Cognitive behavioral therapy for chronic pain is effective, but for whom?

Treatment Effect Modifiers for Return-to-Work in Patients With Musculoskeletal Disorders

Investigating how individual characteristics modify treatment effects can improve understanding, interpretation, and translation of trial findings. The purpose of this secondary analysis was to identify treatment effect modifiers of the MI-NAV trial, a 3 arm, parallel randomized controlled trial which compared motivational interviewing and stratified vocational advice intervention in addition to usual case management (UC), to UC alone. This study included (n = 514) participants with musculoskeletal disorders on sick leave for at least 50% of their contracted work hours for at least 7 consecutive weeks with the Norwegian Labour and Welfare Administration. Sickness absence days was the primary outcome, measured from baseline assessment date until the 6-month follow-up. Potential treatment effect modifiers, identified a priori and informed by expert consultation and literature, were evaluated using linear regression models and statistical interaction tests. For motivational interviewing versus UC, age (mean difference [MD] -.7, 95% confidence interval [CI] -1.5 to .2; P = .13) and self-perceived health status (MD -.3, 95% CI -.7 to .1; P = .19) were identified as potential effect modifiers (P ≤ .2). For stratified vocational advice intervention versus UC, analgesic medication use (MD -26.2, 95% CI -45.7 to -6.7; P = .009) was identified as a treatment effect modifier (P ≤ .05). These findings may assist in more targeted treatment adaptation and translation as well as the planning of future clinical trials. PERSPECTIVE: This secondary analysis of the MI-NAV trial found that analgesic medication use, age, and self-perceived health may modify the effect of 2 vocational interventions on reducing sickness absence in people with musculoskeletal disorders.

Reconsidering the Role of Weight Loss in Treatment for Chronic Pain: Knee Osteoarthritis as an Exemplar

Chronic pain is prevalent among individuals with higher body weight and associated with greater impairment. As a result, weight loss is a common recommendation for pain management among those with higher body weight. Body weight is an appealing target because it is modifiable and evidence-based treatments to produce weight loss are well-established. In the last 2 decades, there has been a growing line of scientific work investigating the application of weight loss to individuals with chronic pain. This represents an important step to integrate the conceptualization of pain and body weight and there is preliminary work suggesting treatment effects are enhanced when weight loss treatment is combined with pain coping skills. However, weight loss outcomes are variable and difficult to sustain, and access to evidence-based treatment is limited. These concerns are set against the backdrop of growing public and academic concern about the weight-centric approach to health care that dominates western medicine. This is a timely moment to reconsider the conceptualization of weight and pain, and the role of weight loss in chronic pain treatment. Using osteoarthritis as an exemplar, we review the evidence for and clinical uptake of weight loss as a chronic pain management strategy and conclude with key areas for consideration to advance the scientific understanding of these comorbid conditions and how to optimize pain management for individuals of higher body weight. PERSPECTIVE: This focus article critically considers the role of weight loss in management of chronic pain among individuals of higher body. Using knee osteoarthritis as an exemplar, the evidence and clinical uptake of weight loss for pain management is reviewed. Limitations are considered to guide future research and clinical care.

Prehabilitation: The underutilised weapon for chronic pain management

Objective

Prehabilitation encompasses preparatory clinical intervention(s) delivered during the period between diagnosis and treatment commencement. Despite widespread successful usage preoperatively, psychological prehabilitation is neglected in outpatient chronic pain management. Although pain management waitlists are associated with treatment attrition and psychological and physical decline, this time window is underutilised in preventing escalation. Waitlists present an under-explored opportunity to 'prehabilitate' patients waiting for treatment. This topical review aimed to: (1) examine the effectiveness of psychological prehabilitation for pain services; (2) evaluate the psychological and physical decline associated with waiting for pain management; (3) highlight key psychological prehabilitative targets for increasing treatment engagement; (4) promote pain management psychological prehabilitation within personalised pain medicine, building recommendations for future interventions.

Methods

Studies regarding the impact of waitlists and prehabilitation for chronic pain were reviewed.

Results

Findings demonstrated that the psychological constructs of patient expectations, health locus of control, self-efficacy and pain catastrophizing dynamically influence attrition, treatment engagement and outcomes while waiting. These constructs are amenable to change, emphasising their potential utility within a targeted waitlist intervention.

Conclusions

Prehabilitating chronic pain patients towards treatment engagement could circumvent cycles of failed treatment seeking, preventing psychological and physical decline, and reducing healthcare utilisation. Utilising the waitlist to identify psychosocial risk factors (external health locus of control, low self-efficacy and high pain catastrophizing) would identify who requires additional support to prevent increased risk of treatment failure, enhancing personalised care before prescribed treatment is accessed. This review cements the urgent need for pain services to engage proactively with prehabilitation innovation.

Rehabilitation Applications Based on Behavioral Therapy for People With Knee Osteoarthritis: Systematic Review

BACKGROUND

The development of digital applications based on behavioral therapies to support patients with knee osteoarthritis (KOA) has attracted increasing attention in the field of rehabilitation. This paper presents a systematic review of research on digital applications based on behavioral therapies for people with KOA.

OBJECTIVE

This review aims to describe the characteristics of relevant digital applications, with a special focus on the current state of behavioral therapies, digital interaction technologies, and user participation in design. The secondary aim is to summarize intervention outcomes and user evaluations of digital applications.

METHODS

A systematic literature search was conducted using the keywords "Knee Osteoarthritis," "Behavior Therapy," and "Digitization" in the following databases (from January 2013 to July 2023): Web of Science, Embase, Science Direct, Ovid, and PubMed. The Mixed Methods Assessment Tool (MMAT) was used to assess the quality of evidence. Two researchers independently screened and extracted the data.

RESULTS

A total of 36 studies met the inclusion criteria and were further analyzed. Behavioral change techniques (BCTs) and cognitive behavioral therapy (CBT) were frequently combined when developing digital applications. The most prevalent areas were goals and planning (n=31) and repetition and substitution (n=27), which were frequently used to develop physical activity (PA) goals and adherence. The most prevalent combination strategy was app/website plus SMS text message/telephone/email (n=12), which has tremendous potential. This area of application design offers notable advantages, primarily manifesting in pain mitigation (n=24), reduction of physical dysfunction (n=21), and augmentation of PA levels (n=12). Additionally, when formulating design strategies, it is imperative to consider the perspectives of stakeholders, especially in response to the identified shortcomings in application design elucidated within the study.

CONCLUSIONS

The results demonstrate that "goals and planning" and "repetition and substitution" are frequently used to develop PA goals and PA behavior adherence. The most prevalent combination strategy was app/website plus SMS text message/telephone/email, which has tremendous potential. Moreover, incorporating several stakeholders in the design and development stages might enhance user experience, considering the distinct variations in their requirements. To improve the efficacy and availability of digital applications, we have several proposals. First, comprehensive care for patients should be ensured by integrating multiple behavioral therapies that encompass various aspects of the rehabilitation process, such as rehabilitation exercises and status monitoring. Second, therapists could benefit from more precise recommendations by incorporating additional intelligent algorithms to analyze patient data. Third, the implementation scope should be expanded from the home environment to a broader social community rehabilitation setting.

How Treatment Motivation Predicts Favorable Outcomes in Interdisciplinary Multimodal Pain Treatment Among Patients with Chronic Primary Pain

As motivation for psychological treatment at intake has been shown to predict favorable outcomes after an inpatient stay, this study aimed to further characterize the different components of psychological treatment motivation that predict favorable treatment outcomes. 294 inpatients with chronic primary pain participating in an interdisciplinary multimodal pain treatment in a tertiary psychosomatic university clinic completed a battery of psychological questionnaires at intake and discharge. Treatment motivation was assessed at intake using the scales of the FPTM-23 questionnaire, while pain intensity, pain interference, anxiety, and depression were assessed both at intake and discharge. After treatment, pain intensity, pain interference, anxiety, and depression were significantly reduced. While higher levels on the FPTM-23 scale of suffering predicted smaller decreases in anxiety after treatment, higher scores on the scale of hope, i.e., lower levels of hopelessness, predicted lower levels of pain interference, anxiety, and depression after treatment. None of the scales of treatment motivation predicted pain intensity levels after treatment. Above and beyond providing symptom relief, reducing hopelessness and fostering hope regarding the treatment process and outcome might help clinicians treat patients with chronic primary pain more effectively.

