Do Pain-related Beliefs Influence Adherence to Multidisciplinary Rehabilitation?: A Systematic Review

Endorsing a Biopsychosocial Perspective of Pain in Individuals With Chronic Pain: Development and Validation of a Scale

OBJECTIVES

Patients' beliefs about pain play an important role in their readiness to engage with chronic pain self-management. The central aim of this study was to validate a self-report instrument to assess a specific set of pain beliefs, patients' endorsement of a biopsychosocial model of chronic pain Patients' Endorsement of a Biopsychosocial Model of Chronic Pain Scale (PEB).

METHODS

Interdisciplinary experts in the field of pain were involved in creating an instrument, the PEB Scale, to operationalize patients' endorsement of a biopsychosocial pain model. A sample of 199 patients with chronic pain was recruited to evaluate the factorial structure (principal axis factoring), the internal consistency (Cronbach alpha), the convergent and discriminant validity (correlational analyses), incremental validity (multiple, hierarchical regression analyses), and construct validity (differential population analysis) of the instrument.

RESULTS

The factor analysis resulted in a unidimensional, 11-item instrument that explained 51.2% of the total variance. Cronbach alpha (=0.92) indicated high internal consistency of the created set of pain-related beliefs. Regression analyses demonstrated that PEB is a strong predictor of patients' engagement with pain self-management ( P < 0.001) after controlling for demographic variables, anxiety, depression, and other pain-related beliefs.

DISCUSSION

Our results show that the PEB Scale is a highly reliable self-report instrument that has the potential to predict patients' readiness to adopt pain self-management. Future research should focus on revalidating the scale to operationalize PEB. Moreover, the PEB Scale should be implemented in longitudinal study designs to investigate its ability to predict the transition from acute to chronic pain and patients' long-term pain management.

Guideline No. 445: Management of Chronic Pelvic Pain

OBJECTIVE

To provide evidence-based recommendations for the management of chronic pelvic pain in females.

TARGET POPULATION

This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain.

BENEFITS, HARMS, AND COSTS

The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability.

EVIDENCE

Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals.

TWEETABLE ABSTRACT

Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments.

SUMMARY STATEMENTS

RECOMMENDATIONS.

The influence of the significant other on treatment adherence in chronic pain management: a qualitative analysis

Objectives. Adherence to treatment recommendations is critical for optimising quality of life for individuals with chronic pain, however adherence rates are low. This study explores the role that significant others are perceived to play in supporting or impeding treatment adherence, as well as examining patient views of the impact of their adherence regimes on their significant others.Design. 25 treatment seeking adults with chronic pain, who were currently living with a romantic partner or adult family member, took part in individual semi-structured interviews.Main outcome measures Interviews were transcribed verbatim and analysed using thematic analysis.Results. Three treatment adherence support themes emerged: social support (emotional, instrumental), positive social control, and supporting autonomy. Participants did not perceive significant others as having any negative influence on their adherence. By contrast, patients perceived that their adherence behaviors had both positive and negative effects on their significant others.Conclusions. These data present an encouraging perspective on the interpersonal context of coping with chronic pain. Significant others facilitated adherence in a range of ways. Future research identifying how best to integrate significant other support into patient self-management programs is needed, in order to lift the poor treatment adherence rates that are noted in the literature.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Virtual embodiment for improving range of motion in patients with movement-related shoulder pain: an experimental study

BACKGROUND

Recent evidence supports the use of immersive virtual reality (VR) as a means of delivering bodily illusions that may have therapeutic potential for the treatment of musculoskeletal conditions. We wanted to investigate whether a single session of an embodiment-based immersive VR training program influences pain-free range of motion in patients with shoulder pain.

METHODS

We designed a rehabilitation program based on developing ownership over a virtual body and then "exercising" the upper limb in immersive VR, while the real arm remains static. We then carried out a single-arm pre-post experiment in which 21 patients with movement-related musculoskeletal shoulder pain were exposed to the 15-min VR program and measured their active pain-free range of motion immediately before and afterwards.

RESULTS

We found that shoulder abduction and hand-behind-back movements, but not shoulder flexion, were significantly and clinically improved post-intervention and that the level of improvement correlated with the level of embodiment. Following this one session, at 1-week follow-up the improvements were not maintained.

CONCLUSIONS

Virtual embodiment may be a useful therapeutic tool to help improve range of motion in patients with movement-related shoulder pain in the short term, which in turn could expedite rehabilitation and recovery in these conditions.

Spanish version of the pain beliefs questionnaire: Translation, cross-cultural adaptation, validation, and psychometric properties in a working population

BACKGROUND

Chronic musculoskeletal pain is a major health problem and a common cause of disability in the workplace. Beliefs related to musculoskeletal pain may influence its onset and perpetuation. Consequently, tools designed to identify potentially harmful beliefs are needed. However, the Pain Beliefs Questionnaire (PBQ) is not available for individuals speaking European-Spanish.

OBJECTIVES

To translate and culturally adapt the original English version of the PBQ into European-Spanish and evaluate its psychometric properties among Spanish workers with and without chronic musculoskeletal pain.

DESIGN

Study on measurement properties.

METHODS

A translation and cultural adaptation process was based on a forward-backward translation process. One hundred fifty-one active workers were included. Participants completed the PBQ (composed of the organic and psychological subscales), the Pain Catastrophizing Scale (PCS), and the Hospital Anxiety and Depression Scale (HADS). Finally, thirty participants completed the PBQ again two weeks later for test-retest reliability.

RESULTS

The PBQ showed adequate internal consistency (Cronbach's alpha: 0.72-0.73), good item response stability (weighted Kappa: 0.65-0.90), and reliability (Intraclass Correlation Coefficient: 0.72-0.80). A positive correlation was found between the PCS and the organic subscale (r = 0.403). However, no significant correlations were found between the HADS and the PBQ subscales. Workers with chronic musculoskeletal pain showed greater scores in the organic subscale and lower scores in the psychological subscale than workers without pain.

CONCLUSION

The Spanish version of the PBQ was linguistically accurate and acceptable for use by workers with and without musculoskeletal pain.

Development and Validation of the Scale for Pain Self-Efficacy (SPaSE) in German and English Languages for Children and Adolescents

No validated measure for pain self-efficacy in children and adolescents is currently available in the German language, and existing English versions have limitations. This study used a thorough development process to create the Scale for Pain Self-Efficacy (SPaSE) in both German and English languages. Scale development was based on self-efficacy theory, adapting items from existing self-efficacy measures, and review of patients' perspectives. The final version of the 11-item SPaSE was created with expert discussions and testing of content validity, comprehensibility, and construct validity. The validation process consisted of exploratory factor analysis, testing of item characteristics, internal consistency, and sensitivity to change in 2 German samples of children and adolescents with chronic pain (study 1: outpatient sample N = 150, inpatient sample N = 31). Cross-validation in a U.S. sample (study 2: N = 98) confirmed the 1-factor structure, the sound psychometric properties and reliability of the SPaSE. Sum scores of the SPaSE were negatively correlated with pain-related disability, pain intensity, passive pain coping strategies, and emotional distress, in line with previous research. The valid and reliable SPaSE can be used in clinical practice to monitor pain treatment progress, advances the field of pain self-efficacy research in Germany, and opens the door to comparative research in German and English samples. PERSPECTIVE: This article presents psychometric properties of a newly developed measure of pain self-efficacy in children and adolescents that is available in both German and English language. This measure could be used in both research and clinical practice to measure treatment progress and outcome.

