A blind randomized controlled trial of cognitive versus behavioral versus cognitive-behavioral therapy for patients with rheumatoid arthritis

A Tale of Two Treatments: A Randomised Controlled Trial of Mindfulness or Cognitive Behaviour Therapy Delivered Online for People with Rheumatoid Arthritis

INTRODUCTION

This study aimed to determine the relative efficacy of mindfulness-based stress reduction (MBSR) or cognitive behaviour therapy (CBT) in comparison to a waitlist control (WLC) for people with rheumatoid arthritis (RA). Participants completed assessments before and after treatment and at 6-month follow-up.

METHODS

Two hundred and sixty-nine participants with RA were recruited and randomised in a 2:2:1 ratio to MBSR:CBT:WLC. Participants completed a semi-structured clinical interview for depression and were stratified for history of recurrent depression. We measured the primary outcome of pain interference, as well as pain severity, depression, anxiety, functional ability, and fear of progression. We predicted that MBSR and CBT would result in improvements compared to WLC. We also predicted that those with a history of recurrent depression would benefit more from MBSR than CBT for depression.

RESULTS

MBSR and CBT were equally efficacious in reducing pain interference compared to WLC. Similar results were found for depression. MBSR demonstrated superior outcomes to CBT for fear of progression at post-treatment and functional ability at 6-month follow-up. CBT only was better than WLC for pain severity at 6-month follow-up. Depressive status did not moderate the efficacy of treatment.

CONCLUSIONS

MBSR and CBT resulted in statistically and clinically significant changes in pain interference compared to WLC. MBSR was more efficacious than CBT for functional ability and fear of progression, while CBT showed superiority for pain severity. The effect sizes were comparable to those achieved with face-to-face interventions, confirming both online treatments are effective for people with RA.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Understanding the Role of Therapist Quality in Accounting for Heterogeneity of Patient Outcomes in Psychosocial Chronic Pain Treatments

A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.

Prevalence, Severity, and Measures of Anxiety in Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

Many studies have reported high rates of anxiety in adults with rheumatoid arthritis (RA). The aim of this systematic review was to examine those findings and determine the overall prevalence, severity, and commonly used measures of anxiety in individuals with RA.

METHODS

Six databases were searched from January 2000 without restrictions on language/location, study design, or gray literature. All identified studies that examined anxiety prevalence and severity in adults with RA, as assessed with clinical diagnostic interview and/or standardized self-report measures, were considered for inclusion. Quality assessment of included studies was conducted using a modified Newcastle-Ottawa Evaluation Scale, and the findings were synthesized via a narrative approach.

RESULTS

Across the 47 studies (n = 11,085 participants), the sample size ranged from 60 to 1,321 participants with seven studies including healthy controls or groups with other health conditions. The studies were conducted across 23 countries, and anxiety prevalence ranged from 2.4% to 77%, predominantly determined with standardized self-report measures, of which Hospital Anxiety and Depression scale was used most frequently; only eight studies used a clinical diagnostic interview to confirm a specific anxiety diagnosis. Notable associations with anxiety in RA were physical disability, pain, disease activity, depression, and quality of life.

CONCLUSION

The reported prevalence of anxiety in RA varied widely potentially because of use of different self-report measures and cutoff points. Such cutoff points will need to be standardized to clinical thresholds to inform appropriate interventions for anxiety comorbidity in RA.

Comparative efficacy of psychological interventions on immune biomarkers: A systematic review and network meta-analysis (NMA)

Psychological interventions are viable, cost-effective strategies for improving clinical and psychological impact of inflammation-related conditions. However, their efficacy on immune system function remains controversial. We performed a systematic review and frequentist random-effects network meta-analysis of randomised controlled trials (RCTs) assessing the effects of psychological interventions, against a control condition, on biomarkers of innate and adaptive immunity in adults. PubMed, Scopus, PsycInfo, and Web of Science were searched from inception up to Oct 17, 2022. Cohen's d at 95% confidence interval (CI) was calculated to assess the effect sizes of each class of intervention against active control conditions at post-treatment. The study was registered in PROSPERO (CRD42022325508). Of the 5024 articles retrieved, we included 104 RCTs reporting on 7820 participants. Analyses were based on 13 types of clinical interventions. Compared with the control conditions, cognitive therapy (d =  - 0.95, 95% CI: -1.64 to - 0.27), lifestyle (d =  - 0.51, 95% CI: -0.99 to - 0.02), and mindfulness-based (d =  - 0.38, 95% CI: -0.66 to - 0.09) interventions were associated with post-treatment reduction of proinflammatory cytokines and markers. Mindfulness-based interventions were also significantly associated with post-treatment increase in anti-inflammatory cytokines (d = 0.69, 95% CI: 0.09 to 1.30), while cognitive therapy was associated also with post-treatment increase in white blood cell count (d = 1.89, 95% CI: 0.05 to 3.74). Results on natural killer cells activity were non-significant. Grade of evidence was moderate for mindfulness and low-to-moderate for cognitive therapy and lifestyle interventions; however, substantial overall heterogeneity was detected in most of the analyses.