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 effectiveness of cognitive behavioural therapy in chronic neck pain: A systematic review with meta-analysis

We evaluated the effects of Cognitive Behavioural Therapy (CBT) alone or with additional interventions on pain, disability, kinesiophobia, anxiety, stress, depression, quality of life, and catastrophizing of patients with chronic neck pain (CNP). Nineteen studies met the inclusion criteria, and fourteen studies were quantitatively analysed. Risk of bias was assessed using the PEDro scale and the certainty of evidence using the GRADE approach. Studies were pooled (where applicable) and subgroup analyses were performed for CNP, or whiplash associated disorders. Studies compared-directly or indirectly-CBT interventions to no treatment, conservative interventions such as exercise and/or physiotherapy, or multimodal interventions. We present effect estimates at 8-week, 12-week, 6-month, and 1-year follow-up. Low certainty evidence suggests a clinically significant pain reduction (short-term) favouring CBT with or without additional intervention compared to no intervention SMD = -0.73; 95%CI: -1.23 to -0.23). Very low and low certainty evidence suggest clinically significant improvements in kinesiophobia (very short-term SMD = -0.83; 95%CI: -1.28 to -0.39 and short-term SMD = -1.30, 95%CI: -1.60 to -0.99), depression SMD = -0.74, 95%CI: -1.35 to -0.14) and anxiety SMD = -0.76, 95%CI: -1.34 to -0.18) favouring a multimodal intervention with CBT (short-term) compared to other conservative interventions. Combining different types of CBT interventions resulted in potentially heterogeneous comparisons.

Comparing the clinical and cost-effectiveness of remote (telehealth and online) cognitive behavioral therapy-based treatments for high-impact chronic pain relative to usual care: study protocol for the RESOLVE multisite randomized control trial

BACKGROUND

Cognitive behavioral therapy for chronic pain (CBT-CP) is an effective but underused treatment for high-impact chronic pain. Increased access to CBT-CP services for pain is of critical public health importance, particularly for rural and medically underserved populations who have limited access due to these services being concentrated in urban and high income areas. Making CBT-CP widely available and more affordable could reduce barriers to CBT-CP use.

METHODS

As part of the National Institutes of Health Helping to End Addiction Long-term® (NIH HEAL) initiative, we designed and implemented a comparative effectiveness, 3-arm randomized control trial comparing remotely delivered telephonic/video and online CBT-CP-based services to usual care for patients with high-impact chronic pain. The RESOLVE trial is being conducted in 4 large integrated healthcare systems located in Minnesota, Georgia, Oregon, and Washington state and includes demographically diverse populations residing in urban and rural areas. The trial compares (1) an 8-session, one-on-one, professionally delivered telephonic/video CBT-CP program; and (2) a previously developed and tested 8-session online CBT-CP-based program (painTRAINER) to (3) usual care augmented by a written guide for chronic pain management. Participants are followed for 1 year post-allocation and are assessed at baseline, and 3, 6, and 12 months post-allocation. The primary outcome is minimal clinically important difference (MCID; ≥ 30% reduction) in pain severity (composite of pain intensity and pain-related interference) assessed by a modified 11-item version of the Brief Pain Inventory-Short Form at 3 months. Secondary outcomes include pain severity, pain intensity, and pain-related interference scores, quality of life measures, and patient global impression of change at 3, 6, and 12 months. Cost-effectiveness is assessed by incremental cost per additional patient with MCID in primary outcome and by cost per quality-adjusted life year achieved. Outcome assessment is blinded to group assignment.

DISCUSSION

This large-scale trial provides a unique opportunity to rigorously evaluate and compare the clinical and cost-effectiveness of 2 relatively low-cost and scalable modalities for providing CBT-CP-based treatments to persons with high-impact chronic pain, including those residing in rural and other medically underserved areas with limited access to these services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04523714. This trial was registered on 24 August 2020.

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.

"The Pain Doesn't Have to Control You." A Qualitative Evaluation of Three Pain Clinics Teaching Nonopioid Pain Management Strategies

PURPOSE

To explore factors related to effectiveness of nonpharmacological treatment for opioid-dependent patients suffering with chronic pain.

APPROACH

A qualitative study incorporating individual interviews and focus group interviews.

SETTING

3 rural Oregon nonopioid pain management clinics.

INTERVENTION

A 10-week nonpharmacological educational program incorporating cognitive-behavioral therapy, movement therapy, mindfulness, and other skills.

PARTICIPANTS AND METHODS

Across sites, we conducted 9 individual interviews with clinic staff and 3 focus group interviews with 34 patients who had participated in the course. Thematic analysis was used to identify themes within and across respondent groups.

RESULTS

Analysis revealed 4 primary themes: program goals; program benefits; characteristics of patients who benefit from the program; coordination of clinic experiences with other care. Several primary findings can be highlighted. The clinics focused on improving patients' quality of life, while opioid use reduction was a potential secondary benefit, driven by patients. Major program benefits included enhanced pain self-management skills, patients' greater assertiveness in communications with healthcare providers, and, in numerous cases, opioid use reduction. Participants were unanimous that predisposition toward active self-management of one's pain was an essential factor for positive outcomes. Patients reported considerable variability in providers' understanding of their clinic participation.

CONCLUSION

Nonpharmacological approaches for treating chronic pain can be effective for many patients. Clinics teaching these approaches should be more fully integrated into the healthcare system.

Factors Affecting the Use of Pain-Coping Strategies in Individuals with Cerebral Palsy and Individuals with Typical Development

Many individuals with cerebral palsy (CP) suffer from pain and must develop pain-coping strategies, although the factors determining them are unknown. This observational study aims at exploring the association between different pain-coping strategies and factors such as age, sex, pain, health status, sleep or motor and cognitive function in individuals with cerebral palsy (CP) and typically developing peers (TD). Main caregivers of 94 individuals with CP (age range = 6-69 years, mean age = 17.78 (10.05)) and the closest relative of 145 individuals with TD (age range = 6-51 years, mean age = 19.13 (12.87)) completed questionnaires on the previous topics (Parent Report of the PEDsQL Pediatric Coping Inventory, the Health Utility Index HUI-3, Epworth Sleepiness Score and the Pittsburgh Sleep Quality Index). Pain presence, duration, intensity, location and ratings of current and worst pain in the last week in an 11-point numerical rating scale were assessed in an interview. Global health was the best predictor the of use of any type of pain-coping strategy, including cognitive self-instruction, problem-solving, distraction, seeking social support and catastrophizing, in both individuals with CP and individuals with TD. However, different health attributes predicted their use in each population. Emotional health was the best predictor in individuals with CP, whereas cognition and pain were the best predictors in individuals with TD. Speech ability was a predictor in both groups. In conclusion, the assessment of health attributes such as emotional health and speech may help design specific interventions for enhancing self-efficacy and adaptive pain coping skills.

Treatment effect modifiers for individuals with acute low back pain: secondary analysis of the TARGET trial

ABSTRACT

Treatment effect modifiers identify patient characteristics associated with treatment responses. The purpose of this secondary analysis was to identify potential treatment effect modifiers for disability from the TARGET trial that compared usual care (control) with usual care + psychologically informed physical therapy (PIPT). The sample consisted of a STarT Back tool identified high-risk patients with acute low back pain that completed Oswestry Disability Index (ODI) data at index visit and 6 months later (n = 1250). Candidate treatment effect modifiers were identified a priori and informed by the literature. Linear mixed models tested for treatment effect modification through tests of statistical interaction. All statistical interactions ( P ≤ 0.20) were stratified by modifier to inspect for specific effects ( P ≤ 0.05). Smoking was identified as a potential effect modifier (treatment * smoking interaction, P = 0.08). In participants who were smokers, the effect of PIPT was (ODI = 5.5; 95% CI: 0.6-10.4; P = 0.03) compared with usual care. In participants who were nonsmokers, the effect of PIPT was (ODI = 1.5; 95% CI: -1.4 to 4.4; P = 0.31) compared with usual care. Pain medication was also identified as a potential effect modifier (treatment × pain medication interaction, P = 0.10). In participants prescribed ≥3 pain medications, the effect of PIPT was (ODI = 7.1; 95% CI: -0.1 to 14.2; P = 0.05) compared with usual care. The PIPT effect for participants prescribed no pain medication was (ODI = 3.5; 95% CI: -0.4 to 7.4; P = 0.08) and for participants prescribed 1 to 2 pain medications was (ODI = 0.6; 95% CI: -2.5 to 3.7; P = 0.70) when compared with usual care. These findings may be used for generating hypotheses and planning future clinical trials investigating the effectiveness of tailored application of PIPT.