The relationship between clinical examination measures and ultrasound measures of fascia thickness surrounding trunk muscles or lumbar multifidus fatty infiltrations: An exploratory study

Patients with chronic low back pain (CLBP) exhibit remodelling of the lumbar soft tissues such as muscle fatty infiltrations (MFI) and fibrosis of the lumbar multifidus (LuM) muscles, thickness changes of the thoracolumbar fascia (TLF) and perimuscular connective tissues (PMCT) surrounding the abdominal lateral wall muscles. Rehabilitative ultrasound imaging (RUSI) parameters such as thickness and echogenicity are sensitive to this remodelling. This experimental laboratory study aimed to explore whether these RUSI parameters (LuM echogenicity and fascia thicknesses), hereafter called dependent variables (DV) were linked to independent variables (IV) such as (1) other RUSI parameters (trunk muscle thickness and activation) and (2) physical and psychological measures. RUSI measures, as well as a clinical examination comprising physical tests and psychological questionnaires, were collected from 70 participants with LBP. The following RUSI dependent variables (RUSI-DV), measures of passive tissues were performed bilaterally: (1) LuM echogenicity (MFI/fibrosis) at three vertebral levels (L3/L4, L4/L5 and L5/S1); (2) TLF posterior layer thickness, and (3) PMCT thickness of the fasciae between subcutaneous tissue thickness (STT) and external oblique (PMCT_STT/EO ), between external and internal oblique (PMCT_EO/IO ), between IO and transversus abdominis (PMCT_IO/TrA ) and between TrA and intra-abdominal content (PMCT_TrA/IA ). RUSI measures of trunk muscle's function (thickness and activation), also called measures of active muscle tissues, were considered as independent variables (RUSI-IV), along with physical tests related to lumbar stability (n = 6), motor control deficits (n = 7), trunk muscle endurance (n = 4), physical performance (n = 4), lumbar posture (n = 2), and range of motion (ROM) tests (n = 6). Psychosocial measures included pain catastrophizing, fear-avoidance beliefs, psychological distress, illness perceptions and concepts related to adherence to a home-based exercise programme (physical activity level, self-efficacy, social support, outcome expectations). Six multivariate regression models (forward stepwise selection) were generated, using RUSI-DV measures as dependent variables and RUSI-IV/physical/psychosocial measures as independent variables (predictors). The six multivariate models included three to five predictors, explaining 63% of total LuM echogenicity variance, between 41% and 46% of trunk superficial fasciae variance (TLF, PMCT_STT/EO ) and between 28% and 37% of deeper abdominal wall fasciae variance (PMCT_EO/IO , PMCT_IO/TrA and PMCT_TrA/IA ). These variables were from RUSI-IV (LuM thickness at rest, activation of IO and TrA), body composition (percent fat) and clinical physical examination (lumbar and pelvis flexion ROM, aberrant movements, passive and active straight-leg raise, loaded-reach test) from the biological domain, as well as from the lifestyle (physical activity level during sports), psychological (psychological distress-cognitive subscale, fear-avoidance beliefs during physical activities, self-efficacy to exercise) and social (family support to exercise) domains. Biological, psychological, social and lifestyle factors each accounted for substantial variance in RUSI-passive parameters. These findings are in keeping with a conceptual link between tissue remodelling and factors such as local and systemic inflammation. Possible explanations are discussed, in keeping with the hypothesis-generating nature of this study (exploratory). However, to impact clinical practice, further research is needed to determine if the most plausible predictors of trunk fasciae thickness and LuM fatty infiltrations have an effect on these parameters.

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.

Predictors of Dropout in a Digital Intervention for the Prevention and Treatment of Depression in Patients With Chronic Back Pain: Secondary Analysis of Two Randomized Controlled Trials

Background

Depression is a common comorbid condition in individuals with chronic back pain (CBP), leading to poorer treatment outcomes and increased medical complications. Digital interventions have demonstrated efficacy in the prevention and treatment of depression; however, high dropout rates are a major challenge, particularly in clinical settings.

Objective

This study aims to identify the predictors of dropout in a digital intervention for the treatment and prevention of depression in patients with comorbid CBP. We assessed which participant characteristics may be associated with dropout and whether intervention usage data could help improve the identification of individuals at risk of dropout early on in treatment.

Methods

Data were collected from 2 large-scale randomized controlled trials in which 253 patients with a diagnosis of CBP and major depressive disorder or subclinical depressive symptoms received a digital intervention for depression. In the first analysis, participants’ baseline characteristics were examined as potential predictors of dropout. In the second analysis, we assessed the extent to which dropout could be predicted from a combination of participants’ baseline characteristics and intervention usage variables following the completion of the first module. Dropout was defined as completing <6 modules. Analyses were conducted using logistic regression.

Results

From participants’ baseline characteristics, lower level of education (odds ratio [OR] 3.33, 95% CI 1.51-7.32) and both lower and higher age (a quadratic effect; age: OR 0.62, 95% CI 0.47-0.82, and age²: OR 1.55, 95% CI 1.18-2.04) were significantly associated with a higher risk of dropout. In the analysis that aimed to predict dropout following completion of the first module, lower and higher age (age: OR 0.60, 95% CI 0.42-0.85; age²: OR 1.59, 95% CI 1.13-2.23), medium versus high social support (OR 3.03, 95% CI 1.25-7.33), and a higher number of days to module completion (OR 1.05, 95% CI 1.02-1.08) predicted a higher risk of dropout, whereas a self-reported negative event in the previous week was associated with a lower risk of dropout (OR 0.24, 95% CI 0.08-0.69). A model that combined baseline characteristics and intervention usage data generated the most accurate predictions (area under the receiver operating curve [AUC]=0.72) and was significantly more accurate than models based on baseline characteristics only (AUC=0.70) or intervention usage data only (AUC=0.61). We found no significant influence of pain, disability, or depression severity on dropout.

Conclusions

Dropout can be predicted by participant baseline variables, and the inclusion of intervention usage variables may improve the prediction of dropout early on in treatment. Being able to identify individuals at high risk of dropout from digital health interventions could provide intervention developers and supporting clinicians with the ability to intervene early and prevent dropout from occurring.

Improvement in Disability Mediates the Effect of Self-Efficacy on Pain Relief in Chronic Low Back Pain Patients with Exercise Therapy

Background. The biopsychosocial mechanism by which exercise leads to improvement in chronic low back pain (CLBP) remains unstudied. This prospective cohort study was performed to examine the effectiveness of exercise on pain, disability, and psychological status for CLBP. We also tested path analytic models in which changes in these variables were included. Methods. CLBP patients who visited the Interdisciplinary Pain Center of Keio University Hospital from July 2018 to April 2020 were included. The propensity score matching was performed between patients who underwent exercise (the exercise group) and those who did not (the control group). At the first visit and at the 3-month follow-up, pain (Numerical Rating Scale (NRS)), disability (Pain Disability Assessment Scale (PDAS)), and psychological status (Pain Self-Efficacy Questionnaire (PSEQ), and Pain Catastrophizing Scale (PCS)) were assessed. Changes in pain and disability at the follow-up were compared between the groups. The relationships between changes in pain, disability, and psychological variables were examined using Pearson’s correlation and mediation analysis. Results. A significantly larger decrease in the PDAS was observed in the exercise group (N = 49) than in the control (N = 49) ( $p<0.05$ ). Increased PSEQ scores were significantly correlated with decreased NRS scores in both groups. In the exercise group, decreased PDAS fully mediated the relationship between increased PSEQ and decreased NRS ( $P<0.05$ ). Conclusion. Exercise improved disability, and the improved disability by exercise mediated the effect of increased self-efficacy on pain relief in CLBP patients.