Self-management support needs of patients with inflammatory arthritis and the content of self-management interventions: a scoping review

BACKGROUND

Self-management skills can empower a person to manage the physical, psychological, and social impact of a health condition. However, the components of self-management interventions differ widely between studies and interventions. By performing a scoping review, we aimed to describe patients' self-management needs and how health professionals (HPs) can provide effective self-management support to patients with inflammatory arthritis (IA).

OBJECTIVES

1) to identify the evidence for self-management support needs of patients with IA, and 2) to identify the content (theory/theoretical approach, mode of delivery, duration and frequency) of self-management interventions that target patients with IA.

METHODS

In May 2021, we performed a systematic literature search (from 2000 onward) in five databases (CINAHL (Ebsco), Cochrane Library, Embase (Ovid), Medline (Ovid) and PsycINFO (Ovid)) regarding self-management in patients with IA.

RESULTS

Out of 11,748 records identified, we included 31 articles describing patients' support needs and 33 articles describing the content of self-management interventions. Patients' support needs were sorted into six topics: 1) disease impact and the pharmacological treatment, 2) care continuity and relations with HPs, 3) the importance of non-pharmacological treatment, 4) the need for support from family and friends, 5) support needs related to work issues, and 6) contextual preferences for self-management support. The theory/theoretical approach, mode of delivery, duration and frequency varied widely and were often unclearly or insufficiently described. In addition, the self-management concept was scarcely - or not - defined in the included articles. The identified topics for support needs were compared with the described content in the included articles. Only a few self-management interventions focused on patients' need for support in relation to work, and to family and friends.

CONCLUSION

HPs provided self-management support to patients with IA in various ways, but there were gaps between the patients' support needs and the identified interventions. In developing self-management interventions, the self-management concept needs to be defined and a clear theory is required to support the development of the intervention. Future studies should seek to investigate various modes of delivery, frequency and duration, to develop effective interventions that meet patients' support needs.

Behavioral activation therapy for depression is associated with a reduction in the concentration of circulating quinolinic acid

BACKGROUND

An inflammation-induced imbalance in the kynurenine pathway (KP) has been reported in major depressive disorder but the utility of these metabolites as predictive or therapeutic biomarkers of behavioral activation (BA) therapy is unknown.

METHODS

Serum samples were provided by 56 depressed individuals before BA therapy and 29 of these individuals also provided samples after 10 weeks of therapy to measure cytokines and KP metabolites. The PROMIS Depression Scale (PROMIS-D) and the Sheehan Disability Scale were administered weekly and the Beck depression inventory was administered pre- and post-therapy. Data were analyzed with linear mixed-effect, general linear, and logistic regression models. The primary outcome for the biomarker analyses was the ratio of kynurenic acid to quinolinic acid (KynA/QA).

RESULTS

BA decreased depression and disability scores (p's < 0.001, Cohen's d's > 0.5). KynA/QA significantly increased at post-therapy relative to baseline (p < 0.001, d = 2.2), an effect driven by a decrease in QA post-therapy (p < 0.001, uncorrected, d = 3.39). A trend towards a decrease in the ratio of kynurenine to tryptophan (KYN/TRP) was also observed (p = 0.054, uncorrected, d = 0.78). Neither the change in KynA/QA, nor baseline KynA/QA were associated with response to BA therapy.

CONCLUSION

The current findings together with previous research show that electronconvulsive therapy, escitalopram, and ketamine decrease concentrations of the neurotoxin, QA, raise the possibility that a common therapeutic mechanism underlies diverse forms of anti-depressant treatment but future controlled studies are needed to test this hypothesis.