Can we characterize A-P/IAP behavioural phenotypes in people with chronic pain?

Two behavioural phenotypes in healthy people have been delineated based on their intrinsic attention to pain (IAP) and whether their reaction times (RT) during a cognitively-demanding task are slower (P-type) or faster (A-type) during experimental pain. These behavioural phenotypes were not previously studied in chronic pain populations to avoid using experimental pain in a chronic pain context. Since pain rumination (PR) may serve as a supplement to IAP without needing noxious stimuli, we attempted to delineate A-P/IAP behavioural phenotypes in people with chronic pain and determined if PR can supplement IAP. Behavioural data acquired in 43 healthy controls (HCs) and 43 age-/sex-matched people with chronic pain associated with ankylosing spondylitis (AS) was retrospectively analyzed. A-P behavioural phenotypes were based on RT differences between pain and no-pain trials of a numeric interference task. IAP was quantified based on scores representing reported attention towards or mind-wandering away from experimental pain. PR was quantified using the pain catastrophizing scale, rumination subscale. The variability in RT was higher during no-pain trials in the AS group than HCs but was not significantly different in pain trials. There were no group differences in task RTs in no-pain and pain trials, IAP or PR scores. IAP and PR scores were marginally significantly positively correlated in the AS group. RT differences and variability were not significantly correlated with IAP or PR scores. Thus, we propose that experimental pain in the A-P/IAP protocols can confound testing in chronic pain populations, but that PR could be a supplement to IAP to quantify attention to pain.

Brain-activation-based individual identification reveals individually unique activation patterns elicited by pain and touch

Pain is subjective and perceived differently in different people. However, individual differences in pain-elicited brain activations are largely overlooked and often discarded as noises. Here, we used a brain-activation-based individual identification procedure to investigate the uniqueness of the activation patterns within the whole brain or brain regions elicited by nociceptive (laser) and tactile (electrical) stimuli in each of 62 healthy participants. Specifically, brain activation patterns were used as "fingerprints" to identify each individual participant within and across sensory modalities, and individual identification accuracy was calculated to measure each individual's identifiability. We found that individual participants could be successfully identified using their brain activation patterns elicited by nociceptive stimuli, tactile stimuli, or even across modalities. However, different participants had different identifiability; importantly, the within-pain, but not within-touch or cross-modality, individual identifiability obtained from three brain regions (i.e., the left superior frontal gyrus, the middle temporal gyrus and the insular gyrus) were inversely correlated with the scores of Pain Vigilance and Awareness Questionnaire (i.e., how a person is alerted to pain) across participants. These results suggest that each individual has a unique pattern of brain responses to nociceptive stimuli which contains both modality-nonspecific and pain-specific information and may be associated with pain-related behaviors shaped by his/her own personal experiences and highlight the importance of a transition from group-level to individual-level characterization of brain activity in neuroimaging studies.

How do psychologically based interventions for chronic musculoskeletal pain work? A systematic review and meta-analysis of specific moderators and mediators of treatment

Psychologically based interventions aim to improve pain-related functioning by targeting pain-related fears, cognitions and behaviors. Mediation and moderation analyses permit further examination of the effect of treatment on an outcome. This systematic review and meta-analysis aims to synthetize the evidence of specific mediators and moderators (i.e., treatment targets) of psychologically based treatment effects on pain and disability. A total of 28 mediation and 11 moderation analyses were included. Thirteen mediation studies were included in a meta-analysis, and the rest was narratively synthetized. Reductions in pain-related fear (indirect effect [IE]: -0.07; 95% confidence interval [CI]: -0.11, -0.04) and catastrophizing (IE: -0.07; 95%CI: -0.14, -0.00), as well as increases in self-efficacy (IE: -0.07; 95%CI: -0.11, -0.04), mediated effects of cognitive behavioral therapy on disability but not on pain intensity, when compared to control treatments. Enhancing pain acceptance (IE: -0.17; 95%CI: -0.31, -0.03) and psychological flexibility (IE: -0.30; 95%CI: -0.41, -0.18) mediated acceptance and commitment therapy effects on disability. The narrative synthesis showed conflicting evidence, which did not support a robust moderated effect for any of the examined constructs. Overall, the methodological quality regarding mediation was low, and some key pitfalls are highlighted alongside recommendations to provide a platform for future research.

Hierarchical Structure of Depression Knowledge Network and Co-word Analysis of Focus Areas

Contemporarily, depression has become a common psychiatric disorder that influences people's life quality and mental state. This study presents a systematic review analysis of depression based on a hierarchical structure approach. This research provides a rich theoretical foundation for understanding the hot spots, evolutionary trends, and future related research directions and offers further guidance for practice. This investigation contributes to knowledge by combining robust methodological software for analysis, including Citespace, Ucinet, and Pajek. This paper employed the bibliometric methodology to analyze 5,000 research articles concerning depression. This current research also employed the BibExcel software to bibliometrically measure the keywords of the selected articles and further conducted a co-word matrix analysis. Additionally, Pajek software was used to conduct a co-word network analysis to obtain a co-word network diagram of depression. Further, Ucinet software was utilized to calculate K-core values, degree centrality, and mediated centrality to better present the research hotspots, sort out the current status and reveal the research characteristics in the field of depression with valuable information and support for subsequent research. This research indicates that major depressive disorder, anxiety, and mental health had a high occurrence among adolescents and the aged. This present study provides policy recommendations for the government, non-governmental organizations and other philanthropic agencies to help furnish resources for treating and controlling depression orders.

Effectiveness of a Guided Internet- and Mobile-Based Intervention for Patients with Chronic Back Pain and Depression (WARD-BP): A Multicenter, Pragmatic Randomized Controlled Trial

INTRODUCTION

There is neither strong evidence on effective treatments for patients with chronic back pain (CBP) and depressive disorder nor sufficiently available mental health care offers.

OBJECTIVE

The aim is to assess the effectiveness of internet- and mobile-based interventions (IMI) as a scalable approach for treating depression in a routine care setting.

METHODS

This is an observer-masked, multicenter, pragmatic randomized controlled trial with a randomization ratio of 1:1.Patients with CBP and diagnosed depressive disorder (mild to moderate severity) were recruited from 82 orthopedic rehabilitation clinics across Germany. The intervention group (IG) received a guided depression IMI tailored to CBP next to treatment-as-usual (TAU; including medication), while the control group (CG) received TAU. The primary outcome was observer-masked clinician-rated Hamilton depression severity (9-week follow-up). The secondary outcomes were: further depression outcomes, pain-related outcomes, health-related quality of life, and work capacity. Biostatistician blinded analyses using regression models were conducted by intention-to-treat and per protocol analysis.

RESULTS

Between October 2015 and July 2017, we randomly assigned 210 participants (IG, n = 105; CG, n = 105), mostly with only a mild pain intensity but substantial pain disability. No statistically significant difference in depression severity between IG and CG was observed at the 9-week follow-up (β = -0.19, 95% CI -0.43 to 0.05). Explorative secondary depression (4/9) and pain-related (4/6) outcomes were in part significant (p < 0.05). Health-related quality of life was significantly higher in the IG. No differences were found in work capacity.

CONCLUSION

The results indicate that an IMI for patients with CBP and depression in a routine care setting has limited impact on depression. Benefits in pain and health-related outcomes suggest that an IMI might still be a useful measure to improve routine care.

Sex Differences in Coping Strategies Based on Chronic Pain Intensity Among Older Adults

The aim of the current study was to investigate chronic pain coping strategies of older adults and the differences between sexes according to the intensity of pain. A cross-sectional study was performed in specialty clinics in midwestern Brazil. Participants comprised 276 older adults with chronic pain. The Brief Pain Inventory and Chronic Pain Coping Inventory-Brazilian version were used to assess self-reported pain intensity and pain coping strategies. Mann-Whitney U, Kruskal-Wallis, and Dunn tests were used for intergroup comparisons. The task persistence and coping self-statements subscales were the most used coping strategies. The strategies of exercise/stretching and task persistence were used differently between males and females. Males showed significant differences in asking for assistance, task persistence, and guarding subscales when pain intensity was taken into account, whereas females showed differences in the guarding and resting subscales. Adaptive coping was the most used coping strategy; however, some non-adaptive subscales were significant in both sexes when compared with levels of chronic pain intensity. [Journal of Gerontological Nursing, 47(10), 30-36.].

