intensity extracorporeal shock wave therapy for III B chronic pelvic pain syndrome

Background

To analyze the efficiency of low-intensity shock wave therapy (LI-ESWT) for patients with III B chronic pelvic pain syndrome (CPPS).

Methods

The study included an uncontrolled population of 32 patients who had suffered with CPPS for ≥3 months. LI-ESWT was performed without anesthesia via a perineal approach. The operation was carried out in four weeks by administering 12,000 shock waves. Using the Visual Analog Scale (VAS) and NIH-developed Chronic Prostatitis Symptom Index (NIH-CPSI), subsequent tests were performed at 1, 2, 4, and 12 weeks after the first LI-ESWT session.

Results

All patients who received the four week course as treatment responded actively on the pain VAS and the NIH-CPSI, and both were significantly improved (P<0.05). Compared with the baseline parameters, the NIH-CPSI total score and VAS exhibited substantial improvement at 4 and 12 weeks, where a total improvement at four weeks was reached. It is easy and safe to perform LI-ESWT without anesthesia on an outpatient basis.

Conclusions

LI-ESWT should be regarded as a promising new therapy for CPPS, as it is convenient to perform without any side-effects.

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

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

The Effects of a Pain Psychology and Neuroscience Self-Evaluation Internet Intervention: A Randomized Controlled Trial

OBJECTIVES

Many patients' chronic musculoskeletal pain is strongly influenced by central nervous system processes such as sensitization or amplification. Education about pain neuroscience can change patients' beliefs but has less consistent effects on pain outcomes. Patients may have greater clinical benefits if the educational intervention is personalized, and they evaluate various psychosocial risk factors with respect to their pain. We developed and tested a brief, internet-based Pain Psychology and Neuroscience (PPN) self-evaluation intervention.

MATERIALS AND METHODS

From a patient registry, 104 adults reporting chronic musculoskeletal pain were randomized to the PPN intervention or a matched, active, education control condition. At baseline and 1-month (primary endpoint) and 10-month follow-ups, participants reported pain severity (primary outcome) and multiple secondary outcomes. Primary analyses compared the 2 experimental conditions using analyses of covariances; post hoc exploratory analyses compared the effects of PPN in subgroups of patients who met criteria for fibromyalgia (FM; n=50) or who did not (n=54; primarily spinal pain).

RESULTS

At 1-month follow-up, compared with the control condition, PPN led to significantly lower pain severity (ηp =0.05) and interference (ηp =0.04), greater brain (ηp =0.07) and psychological (ηp =0.07) attributions for pain, and greater readiness for pain self-management (ηp =0.08). Effects on distress, pain catastrophizing, kinesiophobia, and life satisfaction were not significant. Exploratory analyses showed that the PPN intervention was especially beneficial for patients without FM but was of less benefit for those with FM. Most of the effects (except attributions) were lost at 10 months.

DISCUSSION

A brief PPN self-evaluation intervention, presented on-line, can yield short-term improvements in musculoskeletal pain severity and interference, especially for people with spinal/localized pain rather than FM, perhaps because the psychology/neuroscience perspective is more novel for such patients.

Do Clinical Correlates of Knee Osteoarthritis Predict Outcome of Intraarticular Steroid Injections?

OBJECTIVE

To determine whether clinical correlates of knee osteoarthritis (OA) affect the outcome of intraarticular steroid injections (IASI) in symptomatic knee OA.

METHODS

Men and women aged ≥ 40 years with painful knee OA who participated in an open-label trial of IASI completed questionnaires and clinical examination. The Outcome Measures in Rheumatology (OMERACT)-Osteoarthritis Research Society International (OARSI) criteria were used to assess response to therapy in the short term (within 2 weeks). Among those who initially responded, those whose pain had not returned to within 20% of the baseline Knee Injury and Osteoarthritis Outcome Score pain score at 6 months were characterized as longer-term responders. Log-binomial regression was used to examine factors associated with outcome.