Non-pharmacological treatment in difficult-to-treat rheumatoid arthritis

Although the management of rheumatoid arthritis (RA) has improved remarkably with new pharmacological therapies, there is still a significant part of patients not reaching treatment goals. Difficult-to-treat RA (D2TRA) is a complex entity involving several factors apart from persistent inflammation, thereafter requiring a holistic management approach. As pharmacological treatment options are often limited in D2TRA, the need for non-pharmacological treatments (NPT) is even more pronounced. The mechanism of action of non-pharmacological treatments is not well investigated, NPTs seem to have a complex, holistic effect including the immune, neural and endocrine system, which can have a significant additive benefit together with targeted pharmacotherapies in the treatment of D2TRA. In this review we summarize the current knowledge on different NPT in rheumatoid arthritis, and we propose a NPT plan to follow when managing D2TRA patients.

Psychosocial Interventions and Immune System Function: A Systematic Review and Meta-analysis of Randomized Clinical Trials

IMPORTANCE

Recent estimates suggest that more than 50% of all deaths worldwide are currently attributable to inflammation-related diseases. Psychosocial interventions may represent a potentially useful strategy for addressing this global public health problem, but which types of interventions reliably improve immune system function, under what conditions, and for whom are unknown.

OBJECTIVE

To address this issue, we conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) in which we estimated associations between 8 different psychosocial interventions and 7 markers of immune system function, and examined 9 potential moderating factors.

DATA SOURCES

PubMed, Scopus, PsycInfo, and ClinicalTrials.gov databases were systematically searched from February 1, 2017, to December 31, 2018, for all relevant RCTs published through December 31, 2018.

STUDY SELECTION

Eligible RCTs included a psychosocial intervention, immune outcome, and preintervention and postintervention immunologic assessments. Studies were independently examined by 2 investigators. Of 4621 studies identified, 62 were eligible and 56 included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and analyzed from January 1, 2019, to July 29, 2019. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed. Data were extracted by 2 investigators who were blind to study hypotheses and analyses, and were then analyzed using robust variance estimation. Analysis included 8 psychosocial interventions (behavior therapy, cognitive therapy, cognitive behavior therapy [CBT], CBT plus additive treatment or mode of delivery that augmented the CBT, bereavement or supportive therapy, multiple or combined interventions, other psychotherapy, and psychoeducation), 7 immune outcomes (proinflammatory cytokine or marker levels, anti-inflammatory cytokine levels, antibody levels, immune cell counts, natural killer cell activity, viral load, and other immune outcomes), and 9 moderating factors (intervention type, intervention format, intervention length, immune marker type, basal vs stimulated markers, immune marker measurement timing, disease state or reason for treatment, age, and sex).

MAIN OUTCOMES AND MEASURES

The primary a priori outcomes were pretest-posttest-control (ppc) group effect sizes (ppc g) for the 7 immunologic outcomes investigated.

RESULTS

Across 56 RCTs and 4060 participants, psychosocial interventions were associated with enhanced immune system function (ppc g = 0.30, 95% CI, 0.21-0.40; t50.9 = 6.22; P < .001). Overall, being randomly assigned to a psychosocial intervention condition vs a control condition was associated with a 14.7% (95% CI, 5.7%-23.8%) improvement in beneficial immune system function and an 18.0% (95% CI, 7.2%-28.8%) decrease in harmful immune system function over time. These associations persisted for at least 6 months following treatment and were robust across age, sex, and intervention duration. These associations were most reliable for CBT (ppc g = 0.33, 95% CI, 0.19-0.47; t27.2 = 4.82; P < .001) and multiple or combined interventions (ppc g = 0.52, 95% CI, 0.17-0.88; t5.7 = 3.63; P = .01), and for studies that assessed proinflammatory cytokines or markers (ppc g = 0.33, 95% CI, 0.19-0.48; t25.6 = 4.70; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that psychosocial interventions are reliably associated with enhanced immune system function and may therefore represent a viable strategy for improving immune-related health.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012.

OBJECTIVES

To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU).

SEARCH METHODS

We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials.

SELECTION CRITERIA

RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end.

DATA COLLECTION AND ANALYSIS

Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment.

MAIN RESULTS

We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned.

AUTHORS' CONCLUSIONS

We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.