Gender Biases in Estimation of Others' Pain

Caregiving and other interpersonal interactions often require accurate perception of others' pain from nonverbal cues, but perceivers may be subject to systematic biases based on gender, race, and other contextual factors. Such biases could contribute to systematic under-recognition and undertreatment of pain. In 2 experiments, we studied the impact of perceived patient sex on lay perceivers' pain estimates and treatment recommendations. In Experiment 1 (N = 50), perceivers viewed facial video clips of female and male patients in chronic shoulder pain and estimated patients' pain intensity. Multi-level linear modeling revealed that perceivers under-estimated female patients' pain compared with male patients, after controlling for patients' self-reported pain and pain facial expressiveness. Experiment 2 (N = 200) replicated these findings, and additionally found that 1) perceivers' pain-related gender stereotypes, specifically beliefs about typical women's vs. men's willingness to express pain, predicted pain estimation biases; and 2) perceivers judged female patients as relatively more likely to benefit from psychotherapy, whereas male patients were judged to benefit more from pain medicine. In both experiments, the gender bias effect size was on average 2.45 points on a 0-100 pain scale. Gender biases in pain estimation may be an obstacle to effective pain care, and experimental approaches to characterizing biases, such as the one we tested here, could inform the development of interventions to reduce such biases. Perspective: This study identifies a bias towards underestimation of pain in female patients, which is related to gender stereotypes. The findings suggest caregivers' or even clinicians' pain stereotypes are a potential target for intervention.

Predictors of Response to an Evidence-Based Behavioral Cancer Pain Management Intervention: An Exploratory Analysis From a Clinical Trial

CONTEXT

Interventions that teach patients cognitive and behavioral strategies for managing cancer pain have demonstrated effectiveness. Systematic reviews of such interventions call for research to inform their implementation in practice, including investigations into which patients are most likely to benefit.

OBJECTIVES

We aimed to identify predictors of response to an evidence-based behavioral intervention for cancer pain, pain coping skills training (PCST).

METHODS

We conducted an exploratory secondary analysis of a randomized noninferiority trial comparing in-person to videoconference-based PCST. Using modified Poisson regression, we estimated the adjusted associations of patient characteristics with clinically meaningful reductions (≥30%) in pain severity and pain interference.

RESULTS

Of the 178 patients who were randomized, 135 completed at least one follow-up assessment and were included in this analysis. Proportions of patients experiencing reductions in pain severity and pain interference were 34% and 46%, respectively. In multivariable analysis, education level was associated with a reduction in pain severity (adjusted relative risk, some college or technical school vs. college or higher: 0.49, 95% CI: 0.26-0.93). Patients with colorectal cancer were 61% more likely to experience a reduction in pain interference than patients with breast cancer (95% CI:1.21-2.34). Marital status was also statistically significantly associated with pain interference reduction, with married patients less likely to experience a reduction in pain interference (adjusted relative risk, married vs. not: 0.69, 95% CI: 0.49-0.98).

CONCLUSION

Our findings elucidate several subgroups of patients who may be especially likely to benefit from PCST, informing both targeted implementation efforts and opportunities to improve delivery for diverse patients.

STarT-Lower Extremity Screening Tool at Six-weeks Predicts Pain and Physical Function 12-months after Traumatic Lower Extremity Fracture

BACKGROUND

Patients with lower extremity fracture requiring surgical fixation often have poor long-term pain and disability outcomes. This indicates the need for a risk stratification tool that can inform patient prognosis early in recovery. The purpose of this study was to determine the predictive validity of the STarT-Lower Extremity Screening Tool (STarT-LE) in patients with lower extremity fracture requiring surgical fixation.

MATERIALS AND METHODS

One-hundred and twenty-two patients (41.7 ± 14.7 years, 54% male) with lower extremity fracture and no history of chronic pain were enrolled in this prospective cohort study. Patients completed the STarT-LE Screening Tool six-weeks after definitive fixation. Validated measures of chronic pain development, pain interference, and physical function were collected at 12-months. STarT-LE low, medium, and high risk subgroups were compared against each outcome measure with chi-square, one-way analysis of variance, and sensitivity and specificity analyses. Multivariable linear regression analyses determined if STarT-LE risk subgroups at six weeks were associated with each outcome at 12 months when controlling for important baseline demographics.

RESULTS

Twelve-month follow-up was completed by 114 patients (93.4%). Increase in STarT-LE risk subgroup at six-weeks was associated with higher frequency of chronic pain (Low: 14.7%, Medium: 48.3%, High: 85.0%), worse pain interference (Low: 48.6 ± 8.88, Medium: 56.33 ± 8.79, High: 61.65 ± 7.74), and worse physical function (Low: 50.77 ± 9.89, Medium: 42.52 ± 6.47, High: 37.44 ± 7.46) at 12-months. The low risk subgroup had high sensitivity (range: 84.9%-93.9%) and the high risk subgroup had high specificity (range: 87.7%-95.2%) for dichotomized 12-month outcomes. The multivariable results showed that medium and high STarT-LE risk categories were associated with chronic pain development (Medium odds ratio: 3.90, 95%CI: 1.11 to 13.66; High odds ratio: 13.14, 95%CI: 2.25 to 76.86), worse pain interference (Medium: β:4.37, 95%CI: 0.17 to 8.58; High: β:7.01, 95%CI: 1.21 to 12.81), and worse physical function (Medium: β:-3.76, 95%CI: -7.41 to -0.11; β:-7.44, 95%CI:-12.47 to -2.41), respectively, when controlling for important baseline variables.

CONCLUSION

The STarT-LE has the potential to identify patients at-risk for poor pain and functional outcomes, and may help inform the post-surgical management of patients with traumatic LE injury.

Activity Patterns and Functioning. A Contextual-Functional Approach to Pain Catastrophizing in Women with Fibromyalgia

Background: The psychological flexibility model states that activity patterns are not deemed to be intrinsically functional or dysfunctional; it is considered that underlying factors, such as personal goals and contextual factors, are what will determine their effects on disability. Pain catastrophizing has frequently been associated with several important pain-related outcomes. Despite its recent conceptualization within affective–motivational approaches, its moderating role between activity patterns and dysfunction has not been analyzed. Methods: This study analyzes the moderating role of pain catastrophizing and its dimensions (Pain Catastrophizing Scale) between activity patterns (Activity Patterns Scale) and disease impact (Fibromyalgia Impact Questionnaire—Revised) in 491 women with fibromyalgia. Results: Activity avoidance (p < 0.001), excessive persistence (p < 0.001) and pacing (p < 0.01) patterns were positively associated with fibromyalgia impact. Helplessness shows a moderating role between pain avoidance (B = 0.100, t =2.30, p = 0.021, [0.01, 0.18]), excessive persistence (B = −0.09, t = −2.24, p = 0.02, [−0.18, −0.01]), pain persistence (B = −0.10, t = −2.04, p = 0.04, [−0.19, −0.004]) and functioning. Conclusion: Helplessness (within pain catastrophizing) is a relevant variable within psychological flexibility models applied to activity patterns. Specifically, pain avoidance is especially dysfunctional in patients with high helplessness. To improve excessive persistence and pain persistence, it is necessary to reduce helplessness before regulating activity patterns.

Web-based cognitive behavior therapy for chronic pain patients with aberrant drug-related behavior: How did it work and for whom?

This study explored mediating pathways, moderating factors, and moderated mediation effects of a web-based, cognitive behavioral therapy (CBT) intervention for chronic pain patients with aberrant drug-related behavior (ADRB). In a 2-arm RCT, patients with chronic pain who screened positive for ADRB received treatment-as-usual (TAU, n = 55) or TAU plus a 12-week, web-based CBT intervention (n = 55). Assessments were conducted at weeks 4, 8, and 12, and at 1- and 3-months post intervention. Web-CBT significantly reduced pain catastrophizing, which, in turn, reduced pain interference and pain severity via a pathway of pain catastrophizing. Web-CBT also significantly reduced ADRB both directly and indirectly by reducing pain catastrophizing. For pain interference and pain severity, web-CBT was more effective than TAU for younger patients (≤ age 50). For pain severity, web-CBT was more effective for both younger patients (≤ age 50), and those with a lifetime substance use disorder. Findings suggest that web-CBT's positive impact on pain outcomes and ADRB are mediated by its effect on pain catastrophizing, and its treatment effects may be most robust for younger patients and those with histories of substance dependence.