RESULTS

One hundred ninety-nine participants were included, of whom 146 (73.4%) were short-term and 40 (20.1%) longer-term responders. Compared to short-term nonresponders, participants with these characteristics were more likely to be short-term responders: medial joint line tenderness [relative risk (RR) 1.42, 95% CI 1.10-1.82], medial and lateral joint line tenderness (RR 1.38, 95% CI 1.03-1.84), patellofemoral tenderness (RR 1.27, 95% CI 1.04-1.55), anserine tenderness (RR 1.27, 95% CI 1.06-1.52), and a belief that treatment would be effective [RR/unit increase (range 0-10) = 1.05 (1.01-1.09)]. Aspiration of joint fluid (RR 0.79, 95% CI 0.66-0.95) and previous ligament/meniscus injury (RR 0.63, 95% CI 0.44-0.91) were associated with a reduced risk of being a short-term responder. Compared to initial nonresponders and those whose pain recurred within 6 months, participants with a higher number of pain sites [RR/unit increase (range 0-10) = 0.83, 95% CI 0.72-0.97], chronic widespread pain (RR 0.32, 95% CI 0.10-0.98), perceived chronicity of disease [RR/unit increase (range 0-10) = 0.86, 95% CI 0.78-0.94], and a higher depression score [RR/unit increase (range 0-21) = 0.89, 95% CI 0.81-0.99] were less likely to be longer-term responders.

CONCLUSION

Among patients with symptomatic knee OA, tenderness around the knee was associated with better short-term outcome of IASI. However, clinical-related factors did not predict longer-term response, while those with chronic widespread pain and depressive symptoms were less likely to obtain longer-term benefits.

A User-Centered Approach to an Evidence-Based Electronic Health Pain Management Intervention for People With Chronic Pain: Design and Development of EPIO

Background

Chronic pain conditions are complicated and challenging to live with. Electronic health (eHealth) interventions show promise in helping people cope with chronic illness, including pain. The success of these interventions depends not only on the technology and intervention content but also on the users’ acceptance and adherence. Involving all stakeholders (eg, patients, spouses, health care providers, designers, software developers, and researchers) and exploring their input and preferences in the design and development process is an important step toward developing meaningful interventions and possibly strengthening treatment outcomes.

Objective

The aim of this study was to design and develop a user-centered, evidence-based eHealth self-management intervention for people with chronic pain.

Methods

The study employed a multidisciplinary and user-centered design approach. Overall, 20 stakeholders from the project team (ie, 7 researchers, 5 editors, 7 software developers, and 1 user representative), together with 33 external stakeholders (ie, 12 health care providers, 1 health care manger, 1 eHealth research psychologist, and 17 patients with chronic pain and 2 of their spouses) participated in a user-centered development process that included workshops, intervention content development, and usability testing. Intervention content was developed and finalized based on existing evidence, stakeholder input, and user testing. Stakeholder input was examined through qualitative analyses with rapid and in-depth analysis approaches.

Results

Analyses from stakeholder input identified themes including a need for reliable, trustworthy, and evidence-based content, personalization, options for feedback, behavioral tracking, and self-assessment/registration as factors to include in the intervention. Evidence-based intervention content development resulted in one face-to-face introduction session and 9 app-based educational and exercise-based modules. Usability testing provided further insight into how to optimize the design of the intervention to the user group, identifying accessibility and a simple design to be essential.

Conclusions

The design and development process of eHealth interventions should strive to combine well-known evidence-based concepts with stakeholder input. This study, designing and developing the pain management intervention EPIO, illustrates how a stakeholder-centered design approach can provide essential input in the development of an eHealth self-management intervention for people with chronic pain.

Trial Registration

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104

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

Introduction

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

Methods

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

Results

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

Conclusions

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

An observational study on risk factors for prolonged opioid prescription after severe trauma

Background and aims:

Trauma is one of the most common causes of morbidity and mortality in people of working age. Following surgery, approximately 10% of patients develop persistent postsurgical pain. Chronic pain is a complex phenomenon that can adversely affect quality of life and is associated with psychiatric conditions such as anxiety and depression. Pharmacological treatment is normally insufficient to fully alleviate chronic pain and improve functional capacity, especially in the long term. The appropriateness of opioid treatment in chronic non-cancer pain has become increasingly examined with high numbers of serious side effects including drug dependency and death. The present study was based on clinical observations suggesting that a problematic opioid use can be initiated during trauma care, which implies the importance of evaluating opioid therapy and its effect on trauma patients. Specific attention is given to patients with known psychiatric conditions which may render them more vulnerable to develop problematic opioid use. The aim of this observational study was to broadly characterize patients referred to a pain specialist after severe trauma regarding their trauma type, psychiatric co-morbidity, and opioid prescription pattern. This was done to tentatively investigate possible risk factors for long-term opioid use following trauma.