Individuals' beliefs about the biopsychosocial factors that contribute to their chronic musculoskeletal pain: protocol for a qualitative study in the UK

INTRODUCTION

Chronic musculoskeletal pain (CMP) is described as pain that persists for longer than 3 months. At present, no research is available that understands why CMP develops and continues from the perspective of the individual. Research is needed to establish if there are any consistent biopsychosocial factors perceived as contributing to CMP and what informs such beliefs. Understanding individual beliefs will inform more effective communication between clinicians and patients about their CMP, as well as informing future research into the epidemiology of CMP. Interpretative phenomenological analysis will be used as a methodological framework as it explores how individuals make sense of their world through personal experiences and perceptions while preserving individual nuance. The aim of this study is to understand individuals' beliefs and perceptions about the biological, psychological and social factors, which contribute to the development and maintenance of their CMP.

METHODS AND ANALYSIS

A qualitative study informed by the Consolidated Criteria for Reporting Qualitative Research using interpretative phenomenological analysis and semistructured interviews. A maximum variation purposive sample of 6-12 adults with CMP will be recruited from the general public in the UK. One semistructured interview will be conducted with each participant via an online video platform with interviews transcribed verbatim. The interview schedule (codesigned with expert patients and informed by existing evidence) identifies three domains of important questions; (1) patient beliefs on why they developed and continue to experience CMP; (2) the relationship between their biopsychosocial experiences and CMP; and (3) the origin of their beliefs. Strategies such as 'member checking' will be employed to ensure trustworthiness.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Research Ethics Office at the University of Birmingham (reference ERN_21-0813). Informed consent will be obtained from all participants. The study findings will be submitted for publication in a peer-reviewed journal and for presentation at conferences.

Depression and work productivity: insights from a longitudinal cohort study on digital care programs for Musculoskeletal conditions

BACKGROUND

Comorbidity between musculoskeletal (MSK) pain and depression is highly common and associated with greater symptom burden and greater loss of work productivity. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement.

OBJECTIVE

Assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels.

METHODS

The present study is an ad-hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP. Three subgroups with different baseline depression severity levels were created based on the Patient Health Questionnaire (PHQ-9): cluster 1 (<5: minimal depression); cluster 2 (5-10: mild depression) and cluster 3 (≥10: moderate depression). The mean change between baseline and end-of-program (8-12 weeks) on depression, anxiety, fear-avoidance beliefs, work productivity and activity impairment and adherence was assessed across subgroups. Outcome changes were analyzed by latent growth curve analysis.

RESULTS

From a total of 7785 eligible participants, 6137 (78.8%) were included in Cluster 1, 1158 (14.9%) in cluster 2 and 490 (6.3%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (5 and 10 for clusters 2 and 3, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from -16.82, 95%CI -20.32 to -13.42 in cluster 1 to -20.10, 95%CI -32.64 to -7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74).

CONCLUSIONS

A multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain.

CLINICALTRIAL

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

Activity-induced pain as a predictor of physical activity behavior among individuals with chronic pain: the role of physical activity enjoyment

Nearly 70% of adults with chronic pain experience increased pain during activity, and this may reduce enjoyment of physical activity (PA), and subsequent PA intention/behavior. The goal of this study was to examine increased pain during activity as a predictor of PA, via its effects on PA enjoyment. Participants included 178 overweight/obese midlife adults with chronic pain who completed an online prospective survey. Results indicated that greater increases in pain during activity were associated with less PA enjoyment, and, in turn, lower intention to exercise over the next week (p < 0.05). Activity-induced pain also predicted lower total volume of PA at 1-week follow-up, and this relationship was mediated by PA enjoyment (p < 0.05). These findings have the potential to inform the refinement of PA promotion interventions for individuals with chronic pain.

Coping and Beliefs as Predictors of Functioning and Psychological Adjustment in Fibromyalgia Subgroups

Objectives

Research has pointed to two profiles of persons with fibromyalgia according to differences in functionality, thus distinguishing between functional and dysfunctional patients. The role of psychological factors underlying such clusters is unclear. This study aims to explore the contribution of pain beliefs and coping on fibromyalgia clustering.

Methods

A cluster analysis was performed to classify 238 women with fibromyalgia using the Fibromyalgia Impact Questionnaire and the Beck Depression Inventory as clustering variables. Cluster differences in physical functioning, depression, pain beliefs, coping, and age were then calculated (Student's t-test). Finally, a binary logistic regression was conducted to study the unique contribution of age, beliefs, and coping on cluster classification.

Results

Two clusters were revealed. Cluster 1 had a poor adaptation to fibromyalgia regarding physical functioning and depression. They generally embraced less adaptive beliefs (i.e., disability, harm, emotion, and requests) and coping strategies (i.e., guarding, resting, and asking for assistance). Cluster 2 showed a better adaptation to fibromyalgia and adopted more favorable beliefs (i.e., control) and coping strategies (i.e., exercise and task persistence). Cluster differences in age were significant but small. The backward binary logistic regression suggested a final model with six predictors (guarding, task persistence, harm, emotion, solicitude, and age) that explained 31% of the variance of group membership. Discussion. These results suggest that only a subset of psychological variables uniquely and independently contribute to functional/dysfunctional group membership. The results support the need to address psychological components in the management of fibromyalgia and point to a subset of preferred target beliefs and coping strategies.

Cross-cultural adaptation, reliability and validity of the Marathi versions of the Back Beliefs Questionnaire and Pain Self-Efficacy Questionnaire in people living with chronic low back pain

PURPOSE

To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) and Pain Self-Efficacy Questionnaire (PSEQ) into Marathi, and to evaluate their clinimetric properties in a native Marathi speaking population with chronic low back pain.

MATERIAL AND METHODS

The BBQ and PSEQ were translated into Marathi using international published guidelines. Fifty native Marathi speakers were recruited. Reliability (n = 43) was evaluated in terms of internal consistency (Cronbach α) and test-retest reliability [intra class correlation coefficient, ICC (2, 1)] and 95% confidence interval (CI). Convergent validity (n = 50) was assessed by correlating the Marathi versions of BBQ and PSEQ with the Marathi version of Roland Morris Disability Questionnaire (RMDQ).

RESULTS

Internal consistency of BBQ (Cronbach α  =  0.67) was good and that for PSEQ (Cronbach α  =  0.93) was high. Test-retest reliability for BBQ (ICC =  0.80; 95% CI: 0.66 to 0.89) was good and PSEQ (ICC = 0.85; 95% CI: 0.74 to 0.92) was excellent. A significant, low negative correlation was found between RMDQ and BBQ scores (r = -0.298; p = 0.036) and PSEQ (r = -0.28; p = 0.049).