Immune response to stress induction as a predictor of cognitive-behavioral therapy outcomes in adolescent mood disorders: A pilot study

Cognitive-behavioral therapy (CBT) alleviates symptoms of depression in youth with bipolar disorder (BD) and major depressive disorder (MDD). Empirical research has linked inflammatory markers to depressive symptoms and acute psychosocial stress; however, a gap remains as to whether immune response to stress may serve as a putative mechanism of treatment. This preliminary pilot study determined the modest feasibility of assessing psychobiological response to stress as a predictor of CBT outcomes for youth with mood disorders. We evaluated whether participation in a 10-session group-CBT intervention for mood disorders altered inflammatory response to a laboratory psychosocial stress induction and if this alteration in immune stress responsivity was related to a decrease in depressive symptoms. Thirty-four youth (age M = 15.03, SD = 1.91) diagnosed with BD or MDD participated in a 10-session CBT group and pre- and post-group assessments; twenty-eight participants who completed the group had usable cytokine data. Pre- and post-group assessments included stress induction with the Trier Social Stress Test (TSST) during which inflammatory cytokines were measured at baseline (time 0) and after the TSST at 30, 60, and 90 min. Results suggest it is modestly feasible to measure immune response to stress alongside CBT treatment for adolescent mood disorders. Our findings were mixed; across seven cytokines, hierarchical linear models indicated two cytokines, IL6 and IL12, were sensitive to acute laboratory stress. We also found significant correlations between life stress, inflammation, and depression both pre- and post- CBT group. Inflammation pre-group, as measured by IL12 and IL1 β predicted depressive symptoms following treatment. Although we did not find significant within-subject reductions in inflammation, chronic stress predicted changes in IL β, signaling the central role of chronic stress. This study offers preliminary evidence that immune responsivity to stress induction could serve as a mechanism of treatment for mood disorders in youth, indicating a potential marker for more personalized model of healthcare.

Effects of psychological interventions on systemic levels of inflammatory biomarkers in humans: A systematic review and meta-analysis

The purpose of the present investigation was to systematically review randomized controlled trials examining the effects of psychological interventions on inflammatory biomarkers in adult populations and to quantitatively analyze those effects by meta-analysis. Two researchers independently searched key electronic databases, selected eligible publications, extracted data, and evaluated methodological quality. Nineteen randomized controlled trials examining a total of 1510 participants were included. The overall combined effect size from pre to post psychological intervention on pro-inflammatory biomarker levels was statistically significant, showing an attenuating effect, although of a small magnitude (s' g = 0.15, p = .008, CI [0.04-0.26]). However, this effect was not maintained into the follow-up period (g < -0.01, p = .964, CI [-0.19-0.18]). Looking at the individual biomarkers assessed across studies, only C-reactive protein (CRP) was found to significantly decrease following psychological intervention. A number of moderation analyses were conducted, none of which reached statistical significance. However, the numerically largest - and significant - within-group effect size was obtained for the group of studies that had preselected participants based on elevated psychological distress (g = 0.29, p = .047). In conclusion, psychological interventions appear efficacious in reducing pro-inflammatory biomarker levels. Future studies are recommended to carefully select individuals based on inflammatory (e.g., the presence of low-grade inflammation) and/or psychological (e.g., psychological distress) criteria.

The Relationship Between Pacing and Avoidance in Chronic Pain: A Systematic Review and Meta-Analysis

Activity pacing is ubiquitous in chronic pain management and aims to reduce pain-contingent avoidance of activity to improve functioning. A meta-analysis, however, has linked pacing with higher levels of pain and disability. One potential explanation is an overlap between existing measures of pacing and avoidance, leading to links with poorer outcomes that are typically associated with avoidance. This study systematically reviews the evidence regarding the relationship between measures of pacing and avoidance. A search was conducted for studies measuring both constructs in adults with chronic pain. A meta-analysis of correlations between pacing and avoidance was conducted; 16 studies were included and a small positive correlation was found (r = .290, P < .001) overall. Single-item and multiple-item measures were also compared; a moderate positive correlation was found for multiple-item measures (r = .410, P < .001), which differed significantly from a small positive correlation found for single-item measures (r = .105, P < .001). Due to limited studies, independent analyses of individual subscales were not possible. Existing measures of pacing-particularly multiple-item measures-may partially confound pacing with avoidance. Further research is required to ensure that a reliable measure of pacing that distinguishes this construct from avoidance is available to adequately evaluate pacing instruction and the effect of pacing on key outcomes in chronic pain.