Neuropsychiatric Symptoms in Pediatric Chronic Pain and Outcome of Acceptance and Commitment Therapy

Considerable heterogeneity among pediatric chronic pain patients may at least partially explain the variability seen in the response to behavioral therapies. The current study tested whether autistic traits and attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical sample of children and adolescents with chronic pain are associated with socioemotional and functional impairments and response to acceptance and commitment therapy (ACT) treatment, which has increased psychological flexibility as its core target for coping with pain and pain-related distress. Children and adolescents aged 8–18 years (N = 47) were recruited. Patients and their parents completed questionnaires pre- and post-ACT of 17 sessions. Correlational analyses and mixed-effects models were used to assess the role of autistic traits and ADHD symptoms in pretreatment functioning and ACT-treatment response. Outcome variables were degree to which pain interfered with daily activities (i.e., pain interference, sleep, and physical and school functioning), socioemotional functioning (i.e., depressive symptoms, emotional, and social functioning), psychological inflexibility, and pain intensity. Autistic traits and ADHD symptoms, pain frequency, and pain duration were measured at pretreatment only. Higher autistic traits were associated with greater pain interference, higher depression, and greater psychological inflexibility. Higher ADHD symptomatology was associated with greater pretreatment pain interference, lower emotional functioning, greater depression, and longer duration of pain. Across patients, all outcome variables, except for sleep disturbances and school functioning, significantly improved from pre- to post-ACT. Higher autistic traits were associated with greater pre- to post-ACT improvements in emotional functioning and sleep disturbance and non-significant improvements in pain interference. ADHD symptomatology was not associated with treatment outcome. The current results showed that neuropsychiatric symptoms in pediatric chronic pain patients are associated with lower functioning, particularly pain interfering with daily life and lower socioemotional functioning. The results suggest that not only pediatric chronic pain patients low in neuropsychiatric symptoms may benefit from ACT, but also those high in autism traits and ADHD symptoms. With the present results in mind, pediatric chronic pain patients higher in autistic traits may actually derive extra benefit from ACT. Future research could assess whether increased psychological flexibility, the core focus of ACT, enabled those higher in autism traits to cope relatively better with pain-related distress and thus to gain more from the treatment, as compared to those lower in autism traits. Moreover, to address specific effects of ACT, inclusion of an appropriate control group is key.

Myofascial Pelvic Pain: An Overlooked and Treatable Cause of Chronic Pelvic Pain

Myofascial pelvic pain is a common, nonarticular musculoskeletal disorder characterized by the presence of myofascial trigger points in the lower abdominal wall and/or pelvic floor muscles. Myofascial pelvic pain is involved in an estimated 22% to 94% of cases of chronic pelvic pain, which is one of the most common gynecologic conditions in the United States. Myofascial pelvic pain may exist independently or in conjunction with disorders such as vaginismus, dysmenorrhea, and endometriosis and is frequently a causative factor in sexual pain or dyspareunia. This article reviews the pathophysiology, assessment, and treatment options for myofascial pelvic pain, with a particular focus on trigger point injections. Increased recognition and treatment of this commonly overlooked diagnosis has the potential to improve care and outcomes for many patients suffering from chronic pelvic pain.

Which Chronic Low Back Pain Patients Respond Favorably to Yoga, Physical Therapy, and a Self-care Book? Responder Analyses from a Randomized Controlled Trial

PURPOSE

To identify baseline characteristics of adults with chronic low back pain (cLBP) that predict response (i.e., a clinically important improvement) and/or modify treatment effect across three nonpharmacologic interventions.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Academic safety net hospital and seven federally qualified community health centers.

SUBJECTS

Adults with cLBP (N = 299).

METHODS

We report patient characteristics that were predictors of response and/or modified treatment effect across three 12-week treatments: yoga, physical therapy [PT], and a self-care book. Using preselected characteristics, we used logistic regression to identify predictors of "response," defined as a ≥30% improvement in the Roland Morris Disability Questionnaire. Then, using "response" as our outcome, we identified baseline characteristics that were treatment effect modifiers by testing for statistical interaction (P < 0.05) across two comparisons: 1) yoga-or-PT vs self-care and 2) yoga vs PT.

RESULTS

Overall, 39% (116/299) of participants were responders, with more responders in the yoga-or-PT group (42%) than the self-care (23%) group. There was no difference in proportion responding to yoga (48%) vs PT (37%, odds ratio [OR] = 1.5, 95% confidence interval = 0.88 - 2.6). Predictors of response included having more than a high school education, a higher income, employment, few depressive symptoms, lower perceived stress, few work-related fear avoidance beliefs, high pain self-efficacy, and being a nonsmoker. Effect modifiers included use of pain medication and fear avoidance beliefs related to physical activity (both P = 0.02 for interaction). When comparing yoga or PT with self-care, a greater proportion were responders among those using pain meds (OR = 5.3), which differed from those not taking pain meds (OR = 0.94) at baseline. We also found greater treatment response among those with lower (OR = 7.0), but not high (OR = 1.3), fear avoidance beliefs around physical activity.

CONCLUSIONS

Our findings revealed important subgroups for whom referral to yoga or PT may improve cLBP outcomes.

"I Could Do It in My Own Time and When I Really Needed It": Perceptions of Online Pain Coping Skills Training For People With Knee Osteoarthritis

OBJECTIVE

To qualitatively explore the perceptions and experiences of people with knee osteoarthritis (OA) who used an online automated pain coping skills training program (PCST).

METHODS

This was a descriptive qualitative study (based on interpretivist methodology) embedded within a randomized controlled trial. Individual semistructured interviews were conducted with 12 people with knee OA who had participated in an 8-week automated online PCST program while also receiving exercise advice and support from a physical therapist via Skype. Interviews in this study focused specifically on the online PCST program, rather than the physical therapy component. Interviews were audiorecorded, transcribed verbatim, and thematically analyzed.

RESULTS

Five themes arose: 1) easy to understand and follow (clearly explained, presented well), 2) better able to cope with pain (controlling pain, helping relax, pacing self, incorporating skills into exercise program), 3) anonymity and flexibility (no judgement by clinician, work at own pace, accessibility), 4) not always relatable or engaging (some techniques not useful, Americanization of the program, annoying character examples, time consuming and slow-paced), and 5) support from clinician desirable (follow-up from a clinician would be beneficial, worked in tandem with physical therapist-prescribed exercise, desire referral to the program by a trusted source).

CONCLUSION

People with knee OA had generally positive experiences using an online PCST program, suggesting that online PCST is a broadly acceptable and accessible way to help people with OA to manage their pain. User engagement may be enhanced by redesigning some aspects of the program and by provision of support from a clinician.

Imaging Brain Mechanisms of Functional Somatic Syndromes: Potential as a Biomarker?

When patients present with persistent bodily complaints that cannot be explained by a symptom-linked organic pathology (medically unexplained symptoms), they are diagnosed with 'functional' somatic syndromes (FSS). Despite their prevalence, the management of FSS is notoriously challenging in clinical practice. This may be because FSS are heterogeneous disorders in terms of etiopathogenesis. They include patients with primarily peripheral dysfunction, primarily centrally driven somatic symptoms, and a mix of both. Brain-imaging studies, particularly data-driven pattern recognition methods using machine learning algorithms, could provide brain-based biomarkers for these clinical conditions. In this review, we provide an overview of our brain imaging data on brain-body interactions in one of the most well-known FSS, irritable bowel syndrome (IBS), and discuss the possible development of a brain-based biomarker for FSS. Anticipation of unpredictable pain, which commonly elicits fear in FSS patients, induced increased activity in brain areas associated with hypervigilance during rectal distention and non-distention conditions in IBS. This was coupled with dysfunctional inhibitory influence of the medial prefrontal cortex (mPFC) and pregenual anterior cingulate cortex (pACC) on stress regulation systems, resulting in the activated autonomic nervous system (ANS) and neuroendocrine system stimulated by corticotropin-releasing hormone (CRH). IBS subjects with higher alexithymia, a risk factor for FSS, showed stronger activity in the insula during rectal distention but reduced subjective sensitivity. Reduced top-down regulation of the ANS and CRH system by mPFC and pACC, discordance between the insula response to stimulation and subjective sensation of pain, and stronger threat responses in hypervigilance-related areas may be a candidate brain-based biomarker.