CONCLUSIONS

The BBQ and PSEQ were successfully cross-culturally adapted into Marathi. Clinimetric evaluation of these questionnaires in a sample of native Marathi speaking populations with chronic low back pain demonstrated good acceptability, acceptable internal consistency, and high test-retest reliability.Implications for rehabilitationThe Back Beliefs Questionnaire (BBQ) and Pain Self Efficacy Questionnaire (PSEQ) were successfully cross-culturally adapted into Marathi.The Marathi versions of BBQ and PSEQ have good acceptability, acceptable internal consistency, and high test-retest reliability.They can be used by clinicians and researchers to evaluate beliefs about back pain and pain self-efficacy in Marathi speaking patients with chronic low back pain.

SOME ASPECTS OF THE POTENTIAL ADHERENCE TO REHABILITATION OF PATIENTS WITH MUSCULOSKELETAL INJURIES

OBJECTIVE

The aim: To investigate and analyse certain aspects of potential adherence to rehabilitation treatment of patients with musculoskeletal injuries.

PATIENTS AND METHODS

Materials and methods: The study was conducted among 108 patients with musculoskeletal injuries. A questionnaire, containing 25 questions, was used to determine the importance for patients of rehabilitation treatment and their readiness to perform its measures.

RESULTS

Results: It was found that for 98.0 ± 2.6% of surveyed patients with injuries it is important not to experience limitations in the future functioning of their bodies. 97.2 ± 3.1% of the surveyed patients with injuries indicated their readiness to do exercises prescribed by a rehabilitation specialist at home, and 87.0 ± 6.3% were ready to perform physical exercises even in case of unpleasant sensations or discomfort. It was determined that 67.6 ± 8.8% of the surveyed patients with injuries are ready to attend rehabilitation classes with specialists, 69.5 ± 8.7% are ready to record their own achievements at home and 73.1 ± 8.4% of the patients consent to maintain regular contact with rehabilitation specialists via the Internet.

CONCLUSION

Conclusions: Patients with musculoskeletal injuries have a high level of understanding of the importance of rehabilitation. The vast majority of them are ready to perform most of the components of rehabilitation, but without significant changes in normal life and with a predominant stay at home. All this requires the development of organizational measures to form the adherence to particular components of rehabilitation.

Power over pain - An interprofessional approach to chronic pain: Program feedback from a medically underserved community

INTRODUCTION

The management of chronic pain is challenging. Biopsychosocial models recommend interprofessional approaches to treatment, but there is sparse information about participants' experiences of these programs, especially in medically underserved populations coping with the intersectionality of racial bias, low socioeconomic status, and psychosocial stressors. This study explored the perspectives and experiences of black participants with low socioeconomic status and concomitant psychosocial stressors in an outpatient interprofessional pain management program, Power over Pain. The program incorporates cognitive-behavioural techniques, creative arts therapies, pain education, and psychoeducation about stress management, self-care, exercise, and medication.

METHOD

This study employed thematic analysis as the qualitative research method. We conducted semi-structured interviews with nine program participants. Interview questions focused on the impact of the program on participants' overall health and wellbeing and ability to manage chronic pain.

RESULTS

Thematic analysis revealed the following treatment benefits as perceived by the participants: (a) moving from feeling stuck to feeling empowered, (b) enhanced understanding of chronic pain resulting in cognitive reframing and debunking certain myths and stigmas, (c) learning new pain management strategies, and (d) social support.

CONCLUSION

The findings suggest that the Power over Pain program may be an effective way to improve self-management and empower medically underserved people who have chronic pain.

Association of preoperative pain beliefs with postoperative pain levels in abdominal surgery patients

AIMS AND OBJECTIVES

This study aimed to analyse the association of preoperative pain beliefs with postoperative pain levels in abdominal surgery patients.

BACKGROUND

Postoperative pain is related to not only clinical and demographic characteristics but also pain beliefs. The perception, intensity and expression of pain as a subjective experience varies among individuals and cultures. Personal beliefs about pain play an important role in pain experiences and responses.

DESIGN

This cross-sectional study consisted of 126 abdominal surgery patients admitted to the General Surgery and Gynecological Surgery Clinics between September 2018-January 2019. The STROBE (Strengthening The Reporting of Observational Studies in Epidemiology) checklist was used as a guideline for this study.

METHODS

Data were collected through descriptive information forms, pain characteristics questionnaires, Visual Analogue Scales and pain beliefs questionnaires. One-way variance analysis and Pearson's correlation and t tests were used for data analysis.

RESULTS

The mean age of the participants was 48.63 ± 14.27 years. A total of 37.3% of the participants experienced moderate pain and 35.7% experienced severe pain at the 8th postoperative hour. Pain intensity significantly decreased at 16, 24 and 32 h postoperatively. In the predischarge interviews, 92.1% of the patients expressed limitations in physical activities due to pain. There was a relationship between 8-16 h postoperatively and sex and pain expectancy. Mean scores obtained from the organic and psychological beliefs subscales of the Pain Belief Questionnaire were 3.12 ± 0.79, and 2.37 ± 1.11, respectively. The psychological beliefs score was negatively associated with the level of education, and the organic beliefs score was higher for those participants who had undergone gynaecological surgery. There was a weak and positive correlation between the organic beliefs and psychological beliefs subscales of the Pain Beliefs Questionnaire.

CONCLUSION

Patients had moderate to severe postoperative pain, and sex and pain expectations affected the experienced level of pain. Most participants believed that the pain was organic in origin. The level of education exerted a significant impact on pain beliefs.

RELEVANCE TO CLINICAL PRACTICE

Characteristics and perception of pain and pain beliefs are important factors that should be determined to personalise pain relief care and maintain effective pain management.

OnTARi: an ontology for factors influencing therapy adherence to rehabilitation

BACKGROUND

Adherence and motivation are key factors for successful treatment of patients with chronic diseases, especially in long-term care processes like rehabilitation. However, only a few patients achieve good treatment adherence. The causes are manifold. Adherence-influencing factors vary depending on indications, therapies, and individuals. Positive and negative effects are rarely confirmed or even contradictory. An ontology seems to be convenient to represent existing knowledge in this domain and to make it available for information retrieval.

METHODS

First, a manual data extraction of current knowledge in the domain of treatment adherence in rehabilitation was conducted. Data was retrieved from various sources, including basic literature, scientific publications, and health behavior models. Second, all adherence and motivation factors identified were formalized according to the ontology development methodology METHONTOLOGY. This comprises the specification, conceptualization, formalization, and implementation of the ontology "Ontology for factors influencing therapy adherence to rehabilitation" (OnTARi) in Protégé. A taxonomy-oriented evaluation was conducted by two domain experts.

RESULTS

OnTARi includes 281 classes implemented in ontology web language, ten object properties, 22 data properties, 1440 logical axioms, 244 individuals, and 1023 annotations. Six higher-level classes are differentiated: (1) Adherence, (2) AdherenceFactors, (3) AdherenceFactorCategory, (4) Rehabilitation, (5) RehabilitationForm, and (6) RehabilitationType. By means of the class AdherenceFactors 227 adherence factors, thereof 49 hard factors, are represented. Each factor involves a proper description, synonyms, possibly existing acronyms, and a German translation. OnTARi illustrates links between adherence factors through 160 influences-relations. Description logic queries implemented in Protégé allow multiple targeted requests, e.g., for the extraction of adherence factors in a specific rehabilitation area.