PERSPECTIVE

This meta-analysis examines the correlation between pacing and avoidance in adults with chronic pain. Results indicate that existing measures may partially confound pacing with avoidance. Directions for future research are proposed to ensure that an adequate measure of pacing exists to evaluate its effect on key outcomes in chronic pain.

Effectiveness of Occupational Therapy Interventions for Adults With Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

We reviewed the efficacy of occupational therapy-related interventions for adults with rheumatoid arthritis.

METHOD

We examined 51 Level I studies (19 physical activity, 32 psychoeducational) published 2000-2014 and identified from five databases. Interventions that focused solely on the upper or lower extremities were not included.

RESULTS

Findings related to key outcomes (activities of daily living, ability, pain, fatigue, depression, self-efficacy, disease symptoms) are presented. Strong evidence supports the use of aerobic exercise, resistive exercise, and aquatic therapy. Mixed to limited evidence supports dynamic exercise, Tai Chi, and yoga. Among the psychoeducation interventions, strong evidence supports the use of patient education, self-management, cognitive-behavioral approaches, multidisciplinary approaches, and joint protection, and limited or mixed evidence supports the use of assistive technology and emotional disclosure.

CONCLUSION

The evidence supports interventions within the scope of occupational therapy practice for rheumatoid arthritis, but few interventions were occupation based.

[EULAR recommendations for patient education of people with inflammatory arthritis. Translation and evaluation in Germany]

In 2015 EULAR published recommendations for patient education of people with inflammatory arthritis. The recommendations included two superior principles and eight recommendations based on the level of evidence and expert knowledge. The German translation of the recommendations was evaluated by 15 German experts. Experts graded the strength of the recommendations (SOR) on an 11 point numerical rating scale (from 0 = no agreement to 10 = total agreement). The mean score was 8,8 ± 0,49.

Systematic Review of Educational Interventions for Rheumatoid Arthritis

OBJECTIVE

In this study, we systematically reviewed the effectiveness of educational interventions falling within the scope of occupational therapy practice for people with rheumatoid arthritis (RA). These interventions included disease education, joint protection and energy conservation, psychosocial techniques, pain management, and a combination category.

METHOD

Two databases, MEDLINE and CINAHL, and select journals were searched for randomized controlled trials published between January 2002 and June 2015. Qualitative synthesis was used for between-study comparisons.

RESULTS

Twenty-two studies, with approximately 2,600 participants, were included. The interventions were found to have strong evidence for constructs that dealt with increasing coping with pain and fatigue as well as maintaining positive affect. There was limited or no evidence supporting the effectiveness of these interventions on most other measured constructs.

CONCLUSION

Interventions in which a combination of educational techniques is used may complement pharmacological therapies in the care of people with RA. Future research is needed to identify specific mechanisms of change.

Self-Management Interventions to Prevent Depression in People with Mobility Limitations

Introduction

This focused review reports on the impact of self-management interventions on depression in people with a mobility disability.

Method

There were two phases to the search including a comprehensive scoping review of the literature examining multiple secondary conditions impacted by self-management programs (Phase 1) and a focused review of the literature detailing the impact of self-management interventions on depression (Phase 2). CINAHL, PubMed, and PsyclNFO were searched for articles published between January 1988 through August 2014 and studies were screened by the first author based on specific inclusion and exclusion criteria.

Results

Twenty-five studies met criteria with results, demonstrating a mixed effect of self-management programs on depression. Sixteen studies included an intervention and control/comparison group, of which eight (50%) had a significant effect on depression. A further nine studies did not include a control/comparison group and five found significant changes in depression and four found no change. Eighteen out of 25 studies (72%) were rated as having moderate-to-high bias and nine different outcome measures were used across studies.

Discussion

Based on the mixed findings and varied approaches adopted for intervention and outcome assessment, future research should adopt a more rigorous methodological approach to examine self-management interventions on depression.