Methods:

Trauma patients referred to the Pain Center at Karolinska University Hospital, Sweden (n=29) were recruited for the study over a period of 2 years. Demographic information, trauma-related data as well as psychiatric diagnoses and pharmacological prescriptions were retrieved from the registry SweTrau and electronic medical records.

Results:

Among the 29 participants (age range 21–55 years, median=34; 76% male), 14 (48%) were prescribed opioids at least once during the 6-months period preceding the trauma. For 21 patients (72%) opioids were prescribed 6 months after the trauma. One year after the trauma, 18 patients (62%) still had prescriptions for opioids corresponding to daily use or more, and two other patients used opioids intermittently. Twenty patients (69%) had psychiatric diagnoses before the trauma. According to the medical records, 17 patients (59%) received pharmacological treatment for psychiatric conditions in the six months period preceding the trauma. During the follow-up period, psychiatric pharmacological treatment was prescribed for 27 (93%) of the patients.

Conclusion and implications:

For most of the participants opioids were still being prescribed one year after trauma. The majority presented with psychiatric co-morbidity before trauma and were also prescribed psychiatric medication. Findings support the notion that patients with a complex pain situation in the acute phase following trauma are at risk for prolonged opioid prescription. These results, although tentative, point at psychiatric co-morbidity, opioid use before trauma, high injury severity, extensive surgery and extended hospital stay as risk factors for prolonged opioid prescription after severe trauma. This study is purely observational, with a small sample and non-controlled design. However, these data further emphasize the need to identify patients at risk for developing problematic long-term opioid use following trauma and to ensure appropriate pain treatment.

Effectiveness and reporting standards of psychological interventions for improving short-term and long-term pain outcomes after total knee replacement: a systematic review

OBJECTIVES

To assess the effectiveness and reporting standards of psychological interventions for improving outcomes after total knee replacement (TKR).

DESIGN

Medline, Embase, and PsycINFO were searched from inception to up to 9 May 2019 with no language restrictions applied. Randomised controlled trials (RCTs) assessing the effectiveness of psychological interventions for short-term and long-term postoperative pain after TKR were included. Screening, data extraction, and assessment of methodological quality were performed in duplicate by two reviewers. The primary effectiveness outcome was postoperative pain severity and the primary harm outcome was serious adverse events. Secondary outcomes included function, quality of life, and psychological well-being. Reporting standards were assessed using the Template for Intervention Description and Replication (TIDieR) checklist for intervention reporting.

RESULTS

12 RCTs were included, with a total of 1299 participants. Psychological interventions comprised music therapy (five studies), guided imagery and music (one study), hypnosis (one study), progressive muscle relaxation with biofeedback (one study), pain coping skills programme (one study), cognitive-behavioural therapy (two studies), and a postoperative management programme (one study). Due to the high heterogeneity of interventions and poor reporting of harms data, it was not possible to make any definitive statements about the overall effectiveness or safety of psychology interventions for pain outcomes after TKR.

CONCLUSION

Further evidence about the effectiveness of psychological interventions for improving pain outcomes after TKR is needed. The reporting of harm outcomes and intervention fidelity is currently poor and could be improved. Future work exploring the impact of intervention timing on effectiveness and whether different psychological approaches are needed to address acute postoperative pain and chronic postoperative pain would be of benefit.

PROSPERO REGISTRATION NUMBER

CRD42018095100.