CONCLUSIONS

With OnTARi, a generic reference model was built to represent potential adherence and motivation factors and their interrelations in rehabilitation of patients with chronic diseases. In terms of information retrieval, this formalization can serve as a basis for implementation and adaptation of conventional rehabilitative measures, taking into account (patient-specific) adherence factors. OnTARi also enables the development of medical assistance systems to increase motivation and adherence in rehabilitation processes.

The Prevalence and Potential Role of Pain Beliefs When Managing Later-Life Pain

OBJECTIVES

In this study of 154 community-dwelling older adults with chronic noncancer pain, we sought to assess participants' beliefs about pain as well as pain management treatments and to determine the influence of those beliefs on participants' willingness to undertake 3 physician-recommended pain treatments, that is, a pharmacologic, physical, and psychological therapy.

MATERIALS AND METHODS

A 16-item questionnaire was employed to ascertain participants' pain beliefs, divided into 4 subscales representing: (1) negative beliefs about pharmacological treatments, (2) positive beliefs about physical treatment approaches, for example, exercise, (3) positive beliefs about psychological treatments, and (4) fatalistic beliefs about pain. Participants were asked to rate their willingness to undertake a pharmacologic, physical, or psychological therapy if their physician recommended that they do so. Agreement with each belief was measured, and we examined willingness to undertake each treatment as a function of pain belief subscale scores after controlling for relevant covariates.

RESULTS

Positive beliefs about physical treatments (eg, benefits of exercise) were the most strongly endorsed items on the pain beliefs questionnaire. All 3 treatment-focused pain beliefs subscales were significantly associated with willingness to undertake that form of treatment (eg, negative beliefs about pain medication use were associated with decreased willingness to take pain medication). Fatalistic attitudes were significantly associated with a decreased willingness to undertake physical treatments.

DISCUSSION

These results support the notion that patients' beliefs about pain and pain treatments can have important effects on treatment engagement and, if assessed, can help guide clinical management of chronic pain in older adults.

Chronic Pain and Pain Belief in Active Military Personnel: a Cross-sectional Study

Background

Chronic pain (CP) and mental disorders are common among active military personnel (AMP) due to their potential exposure to various physical and psychological stressors.

Aim

The aim of this study was to evaluate pain perception and beliefs regarding their pain among AMP suffering from CP using self-reported measures, and to understand the development and persistence of pain in AMP.

Methods

Sixty male AMP outpatients suffering CP were included. All participants completed the following forms and questionnaires: Oswestry Disability Index(ODI), Visual Analogue Scale(VAS), Neck Disability Index(NDI), Bournemouth Questionnaire for neck(BQN), International Physical Activity Questionnaire(IPAQ), Hospital Anxiety and Depression Index(HADS), 36-item Short Form Survey(SF-36), Automatic Thoughts Questionnaire(ATQ), and Pain Belief Questionnaire(PBQ).

Results

The mean age of the participants was 22.85±3.50 years, the median duration and frequency of pain were 12 months and 14.5 days in a month, respectively. The median of ODI scores was 26; three of patients were evaluated as crippled while 8 patients had severe disability. The HADS and PBQ-psychological scores were high in the patient group. Positive correlations were found between pain frequency and the ODI, VAS, NDI and PBQ-psychological scores. Relationships were also shown between PBQ-psychological and the VAS and ATQ scores. Correlations between ODI scores and ATQ scores were also revealed.

Conclusions

Our results suggest that, in addition to the organic basis of pain, there is strong evidence for significant contribution from the psychological characteristics and pain-related beliefs of the patients. Physicians may choose a multi-dimensional perspective in the diagnosis and treatment of pain, especially in patients suffering from CP.

Key Factors Associated with Adherence to Physical Exercise in Patients with Chronic Diseases and Older Adults: An Umbrella Review

Physical inactivity is a major concern and poor adherence to exercise programs is often reported. The aim of this paper was to systematically review published reviews on the study of adherence to physical exercise in chronic patients and older adults and to identify those adherence-related key factors more frequently suggested by reviews for that population. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results were classified considering the target population and participants’ characteristics to identify the most repeated factors obtained for each condition. Fifty-five articles were finally included. Fourteen key factors were identified as relevant to increase adherence to physical exercise by at least ten reviews: (a) characteristics of the exercise program, (b) involvement of professionals from different disciplines, (c) supervision, (d) technology, (e) initial exploration of participant’s characteristics, barriers, and facilitators, (f) participants education, adequate expectations and knowledge about risks and benefits, (g) enjoyment and absence of unpleasant experiences, (h) integration in daily living, (i) social support and relatedness, (j) communication and feedback, (k) available progress information and monitoring, (l) self-efficacy and competence, (m) participant’s active role and (n) goal setting. Therefore, adherence to physical exercise is affected by several variables that can be controlled and modified by researchers and professionals.

Rotator cuff-related shoulder pain: does the type of exercise influence the outcomes? Protocol of a randomised controlled trial

INTRODUCTION

Lifetime prevalence of shoulder pain is 70%, and approximately 50% of people with shoulder pain will experience pain for more than a year. Rotator cuff-related shoulder pain (RCRSP) is the most common shoulder condition and the main non-surgical intervention is exercise therapy. For approximately 30% of people with RCRSP, this approach does not lead to a significant reduction in symptoms. This may be due to an inappropriate dosage or choice of exercises. The aim of this investigation is to compare the short, mid and long-term effects, in terms of symptoms, functional limitations, kinesiophobia and pain catastrophising, of three different shoulder rehabilitation approaches (education, strengthening, motor control) in adults with RCRSP.

METHODS AND ANALYSIS

In this single-blind (assessor), parallel-group, randomised clinical trial, 123 adults presenting with RCRSP will take part in a 12-week rehabilitation programme. They will be randomly assigned to one of three groups (education only, strengthening approach or motor control-focused approach). Abbreviated version of the Disabilities of the Arm, Shoulder and Hand Questionnaire, the primary outcome, Western Ontario Rotator Cuff Index and Brief Pain Inventory will evaluate symptoms and functional limitations, while Tampa Scale of Kinesiophobia and Pain Catastrophizing Scale will evaluate pain-related fear and catastrophising at baseline and at 3, 6, 12 and 24 weeks. Ultrasonographic acromiohumeral distances and tendon thickness will be assessed at baseline and 12 weeks. Intervention groups will be compared on outcomes with intention-to-treat analyses using two-way repeated measures analysis of variance if the data are normally distributed or non-parametric analysis of longitudinal data if they are not.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Sectorial Rehabilitation and Social Integration Research Ethics Committee of the Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale Nationale (CIUSSS-CN). Results will be disseminated through international publications in peer-reviewed journals, in addition to international conference presentations.

TRIAL REGISTRATION NUMBER

NCT03892603; pre-results.