Effectiveness of Conventional Cognitive-Behavioral Therapy and Its Computerized Version on Reduction in Pain Intensity, Depression, Anger, and Anxiety in Children with Cancer: A Randomized, Controlled Trial

Background: Experiencing painful procedures during life is inevitable. Poor pain management is associated with negative effects on the quality of life, remaining for a long time after the experience. Long-term negative effects of pain possess a significant cost burden on society. Nowadays, computers are globally available, and computerized psychological interventions can reduce negative emotions. Objectives: The present study aimed at examining the effectiveness of conventional cognitive-behavioral therapy (CBT) and its computerized version on reduction in pain intensity, depression, anger, and anxiety in children with cancer. Methods: The present randomized, controlled, clinical trial was performed on three groups of conventional CBT, computerized CBT (cCBT), and control. Children with cancer, referring to Shafa Hospital of Ahvaz, Iran, constituted the study samples. A total of 15 children aged 9 - 12 years were assigned to each group by using the lottery method. All three groups received routine medical treatments during the study, but the two intervention groups also received psychological interventions as a complementary treatment. The control group received routine medical treatment and underwent cCBT intervention after the study. The data-i e, pre- and post-tests, were collected by a masters’ student in clinical psychology that was blind to the study objectives. Data were analyzed by MANCOVA, ANOVA, and t-tests of differential scores. Results: The findings of the study indicated that both interventions could reduce negative emotions associated with cancer (i. e, pain, anger, anxiety, and depression) in children compared with the control group (P < 0.0001). In addition, there were no significant differences between the two intervention groups (P < 0.01). It means both interventions were useful to reduce pain and enhance adjustment. Conclusions: The cCBT can be utilized in case of no access to psychologists and psychological services.

Effectiveness of pain coping skills training on pain, physical function, and psychological outcomes in patients with osteoarthritis: A systemic review and meta-analysis

OBJECTIVE

To investigate the effectiveness of pain coping skills training in pain, function, and psychological outcomes for patients with osteoarthritis, compared to the control group; and to compare the effectiveness of pain coping skills training between the intervention involving and without involving exercise.

DATA SOURCES

PubMed, Embase, the Cochrane Library, PEDro, Clinical Trials, and the WHO Clinical Trials Registry Platform (to 30 September 2020).

REVIEW METHODS

To calculate the results, we used standardized mean difference, and mean difference for the outcomes of continuous variables, risk difference for the risk of adverse events. Heterogeneity was identified with I² test, and publication bias was identified with Egger's test.

RESULTS

A total of 1195 patients with osteoarthritis underwent ten trials were included. The intervention group had significant differences in pain (SMD = -0.18; 95% CI -0.29 to -0.06), function (SMD = -0.19; -0.30 to -0.07), coping attempts (SMD = 0.37; 0.24 to 0.49), pain catastrophizing (SMD = -0.16; -0.29 to -0.02), and self-efficacy (SMD = 0.27; 0.07 to 0.46) than the control group. Between-group differences measured by the McMaster Universities Osteoarthritis Index subscales of pain (MD = -0.62; -1.48 to 0.24) or function (MD = -3.01; -6.26 to 0.24) were not statistically significant and did not reach the minimal clinically important differences that have been established. Subgroup analyses revealed no significant subgroup differences. Besides, no specific intervention-related adverse events were identified.

CONCLUSION

Our results supported the effectiveness and safety of pain coping skills training for managing osteoarthritis in pain, function, and psychological aspects. Besides, exercise could not add benefits when combined with pain coping skills training.

All-Cause Opioid Prescriptions Dispensed: The Outsized Role of Adults With Arthritis

INTRODUCTION

Limited estimates of prescribed opioid use among adults with arthritis exist. All-cause (i.e., for any condition) prescribed opioid dispensed (referred to as opioid prescription in the remainder of this abstract) in the past 12 months among U.S. adults aged ≥18 years (n=35,427) were studied, focusing on adults with arthritis (n=12,875).

METHODS

In 2018-2019, estimates were generated using Medical Expenditure Panel Survey data: (1) 2015 prevalence of 1 or more opioid prescriptions to U.S. adults overall and by arthritis status and (2) in 2014-2015, among adults with arthritis, multivariable-adjusted associations between 1 or more opioid prescriptions and sociodemographic characteristics, health status, and healthcare utilization characteristics.

RESULTS

In 2015, the age-standardized prevalence of 1 or more opioid prescriptions among adults with arthritis (29.6%) was almost double of that for all adults (15.4%). Adults with arthritis represented more than half of all adults (55.3%) with at least 1 opioid prescription; among those with 1 or more prescriptions, 43.2% adults had 4 or more prescriptions. The strongest multivariable-adjusted associations with 1 or more opioid prescriptions were ambulatory care visits (1-4: prevalence ratios=1.9-2.0, 5-8: prevalence ratios=2.5-2.7, 9 or more: prevalence ratios=3.4-3.7) and emergency room visits (1: prevalence ratios=1.6, 2-3: prevalence ratios=1.9-2.0, 4 or more: prevalence ratios=2.4); Ref for both: no visits.

CONCLUSIONS

Adults with arthritis are a high-need target group for improving pain management, representing more than half of all U.S. adults with 1 or more opioid prescriptions. The association with ambulatory care visits suggests that providers have routine opportunities to discuss comprehensive and integrative pain management strategies, including low-cost evidence-based self-management approaches (e.g., physical activity, self-management education programs, cognitive behavioral therapy). Those with multiple opioid prescriptions may need extra support if transitioning to nonopioid and nonpharmacologic pain management strategies.

Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia

BACKGROUND AND AIM

The goal was to evaluate the moderators of mindfulness-based cognitive therapy (MBCT) and cognitive behavioral therapy (CBT) to improve dyspareunia, reduce pain catastrophizing, and improve overall sexual function in women with provoked vestibulodynia (PVD). Both treatments effectively reduced self-reported pain, sexual dysfunction, and pain catastrophizing in women with PVD.

METHODS

A total of 130 women with PVD were assigned to CBT or MBCT.

OUTCOMES

Potential moderators included (i) PVD subtype (primary or secondary), (ii) baseline pain intensity, (iii) trait mindfulness, (iv) treatment credibility, (v) relationship duration, and (vi) age. Outcomes were pain intensity, sexual function, and pain catastrophizing at 4 time points: before and after treatment and 6- and 12-month follow-up. Moderation was tested using multilevel models, nesting 4 time points within participants. The interaction of the moderator, time effect, and treatment group was evaluated for significance, and a simple slope analysis of significant interactions was performed.

RESULTS

Pain reduction across 4 time points was the greatest in women who were younger, in relationships of shorter duration, and with greater baseline pain. Treatment credibility moderated pain intensity outcomes (B = 0.305, P < .01) where those with higher treatment credibility ratings (for that particular treatment) improved more in MBCT than CBT. PVD subtype moderated pain catastrophizing (B = 3.150, P < .05). Those with primary PVD improved more in the CBT condition, whereas women with secondary PVD improved more in the MBCT condition. Relationship length moderated sexual function (B = 0.195, P < .01). Women in shorter relationships improved more with MBCT, whereas women in longer relationships improved more on sexual function with CBT. No other tested variables moderated outcomes differentially across both treatment conditions.

CLINICAL IMPLICATIONS

Women who present with high credibility about mindfulness, in shorter relationships, and with secondary PVD might respond better to MBCT whereas those with primary PVD and longer relationships might respond better to CBT.

STRENGTHS & LIMITATIONS

Clinical sample. Half the women who were not sexually active were omitted from analyses of sexual function.

CONCLUSION

Overall, treatment credibility, relationship length, and PVD subtype were found to moderate improvements differently in MBCT and CBT. These findings may assist clinicians in individualizing psychological treatment for women with PVD.

CLINICAL TRIAL REGISTRATION

This clinical trial was registered with clinicaltrials.gov, NCT01704456. Brotto LA, Zdaniuk B, Rietchel L, et al. Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia. J Sex Med 2020;17:2247-2259.

Pain coping skills training for African Americans with osteoarthritis: results of a randomized controlled trial

African Americans bear a disproportionate burden of osteoarthritis (OA), but they have been underrepresented in trials of behavioral interventions for pain. This trial examined a culturally tailored pain coping skills training (CST) program, compared to a wait list control group, among 248 African Americans with knee or hip OA. The pain CST program involved 11 telephone-based sessions over 3 months. Outcomes were assessed at baseline, 3 months (primary), and 9 months, and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale (primary outcome), WOMAC total score and function subscale, PROMIS Pain Interference, Short-Form 12 Mental and Physical Composite Subscales, Coping Strategies Questionnaire-Total Coping Attempts, Pain Catastrophizing Scale, Patient Health Questionnaire-8, Arthritis Self-Efficacy Scale, and Patient Global Impression of Arthritis Symptom Change. Linear mixed models were fit for all outcomes. There were no significant between-group differences in WOMAC pain score at 3 months (-0.63 [95% confidence interval -1.45, 0.18]; P = 0.128) or 9 months (-0.84 [95% confidence interval -1.73, 0.06]; P = 0.068). Among secondary outcomes, at 3 months, there were significant differences, in favor of the CST group, for Coping Strategies Questionnaire Total Coping Attempts, Pain Catastrophizing Scale, Arthritis Self-Efficacy, and Patient Global Impression of Arthritis Symptom Change (P < 0.01). Coping Strategies Questionnaire Total Coping Attempts, Arthritis Self-Efficacy, and Patient Global Assessment Change were also significantly improved at 9 months in the CST group, compared with wait list (P < 0.01). The culturally tailored pain CST program did not significantly reduce pain severity but did improve key measures of pain coping and perceived ability to manage pain among African Americans with OA.