Beyond Adaptive Mental Functioning With Pain as the Absence of Psychopathology: Prevalence and Correlates of Flourishing in Two Chronic Pain Samples

Chronic pain outcomes are traditionally defined in terms of disability and illness. A definition of adaptive functioning in the context of chronic pain beyond the mere absence of negative outcomes, is the ability to flourish (i.e., experience emotional, psychological and social well-being; Keyes, 2002). We explored in two chronic pain samples the prevalence and sociodemographic, physical and psychological correlates of flourishing, and complemented this exploration with a similar examination of (being at risk for) psychopathology to help contextualize findings. Sample 1 (n = 1498) was a nationally representative sample. Subgroups included people with regular joint pain (1), regular joint pain and rheumatoid arthritis (2) and without chronic pain (3). Using chi-square tests we calculated the prevalence of both mental health outcomes and examined if people with or without chronic pain were more/less likely to flourish/at risk for psychopathology. Sample 2 (n = 238) concerned baseline data of a Randomized Controlled Trial on the effectiveness of Acceptance and Commitment Therapy for chronic pain (Trompetter et al., 2015b). We performed logistic regression analysis to identify flourishers/those at risk for depression. The Mental Health Continuum-Short Form was used to measure flourishing. The prevalence of flourishing was 34% (recurrent joint pain) and 38% (recurrent joint pain and arthritis) in sample 1, and 23% in sample 2. Compared to those without chronic pain, people with chronic pain were as likely to flourish, but more likely to be at risk for psychopathology. In sample 2, both flourishing and being at risk for depression were related foremost to psychological correlates. While engaged living was the most important correlate of flourishing, pain catastrophizing and psychological inflexibility were most important correlates of being at risk for depression. In conclusion, people with chronic pain are able to flourish. Findings suggest that positive and negative chronic pain outcomes function on two different continua, with potentially unique protective and risk factors. The Psychological Flexibility model provides pathways to explain both poor and optimal functioning in the presence of chronic pain. A better understanding of people with chronic pain who are able to flourish can be a fruitful endeavor to improve chronic pain models and interventions.

No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain

OBJECTIVE

To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain.

BURDEN OF SUFFERING

CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates.

OUTCOMES

Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state.

EVIDENCE

Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations.

VALUES

The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1).

RECOMMENDATIONS

The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

Pain interference type and level guide the assessment process in chronic pain: Categorizing pain patients entering tertiary pain treatment with the Brief Pain Inventory

Chronic pain patients enter treatment with different problem profiles making careful assessment a necessity for more individualized treatment plans. In this cross-sectional study we assigned 320 patients entering tertiary multidisciplinary pain treatment into four categories based on whether they scored low or high on the activity and the affective pain interference dimensions of the Brief Pain Inventory (BPI). To determine whether this categorization system delineates issues that should be assessed further, the categories were compared with ANOVA and MANOVA analyses on three domains: variables affecting physical well-being (body mass index, exercise, substance use), psychological resources (mood), and pain-specific psychological factors (pain anxiety, pain acceptance). The results indicated that subjects who scored low on both interference dimensions compared similarly in weight: mean Body Mass Index (BMI) 27.0 (SD 6.0) kg/m², and exercise: mean of 2.4 (SD 1.7) exercising sessions over 20 minutes per week, to the general population, had no depressive symptoms on average: mean Beck Depression Index II (BDI-II) score 11.7 (SD 7.5), and had the most favorable psychological reactions to pain relative to the other categories: mean total Pain Anxiety Symptoms Scale-20 (PASS-20) score 36.4 (SD 17.9). In contrast, when interference was high on activity, more physical well-being problems were evident e.g. weight: mean BMI 31.0 (SD 7.3) kg/m², diminished exercise: mean of 1.5 (SD 1.6) exercising sessions per week, and avoidance behavior: mean PASS-20 Escape/Avoidance subscale 3.7 (95% CI: 1.7 to 5.8) scores higher in comparison to activity interference remaining low. With high affective interference, more depressive symptoms: mean BDI-II score 17.7 (SD 7.3), and more cognitive pain anxiety: mean PASS-20 Cognitive Anxiety subscale 2.8 (95% CI 0.7 to 4.8) scores higher in comparison to affective interference remaining low, emerged. Having high interference on both dimensions indicated accumulated risks for reduced physical well-being: mean BMI 29.9 (SD 6.1) kg/m², mean of 1.2 (SD 1.7) exercising sessions per week, mood problems: mean BDI-II 20.3 (SD 10.6), and negative psychological reactions to pain: mean total PASS-20 score 53.2 (18.4). The results suggest that low interference on both dimensions may allow assessment with only physician consultations, while high interference on either dimension may call attention to distinct issues to be addressed with the help of a physiotherapist or a psychologist, whereas high interference on both dimensions highlights the need for a full multidisciplinary assessment.