The Effects of a Ketogenic Diet on Sensorimotor Function in a Thoracolumbar Mouse Spinal Cord Injury Model

Spinal cord injury and peripheral nerve injuries are traumatic events that greatly impact quality of life. One factor that is being explored throughout patient care is the idea of diet and the role it has on patient outcomes. But the effects of diet following neurotrauma need to be carefully explored in animal models to ensure that they have beneficial effects. The ketogenic diet provides sufficient daily caloric requirements while being potentially neuroprotective and analgesic. In this study, animals were fed a high-fat, low-carbohydrate diet that led to a high concentration of blood ketone that was sustained for as long as the animals were on the diet. Mice fed a ketogenic diet had significantly lower levels of tyrosine and tryptophan, but the levels of other monoamines within the spinal cord remained similar to those of control mice. Mice were fed a standard or ketogenic diet for 7 d before and 28 d following the injury. Our results show that mice hemisected over the T10–T11 vertebrae showed no beneficial effects of being on a ketogenic diet over a 28 d recovery period. Similarly, ligation of the common peroneal and tibial nerve showed no differences between mice fed normal or ketogenic diets. Tests included von Frey, open field, and ladder-rung crossing. We add to existing literature showing protective effects of the ketogenic diet in forelimb injuries by focusing on neurotrauma in the hindlimbs. The results suggest that ketogenic diets need to be assessed based on the type and location of neurotrauma.

Development, preliminary validation and reliability testing of SEDA - Self-Efficacy in Daily Activities for children with pain

BACKGROUND

Self-efficacy can affect a child's ability to perform important activities, infuse him/her with a sense of control and is likely an integral target for successful treatment in pediatric pain rehabilitation. Modern physical therapy treatment includes behavioral aspects and valid measures of self-efficacy are important for both research and clinical practice. In this study, the aim was to develop and perform preliminary testing of a self-efficacy scale for children and adolescents with pain.

METHODS

Children and adolescents participated, along with researchers and healthcare staff, in developing the Self-Efficacy in Daily Activities (SEDA) measure. A total of 109 children and adolescents seeking physical therapy treatment for pain lasting longer than 3 months responded to the SEDA. Pain and pain-related disability were assessed using the Functional Disability Inventory (FDI). Exploratory analyzes for testing validity and reliability - principal component analyses (PCA), intraclass correlation coefficients (ICCs) and bivariate correlations - were performed.

RESULTS

The PCA revealed a 16-item SEDA and a three-component scale. The components represented self-efficacy for physical activities, self-efficacy for personal care and self-efficacy for daily exertion. Validity correlation analyses showed moderate association between SEDA and FDI, -0.72 (p < .01), and low correlation with pain intensity, -0.29 (p = .03).

CONCLUSIONS

The 16-item SEDA has satisfactory psychometric properties in children moderately affected by long-term pain. Further validation of the SEDA in other populations and confirmatory analyses are warranted.

Big Five Personality Traits and Disabling Chronic Low Back Pain: Association with Fear-Avoidance, Anxious and Depressive Moods

Purpose

Physical dysfunction in chronic low back pain patients is influenced by psychological variables rather than by pain severity. Assessing personality traits may help clinicians address the complexity of patients’ experiences and design treatments that target these vulnerabilities. This study aimed to identify the distinguishing personality traits of a cohort of patients with disabling chronic low back pain and to determine associations between those traits and fear-avoidance beliefs, depressive, and anxious moods.

Patients and Methods

This cross-sectional study included 102 chronic low back pain patients (57% male), who failed standard management and were referred to a multidisciplinary rehabilitation program. All patients completed the five domains of the NEO Personality Inventory (NEO PI)–Revised (Neuroticism, Extraversion, Openness to experience, Agreeableness and Conscientiousness), the Tampa Scale for Kinesiophobia (TSK), and the Hospital Anxiety and Depression Scale (HADS). One-sample t-test was used to compare sample personality means with average population norms. Association between the five personality domains with TSK and HADS was assessed using Pearson’s correlation, adjusted for patient demographics and pain-related variables. Linear regression was used to estimate associations adjusted for covariates.

Results

Both men and women had significantly lower scores in the Openness to experience domain and significantly higher scores in the Conscientiousness domain than the general population norms. After adjusting for covariates, Neuroticism was associated with higher fear-avoidance, depression and anxiety scores. Conversely, Extraversion and Openness to experience negatively correlated with depression scores. Extraversion also inversely correlated with fear-avoidance. Conscientiousness negatively correlated with depression and anxiety after adjustment.

Conclusion

Patients with disabling chronic low back pain show personality characteristics that deviate significantly from the normal population norms but do not reach maladaptive forms of personality disorders. Clinicians would benefit from assessing patients’ personality traits to address protective and risk factors for psychological distress, particularly in difficult-to-treat, highly disabled low back pain patients.

Pain Self-Management: Easier Said than Done? Factors Associated with Early Dropout from Pain Self-Management in a Rural Primary Care Population

OBJECTIVE

To explore whether psychosocial or demographic factors are associated with early dropout from pain self-management in a rural, low-socioeconomic status population.

DESIGN

Secondary analysis of retrospective data.

SETTING

Multidisciplinary pain clinic located in an outer regional area of Australia.

SUBJECTS

One hundred eighty-six people attending a public community health center with chronic noncancer pain (mean age 54.9 years; 58.1% women; 81.7% in receipt of government benefit as their primary source of income).

METHODS

Bivariate analysis and logistic regression, with early dropout as the dependent variable and a range of demographic and psychological independent variables.

RESULTS

Following bivariate analysis, early dropout was significantly associated (P < 0.05) with male gender, younger age, history of substance use, being a past victim of assault/abuse, receiving unemployment or disability benefit, having literacy difficulties, higher pain catastrophizing score, higher daily opioid dose, and not holding a multifactorial belief about the cause of pain. Logistic regression analysis resulted in three significant predictors of dropout: substance use history (P = 0.002), past victim of assault or abuse (P = 0.029), high pain catastrophising score (P = 0.048); and one of engagement: holding a multifactorial belief about pain cause (P = 0.005).

CONCLUSIONS

In a rural, low-socioeconomic status population, addressing social stressors related to lifetime adversity may be important to increasing engagement in pain self-management. Lack of attention to these factors may increase health inequity among those most disabled by chronic pain. Further research into dropout and engagement, especially among disadvantaged populations, is recommended.

Parent Pain Cognitions and Treatment Adherence in Juvenile Idiopathic Arthritis

OBJECTIVE

Given the high levels of pain and low rates of treatment adherence in children with juvenile idiopathic arthritis (JIA) and their families, this study sought to examine the relationship between parent pain cognitions (i.e., pain catastrophizing, fear of pain) and treatment adherence, and how barriers to treatment (e.g., forgetting treatments, children resisting injections) may be implicated in this relationship.

METHODS

Parents of children under 18 years of age who have been diagnosed with JIA were recruited to complete an online survey. In total, 221 parents (93% mothers) of children aged 2-17 years (M = 11.10, SD = 4.25) took part, completing questions regarding their pain cognitions, perceived barriers to treatment, and their child's arthritis treatment adherence ability.

RESULTS

Hierarchical regressions demonstrated that both pain cognitions (i.e., pain catastrophizing and fear of pain) were related to a decrease in parent-reported treatment adherence, however, pain catastrophizing was no longer significant when fear of pain was added to the model. The presence of treatment barriers partially mediated the relationship between fear of pain and treatment adherence, above and beyond the alternate model proposed.