Serious Gaming During Multidisciplinary Rehabilitation for Patients With Chronic Pain or Fatigue Symptoms: Mixed Methods Design of a Realist Process Evaluation

BACKGROUND

Serious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens.

OBJECTIVE

To realize this potential, insight is needed into how, why, for whom, and when it works in actual treatment circumstances.

METHODS

Following a realist approach, process evaluations were performed before, during, and after a two-armed, natural quasi-experiment (n=275). A group of patients with interfering chronic pain or fatigue symptoms received a short additional blended mindfulness-based serious gaming intervention during a multidisciplinary rehabilitation program. A control group only received the regular rehabilitation program. During two sessions before and one session after the experiment, expectations about serious gaming processes were discussed in focus groups with local care providers, implementers, and experts. Patients participated in a survey (n=114) and in semistructured interviews (n=10). The qualitative data were used to develop tentative expectations about aspects of serious gaming that, in certain patients and circumstances, trigger mechanisms of learning and health outcome change. Hypotheses about indicative quantitative data patterns for tentative expectations were formulated before inspecting, describing, and analyzing-with regression models-routinely collected clinical outcome data. An updated program theory was formulated after mixing the qualitative and quantitative results.

RESULTS

Qualitative data showed that a subset of patients perceived improvement of their self-awareness in moments of daily social interactions. These results were explained by patients, who played the serious game LAKA, as a "confrontation with yourself," which reflected self-discrepancies. Important characteristics of serious gaming in the study's context included innovation factors of relative advantage with experiential learning opportunity, compatibility with the treatment approach, and the limited flexibility in regard to patient preferences. Perceived patient factors included age and style of coping with stress or pain. Learning perceptions could also depend on care provider role-taking and the planning and facilitating (ie, local organization) of serious gaming introduction and feedback sessions in small groups of patients. Quantitative data showed very small average differences between the study groups in self-reported depression, pain, and fatigue changes (-.07<beta<-.17, all 95% CI upper bounds <0), which were mediated by small group differences in mindfulness (beta=.26, 95% CI .02-.51). Mindfulness changes were positively associated with patient involvement in serious gaming (n=114, beta=.36, P=.001). Acceptance of serious gaming was lower in older patients. Average health outcome changes went up to a medium size in patients that reported lower active coping with stress and lower pain coping before serious gaming. Mindfulness changes and gaming acceptance perceptions covaried with group structure and immediate feedback sessions after serious gaming.

CONCLUSIONS

This study developed transferable insight into how and why serious gaming can facilitate additional learning about coping in order to reduce burdens of chronic pain or fatigue symptoms in certain patients and in actual treatment circumstances. Future studies are needed to continue the development of this fallible theory. Such research will further support decisions about using, designing, allocating, and tailoring serious gaming to optimize important patient health benefits.

TRIAL REGISTRATION

Netherlands Trial Register NTR6020; https://www.trialregister.nl/trial/5754.

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.

No effect of cognitive behavioral patient education for patients with pain catastrophizing before total knee arthroplasty: a randomized controlled trial

Background and purpose - Pain catastrophizing contributes to acute and long-term pain after total knee arthroplasty (TKA) but currently there are only limited treatment options. This study investigates the effectiveness of patient education in pain coping among patients with moderate to high pain catastrophizing score before TKA. Secondary outcomes were physical function, quality of life, self-efficacy, and pain catastrophizing.Patients and methods - The study was a parallel-group randomized controlled trial including patients with moderate to high levels of pain catastrophizing. 60 patients were recruited from December 2015 to June 2018. The mean age of the patients was 66 (47-82) years and 40 were women. The patients were randomized to either cognitive-behavioral therapy (CBT) based pain education or usual care. The primary outcome measure was pain under activity measured with the Visual Analog Scale (VAS). All outcomes were measured preoperatively, at 3 months, and at 1 year after surgery.Results - We found no difference in the primary outcome measure, VAS during activity, between the 2 groups but both groups had large reductions over time. The CBT-based pain education group reduced their VAS score by 37 mm (95% CI 27-46) and the control group by 40 mm (CI 31-49). We found no statistically significantly differences between the 2 groups in any of the secondary outcomes.Interpretation - Future research is warranted to identify predictors of persistent pain and interventions for the approximately 20% of patients with persisting pain after a TKA.

The Pain Catastrophizing Scale-short form: psychometric properties and threshold for identifying high-risk individuals

OBJECTIVE

The Pain Catastrophizing Scale (PCS) measures three aspects of catastrophic cognitions about pain-rumination, magnification, and helplessness. To facilitate assessment and clinical application, we aimed to (a) develop a short version on the basis of its factorial structure and the items' correlations with key pain-related outcomes, and (b) identify the threshold on the short form indicative of risk for depression.

DESIGN

Cross-sectional survey.

SETTING

Social centers for older people.

PARTICIPANTS

664 Chinese older adults with chronic pain.

MEASUREMENTS

Besides the PCS, pain intensity, pain disability, and depressive symptoms were assessed.

RESULTS

For the full scale, confirmatory factor analysis showed that the hypothesized 3-factor model fit the data moderately well. On the basis of the factor loadings, two items were selected from each of the three dimensions. An additional item significantly associated with pain disability and depressive symptoms, over and above these six items, was identified through regression analyses. A short-PCS composed of seven items was formed, which correlated at r=0.97 with the full scale. Subsequently, receiver operating characteristic (ROC) curves were plotted against clinically significant depressive symptoms, defined as a score of ≥12 on a 10-item version of the Center for Epidemiologic Studies-Depression Scale. This analysis showed a score of ≥7 to be the optimal cutoff for the short-PCS, with sensitivity = 81.6% and specificity = 78.3% when predicting clinically significant depressive symptoms.

CONCLUSIONS

The short-PCS may be used in lieu of the full scale and as a brief screen to identify individuals with serious catastrophizing.

Internet-based cognitive behavioral therapy aimed at alleviating treatment-induced menopausal symptoms in breast cancer survivors: Moderators and mediators of treatment effects

OBJECTIVES

Results from our recently conducted randomized controlled trial (RCT) indicated that Internet-based cognitive behavioral therapy (iCBT), with or without therapist support, is effective in reducing the perceived impact of hot flushes and night sweats (HF/NS) and overall levels of menopausal symptoms in breast cancer survivors with treatment-induced menopausal symptoms.

STUDY DESIGN

We used data of 235 women and compared the iCBT groups combined (n = 156) with the control group (n = 79). Bootstrapped multiple regression analyses with interaction terms (group x potential moderator) or indirect effects (mediation pathway) were conducted.

MAIN OUTCOME MEASURES

Reductions in perceived impact of HF/NS and overall levels of menopausal symptoms.

RESULTS

Women with lower levels of education benefited most from the iCBT. Age, time since diagnosis, current endocrine treatment, oophorectomy, frequency of HF/NS, and psychological distress did not moderate the treatment effects. Factors that mediated treatment effects were the development of healthier beliefs about experiencing hot flushes in a social context, about the impact of night sweats on sleep and daily functioning, and about the ability to control and cope with hot flushes. The acquisition of behavioral coping strategies and decreased psychological distress did not mediate treatment effects.

CONCLUSION

The results suggest that women with lower levels of education may benefit most from the current iCBT program, with or without therapist support. The development of healthier HF/NS beliefs contribute significantly to the observed positive effect of iCBT on the burden of menopausal symptoms.

CLINICAL TRIAL INFORMATION

NCT02672189.

Depression According to ICD-10 Clinical Interview vs. Depression According to the Epidemiologic Studies Depression Scale to Predict Pain Therapy Outcomes

Purpose

Pain and depression have been shown to have a bidirectional interaction. Although several outcome studies have been conducted, it is still unclear if and how depression influences pain outcome. The current study aims to further clarify this relationship by comparing the predicting value of an interview- and a questionnaire-based assessment of depression.

Patients and Methods

This retrospective study analyzed data of N = 496 chronic pain patients who received a multimodal pain management program. Multilevel models were performed with depression as predictor, pain measures as dependent variables, and the respective pain score at baseline as covariate. Depression was measured at baseline with (1) a semi-structured psychiatric interview corresponding to the ICD-10 and (2) the Center for Epidemiologic Studies Depression Scale (CES-D). Pain outcomes were pain intensity assessed with the Numeric Rating Scale (NRS), pain disability measured with the pain disability index (PDI), and affective as well as sensory pain perception assessed with the Pain Perception Scale (PPS-A/PPS-S).

Results

At post-treatment, pain intensity (NRS) was higher in patients with depression. This result emerged for interview- (ICD-10) and questionnaire- (CES-D) based depression. These results were significant after correction for multiple testing as well. Moreover, affective pain perception (PSS-A) at post-treatment was higher in patients with depression. Again, this result emerged for interview- (ICD-10) and questionnaire- (CES-D) based depression but it was not significant anymore after correction for multiple testing. Furthermore, pain disability (PDI) was higher at post-treatment in patients with depression according to the CES-D than in those without CES-D depression and this difference in the PDI did not emerge for interview-based depression. Yet, this difference on the PDI between the CES-D depression group and the CES-D no depression group was not significant anymore after correction for multiple testing.

Conclusion

The hypothesis that how depression is assessed – interview-based corresponding to the ICD-10 or with the CES-D – contributes to the association between depression and pain treatment outcome could not be confirmed. Future research should use more than one interview and questionnaire to assess depression, since our results are limited to the clinical ICD-10 interview and the CES-D.

An Evaluation of Sex Differences in Patients With Chronic Pain Undergoing an Interdisciplinary Pain Treatment Program

OBJECTIVES

To determine if there are sex differences in a sample of patients participating in a 4-week interdisciplinary pain treatment program in (1) pretreatment pain intensity, physical function, psychological function, pain beliefs, kinesiophobia, pain catastrophizing, and activity management patterns; and (2) treatment response.

METHODS

Seventy-two men and 130 women with chronic pain completed study measures. Analyses of covariance (ANCOVAs) were performed to compare men and women on pretreatment measures. Repeated-measures ANCOVAs were used to compare both sexes on 3 treatment outcomes (pain intensity, physical function, and depressive symptoms).

RESULTS

Before treatment, compared to women, men reported higher levels of kinesiophobia, were more likely to view their pain as being harmful, and used more activity pacing when doing daily activities. Women were more likely to use an overdoing activity pattern than men. No sex differences emerged for pretreatment pain intensity, physical function, psychological function, catastrophizing, activity avoidance, or measures of other pain-related beliefs. At posttreatment, women reported more improvements in pain intensity and physical function compared to men, while both sexes reported similar reductions in depressive symptoms. All effect sizes for statistically significant findings were of small to moderate magnitude.

DISCUSSION

The results of this study suggest that men and women have a comparable profile with respect to the overall burden of chronic pain. Nevertheless, sex differences were found for certain pain beliefs and coping styles. Women appear to reap more benefits from the interdisciplinary pain management program than men. These findings indicate that further research to develop sex-specific assessment procedures and tailored pain treatments may be warranted.

Self-Efficacy and the Role of Non-Pharmacologic Treatment Strategies to Improve Pain and Affect in Arthritis

PURPOSE OF REVIEW

There is increasing evidence that adjunctive, non-pharmacologic treatment programs are beneficial in the management of arthritis when added to traditional disease-modifying medications. This review focuses on non-pharmacologic management strategies that impact pain and affect, with a focus on self-efficacy, for those with osteoarthritis (OA) and rheumatoid arthritis (RA).

RECENT FINDINGS

We reviewed both office-based and internet-based self-management strategies, mindfulness based interventions (MBIs), and cognitive behavioral therapies (CBTs) for patients with arthritis. These behavioral strategies have shown to improve pain, mood disturbance, and physical function in those with both osteoarthritis and rheumatoid arthritis. Improvements in self-efficacy and coping capacity are associated with improvements in patient-reported outcomes (PROs) related to pain and functioning.

SUMMARY

Self-management programs, MBIs, and CBTs are more effective at improving pain and mood disturbance compared to usual care for patients with arthritis although high quality randomized controlled trials are lacking. Non-pharmacologic management programs are increasingly available via the internet and mobile applications.

[Psychogenic pain]

Psychogenic pain is one of the urgent problems of medicine. To date, pathogenetic mechanisms of development of pain syndrome are unclear, there is no uniform classification. Pain, developing in patients with a mental disorder without an organic damage to the nervous system, and pain, which is a complication of an already existing pain syndrome of neuropathic or nociceptive nature, should be considered separately. Treatment of psychogenic pain syndromes should be integrated with the mandatory use of methods aimed at modifying the patient's lifestyle and attitude towards the illness.

A Reduction in Pain Intensity Is More Strongly Associated With Improved Physical Functioning in Frustration Tolerant Individuals: A Longitudinal Moderation Study in Chronic Pain Patients

OBJECTIVE

The onset and chronification of pain often has devastating consequences on the physical and mental functioning of individuals. Medical interventions are quite efficacious in reducing pain levels. However, changes in physical and mental health status after medical interventions are not proportional. In the past decades, rational/irrational beliefs, especially catastrophizing, have contributed to a better understanding of the pain experience. This study explores whether pain reduction efforts are more beneficial for individuals scoring high in rational thinking (moderation).

METHODS

The study design was longitudinal. Patients were assessed twice, 2 weeks prior to the start of medical treatment at the pain clinic and 6 months after. A total of 163 patients with heterogeneous pain (mostly low back and neck pain) participated in the study. Their mean age was 58.74 years (SD = 14.28) and 61.3% were female.

RESULTS

Overall, there was a reduction in pain intensity (t = 4.25, p < 0.001, d = 0.32). An improvement in physical functioning (t = 4.02, p < 0.001, d = 0.19), but not mental health (t = -0.66, p = 0.511, d = 0.11) was also observed. In the regression analyses, a decrease in pain intensity was moderately associated with improved physical health (β = 0.87, t = 4.96, p < 0.001, R 2 change = 0.177). This association was found to be moderated by frustration tolerance (β = -0.49, t = -2.80, p = 0.006, R 2 change = 0.039). Specifically, post hoc analyses indicated that changes in pain intensity only correlated with changes in physical health when patients reported high frustration tolerance levels (r = 0.47, p = 0.006, M = 7, n = 32), but not when patients were intolerant to frustration (r = 0.28, p = 0.078, M = 17, n = 41).

CONCLUSION

The results suggest that frustration tolerance may render adaptive by facilitating the positive effect that a reduction in pain intensity has on physical health status. The study findings are discussed in the context of personalized therapy with an emphasis on how to maximize the effectiveness of current interventions for pain.

Passive Coping Strategies Are Associated With More Impairment In Quality Of Life In Patients With Fibrous Dysplasia

Impairments in quality of life (QoL) have been reported in patients with fibrous dysplasia (FD). Here, we examine coping strategies in FD and assess whether these coping strategies are associated with QoL and disease severity. Ninety-two patients (66% females) filled out the Utrecht Coping List (UCL), Short Form-36, and the Brief Pain Inventory (BPI). Coping strategies of patients with FD were compared with reference data from a random sample of Dutch women and patients with chronic pain. Compared to healthy adults, patients expressed more emotions (p < 0.01). Compared to patients with chronic pain, patients with FD used more active coping strategies (p < 0.001), and sought more distraction (p = 0.01) and more social support (p < 0.001). Using more passive coping strategies was associated with more impairment in social function, physical role, mental health, vitality (all p < 0.001), and general health (p < 0.01). Using more avoidant coping strategies was associated with worse mental health and less vitality (both p < 0.01). More expression of emotions was associated with worse mental health (p < 0.01). Type and clinical severity of FD were not associated with coping behavior. Patients with FD have different coping strategies compared to random Dutch reference populations with or without pain. In FD, using more passive coping strategies was associated with more impairment in several aspects of QoL. There was no relationship between coping behavior and clinical characteristics, pointing to biomedical variables not determining the way patients cope with their illness. Recognition of less effective coping strategies can be helpful in the understanding and adaptation of these coping strategies, improving personalized clinical care, with the ultimate goal to improve QoL in patients with FD.