CONCLUSION

These results suggest that parent pain catastrophizing and fears of pain are related to a greater difficulty following treatment plans, possibly in part because of barriers parents experience that preclude adherence. Given these findings, the identification and management of parent pain cognitions is critical to improving treatment adherence and outcomes for children with JIA and their families.

Enhancing Motivation for Change in the Management of Chronic Painful Conditions: a Review of Recent Literature

PURPOSE OF REVIEW

The purpose of this review is to evaluate and summarize recent empirical research investigating motivational factors for management of chronic pain and headache disorders.

RECENT FINDINGS

Research on motivation for non-pharmacological treatment of chronic pain and headache disorders has identified factors that influence initiation of and adherence to treatment. To address common factors that inhibit initiation of treatment (i.e., cost, time commitment), several electronic treatments have been developed. Self-efficacy is the most commonly studied psychosocial influence on treatment adherence, with evidence that it is positively correlated with adherence. Other studies have sought to improve adherence to treatment using motivational interviewing interventions. There is currently limited research on how to enhance motivation for initial adherence to non-pharmacological treatment for chronic pain and headache disorders. Instead of enhancing motivation, researchers have looked to reduce barriers to treatment with electronic health treatments; however, many of these studies have focused on intervention feasibility, rather than efficacy or effectiveness. Numerous studies have identified a relationship between self-efficacy and treatment adherence. Although motivational interviewing interventions have been shown to improve adherence to treatment, there is little evidence that they improve treatment outcomes. Recommendations for further investigation include improving interventions to enhance accessibility and adherence to treatment with the goal of improving outcomes, as well as identifying ways to improve treatment initiation and adherence in patients who are currently engaged in long-term opioid therapy.

Association between change in self-efficacy and reduction in disability among patients with chronic pain

Purpose

This study aimed to investigate whether changes in psychosocial factors and pain severity were associated with reduction in disability due to pain among patients with chronic pain. We hypothesized that increased self-efficacy would reduce disability.

Patients and methods

This longitudinal observational study included 72 patients. Patients’ psychological and physical variables were assessed before and after 3 months of treatment. Demographic and clinical information were collected, including the Pain Disability Assessment Scale (PDAS), the Pain Self-Efficacy Questionnaire (PSEQ), the Hospital Depression and Anxiety Scale, and the Numeric Rating Scale (NRS) to assess pain intensity. First, univariate regression analyses were conducted to clarify associations between change in PDAS and sex, age, pain duration, changes in psychosocial factors (self-efficacy, anxiety, and depression) and change in pain intensity. Second, multivariate regression was conducted using the variables identified in the univariate analyses (PSEQ and NRS) to detect the most relevant factor for reducing disability.

Results

Univariate regression analyses clarified that changes in PSEQ (β = −0.31; 95% CI: −0.54–−0.08, p = 0.008) and NRS (β = 0.24; 95% confidence interval [CI]: 0.01–0.47, p = 0.04) were associated with reduction in PDAS. Multivariate regression analysis demonstrated that change in PSEQ (β = 0.26; 95% CI: −0.50–−0.02; p = 0.01) was associated with a reduction in disability, independent of change in NRS.

Conclusion

These findings suggest improved self-efficacy is associated with reduced disability in patients with chronic pain, independent of reduction in pain intensity. Focusing on improvement in self-efficacy may be an effective strategy in chronic pain treatment in addition to pain relief.

Evaluation of an interdisciplinary chronic pain program and predictors of readiness for change

Background: One in five Canadians experience chronic pain, and interdisciplinary pain programs are well established as the gold standard of treatment. However, not all patients are ready to engage in interdisciplinary treatment for chronic pain. Aims: The aims of this study were to (1) first demonstrate changes in patient-related outcomes after attending a publicly funded 8-week interdisciplinary pain program and (2) evaluate pain-related predictors of readiness for change. Methods: The institution's research ethics board approved this study. One hundred twenty-nine patients completed questionnaires on the first and last day of attending the program. Paired sample t-tests were utilized to evaluate the changes in patient-related outcomes after attending the program, and linear regressions were utilized to evaluate pain-related predictors of the stages of change. Results: Postprogram, there were significant decreases in pain-related interference, fear of pain/re-injury, pain catastrophizing, and symptoms of stress, depression, and anxiety and a significant increase in wellness-focused coping and self-efficacy. Postprogram, patients also demonstrated lower scores in precontemplation and contemplation and higher scores in action and maintenance stages of readiness for change. In predicting precontemplation, fear of pain/re-injury was the sole predictor, and self-efficacy was the sole predictor of the contemplation, action, and maintenance stages. Conclusion: These results demonstrate the short-term benefits of an 8-week interdisciplinary pain program. It is suggested that preprogram interventions targeting kinesophobia for individuals who are precontemplative and self-efficacy for others may be important to facilitate patient engagement.

Health beliefs, attitudes, and health-related quality of life in persons with fibromyalgia: mediating role of treatment adherence

Fibromyalgia is a chronic illness characterized by pain and fatigue. Persons with fibromyalgia experience increased the risk for poor mental and physical health-related quality of life, which may be dependent on multiple factors, including health beliefs, such as confidence in physicians and the health-care system, and health behaviors, such as treatment adherence. Respondents with fibromyalgia (n = 409) were recruited nationally, via support organizations, and completed self-report measures: Multidimensional Health Profile - Health Functioning Index (MHP-H), Short-Form-36 Health Survey (SF-36v2), and Medical Outcomes Study (MOS) Measure of Patient Adherence - General Adherence Items. In mediation models, belief in the healthcare system and health-care personnel, and health efficacy exerted an indirect effect through treatment adherence on mental and physical quality of life. Adaptive health beliefs and attitudes were related to greater treatment adherence and, in turn, to a better quality of life. Maladaptive health beliefs and mistrusting attitudes about physician-level and systemic-level healthcare provision are negatively related to both treatment adherence and consequent physical and mental health-related quality of life in persons with fibromyalgia. Future randomized controlled trials are needed to determine if therapeutic strategies to alter health values might improve adherence and self-rated health.

Differences in Self-Reported Physical Activity, Exercise Self-Efficacy and Outcome Expectancies, and Health Status by Body Mass Index Groups in People with Chronic Pain

The study purpose was to determine how self-reported lifestyle physical activity levels, exercise self-efficacy and outcome expectancies, and health status differ by body mass index for persons with chronic pain. From U.S. clinics and community networks, 209 adults reporting chronic musculoskeletal pain were recruited for the cross-sectional survey. Data were analyzed using analysis of variance. Participants with self-described obesity reported the lowest physical activity, reduced exercise self-efficacy and positive outcome expectancies, and poorer health status. Promoting graded activity while addressing motivational factors from health behavior theory for people with chronic pain and obesity should be encouraged in rehabilitation programs.

The role of self-efficacy in pain intensity, function, psychological factors, health behaviors, and quality of life in people with rheumatoid arthritis: A systematic review

Objective: The aim of this study was to systematically review and critically appraise the role of self-efficacy in pain intensity, function, psychological factors, health behaviors, and quality of life in people with rheumatoid arthritis, based on the analyses of longitudinal studies. Methods: An electronic search of PubMed, AMED, CINAHL, PsycINFO, and PubPsych was carried out from inception to July 2017. Study selection was based on longitudinal studies which have explored the role of self-efficacy in rheumatoid arthritis. The Newcastle-Ottawa Scale adapted version was used to evaluate the risk of bias, whereas the Grading of Recommendations Assessment, Development and Evaluation evaluated the quality of the evidence per outcome. Results: A total of 11 articles met the inclusion criteria. Our results suggest an association between higher self-efficacy and greater goal achievement, positive affect, acceptance of illness, problem-solving coping, physical function, physical activity participation, and quality of life. Inversely, there was also an association between higher self-efficacy and lower pain intensity, depressive symptoms, and anxiety. Conclusions: The findings of this systematic review suggest that self-efficacy might have a positive effect on the prognosis of this condition, although further longitudinal studies are needed.

Reducing Opioid Use for Patients With Chronic Pain: An Evidence-Based Perspective

The implementation of recent Centers for Disease Control and Prevention recommendations to move away from opioids and toward nonpharmacological therapies for the treatment of chronic pain could involve a difficult transition period for patients and practitioners. The focus of treatment should shift from eliminating pain completely to minimizing the impact of pain on quality of life. Many patients with chronic pain take opioids either because opioids were previously prescribed as a first-line treatment for chronic pain, on the basis of old standards of care, or because opioids were initially prescribed for acute pain. Patients currently taking opioids will need a tapering period during which they transition their pain management to interdisciplinary care and nonpharmacological treatments. To provide useful treatment options, physical therapists need to have a good understanding of the neuroscientific mechanisms of chronic pain, biopsychosocial components of chronic pain management, issues related to opioid use, and pain management strategies used by other health care professionals. Armed with knowledge and good communication skills, physical therapists can work within an interdisciplinary team to adapt care to each patient's needs and abilities. This perspective article provides guidance for physical therapists to effectively treat patients with chronic pain during the opioid tapering process. A framework has been created to help health care providers structure their reasoning as they collaborate to develop a unique approach for each patient.

Experiences of Urban African Americans with Cancer Pain

The experience of cancer pain is poorly understood from the perspective of African Americans, who experience higher levels of pain, more pain-related distress, and poorer function than Caucasians. Decreased perceived control over pain may play a greater role for African American patients, affecting pain-related distress and function. The purpose of this study was to add to the understanding of cancer pain and perceived control over pain in African Americans, from the patients' perspective. This qualitative inquiry was part of a larger mixed-methods study testing an intervention to improve pain, pain-related distress, and functional status through increasing perceived control over pain. Participants were recruited from the waiting room of an urban comprehensive cancer and interviewed in their homes. Interviews with 18 adult cancer patients who self-identified as African American and reported experiencing moderate to severe pain (>4 on a 0-10 scale) within the past two weeks were included. Qualitative interviews were audiotaped, transcribed, and analyzed using a constant comparative method. Two major themes emerged from this qualitative inquiry: struggles of the chronic pain experience and benefits of perceived control over pain. Each theme contained several categories. The study unveiled the participants account of both struggles of the chronic pain experience and barriers of perceived control that can be assessed for and targeted in nursing intervention. Benefits to having perceived control over pain were also illustrated in the participants' narratives.

The Role of Self-Efficacy on the Prognosis of Chronic Musculoskeletal Pain: A Systematic Review

Evidence suggests that self-efficacy can play an essential role as a protective factor as well as a mediator in the relationship between pain and disability in people suffering from chronic musculoskeletal pain. This study systematically reviewed and critically appraised the role of self-efficacy on the prognosis of chronic musculoskeletal pain. Study selection was on the basis of longitudinal studies testing the prognostic value of self-efficacy in chronic musculoskeletal pain. The Newcastle-Ottawa Scale, the Cochrane Collaboration's tool, and the Methodological Index for Non-Randomized Studies checklist were used to evaluate the risk of bias of included studies. A total of 27 articles met the inclusion criteria. Our results suggest that higher self-efficacy levels are associated with greater physical functioning, physical activity participation, health status, work status, satisfaction with the performance, efficacy beliefs, and lower levels of pain intensity, disability, disease activity, depressive symptoms, presence of tender points, fatigue, and presenteeism. Despite the low quality of evidence of included studies, clinicians should be encouraged identify people with chronic musculoskeletal pain who present low self-efficacy levels before prescribing any therapy. It may help clinicians in their clinical decision-making and timely and specific consultations with-or referral to-other health care providers.

PERSPECTIVE

This article presents promising results about the role of self-efficacy on the prognosis of chronic musculoskeletal pain. However, because of the low quality of evidence of included studies, these findings should be taken with caution, and further research is needed.

Influence of psychological factors on the prognosis of chronic shoulder pain: protocol for a prospective cohort study

INTRODUCTION

Shoulder pain is a highly prevalent condition. Psychological factors could play an essential role in the prognosis of chronic shoulder pain (CSP). The aims of the study will be to analyse the level of association between psychological factors and pain-disability at baseline and prospectively to assess their prognostic role; to evaluate the association of pain catastrophising and kinesiophobia at baseline and prospectively in the relationship between pain intensity and disability, or between self-efficacy and disability in patients with CSP; to explore the association of self-efficacy at baseline and prospectively in the relationship between pain intensity and disability, in comparison with kinesiophobia and pain catastrophising.

METHODS AND ANALYSIS

The study is a longitudinal, prospective cohort study with a 12-month follow-up. It will be conducted in 4 primary-care centres and one hospital of the province of Malaga, Spain. 307 participants aged between 18 and 70 years suffering from CSP (3 months or more) will be included. Primary outcomes will include pain, disability and self-efficacy, whereas kinesiophobia, pain-related fear, pain catastrophising, anxiety, depression, patient expectations of recovery, age, gender, duration/intensity of symptoms, educational level and other factors will be predictive measures.

FOLLOW-UP

baseline, 3, 6 and 12 months.

ETHICS AND DISSEMINATION

The local ethics committee (The Costa del Sol Ethics Committee, Malaga, 28042016) has approved this protocol. Dissemination will occur through presentations at National and International conferences and publications in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02738372; pre-results.

Locus of control and pain: Validity of the Form C of the Multidimensional Health Locus of Control scales when used with adolescents

The objective of this study was to examine the factor structure, reliability, and validity of the Form C of the Multidimensional Health Locus of Control scales in adolescents. A confirmatory factor analysis indicated that adequate fit of a four-factor model and the internal consistency of the scales were adequate. Criterion validity of the four scales of the Form C of the Multidimensional Health Locus of Control was also supported by significant correlations with measures of pain-related self-efficacy, anxiety, and coping strategies. The results indicate that the four Form C of the Multidimensional Health Locus of Control scale scores are reliable and valid and therefore support their use to assess pain-related locus of control beliefs in adolescents.

Management of fibromyalgia syndrome in 2016

Fibromyalgia syndrome is a chronic pain disorder and defies definitively efficacious therapy. In this review, we summarize the results from the early treatment research as well as recent research evaluating the pharmacological, interventional and nonpharmacological therapies. We further discuss future directions of fibromyalgia syndrome management; we specifically focus on the issues that are associated with currently available treatments, such as the need for personalized approach, new technologically oriented and interventional treatments, the importance of understanding and harnessing placebo effects and enhancement of patient engagement in therapy.