Psychosocial management of chronic pain in patients with rheumatoid arthritis: challenges and solutions

There are numerous reviews and meta-analyses that confirm that psychological therapy is efficacious for patients with rheumatoid arthritis (RA) in terms of managing pain. Therefore, the literature has moved on to answer additional questions: 1) What types of interventions are most strongly supported by the current evidence? 2) Do different patients benefit from different approaches? 3) When is it best to intervene? 4) What modalities are best for administering the intervention? 5) What model of care should we be proposing that will result in widespread implementation and will ensure access for patients with RA? This review concludes that cognitive behavioral therapy (CBT) is the most efficacious treatment for pain management in RA; however, there are indications that mindfulness may have particular benefits for patients with a history of depression. CBT is most effective when administered early in the course of the disease. However, there is at present little evidence to confirm whether or not psychosocial interventions are effective for patients with comorbid psychological disorders. One of the major challenges is ensuring access to effective interventions for patients, particularly early on in the course of the disease, with a view to preventing physical and psychological morbidity. A stepped-care model is proposed; however, we urgently need more, better-quality trials of minimal interventions, particularly in Internet-delivered CBT, which appears promising and may form the cornerstone of future stepped-care models for providing psychosocial care to patients with RA.

Psychological Treatments and Psychotherapies in the Neurorehabilitation of Pain: Evidences and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

BACKGROUND

It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams.

OBJECTIVES

To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases.

METHODS

A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions.

RESULTS

The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive-Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post-Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache.

CONCLUSIONS

Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the paper.

[Psychiatric aspects of rheumatoid arthritis: Review of literature]

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory degenerative disease whose symptoms are mainly joint with significant functional impact, resulting in a restriction of the activities of the patient and increasing the impact on mental well-being. Several studies have been conducted to explore psychiatric disorders comorbid with RA.

OBJECTIVE

The objective of this review is to present the various psychiatric manifestations of RA reported in the medical literature.

METHODS

A literature review was conducted using the Pubmed search with the following keywords: psychiatry, psychiatric manifestations, rheumatoid arthritis. Three hundred and sixty-one articles were reviewed for relevance and 47 references were selected.

RESULTS

Among the major psychiatric disorders found in RA, the anxiety and depressive disorders are prevalent (13 to 48% of patients), as well as suicide, insomnia and tiredness. The impairment of quality of life is markedly after age 65. The association between RA and schizophrenia seems negative so that factors predisposing one is protective for the other.

CONCLUSION

Comorbid psychiatric disorders with RA are prevalent and may increase the impairment of quality of life for patients. The detection and treatment of psychiatric disorders improve the care of patients with RA.

The role of outcome expectancies for a training program consisting of meditation, breathing exercises, and cold exposure on the response to endotoxin administration: a proof-of-principle study

Expectancies play a major role for the treatment outcome of a broad variety of immune-mediated conditions and may strengthen or mimic the effects of regular long-term therapies. This study adds to a recently published study of Kox et al. (PNAS 111:7379-7384, 2014) on the ability to voluntarily influence the physiological stress response in healthy men after a training program consisting of meditation, breathing techniques, and exposure to cold, which found highly promising results on the clinical, autonomic, and immune response to experimentally induced inflammation (using the experimental human endotoxemia model). Within this project, a number of variables were included to assess the role of generalized (optimism, neuroticism) and specific outcome expectancies (related to the effects of the training on health) on the response to endotoxin administration after training. Indications were found that especially the generalized outcome expectancy optimism is a potential determinant of the autonomic (epinephrine: rho = 0.76, p < .01) and immune response (interleukin-10: rho = 0.60, p < .05) to induced inflammation after training, whereas more specific expectations with regard to the effects of the training could be especially relevant for the clinical symptom report (flu-like symptoms: rho = -0.71, p < .01). This proof-of-principle study provides first indications for potential innovative treatments to change immune-modulating responses by means of psychological mechanisms. If replicated, these findings may be used for predicting training responses and potentiate their effects by means of optimism-inducing interventions in patients with immune-mediated rheumatic conditions.

EULAR recommendations for patient education for people with inflammatory arthritis

OBJECTIVES

The task force aimed to: (1) develop evidence-based recommendations for patient education (PE) for people with inflammatory arthritis, (2) identify the need for further research on PE and (3) determine health professionals' educational needs in order to provide evidence-based PE.

METHODS

A multidisciplinary task force, representing 10 European countries, formulated a definition for PE and 10 research questions that guided a systematic literature review (SLR). The results from the SLR were discussed and used as a basis for developing the recommendations, a research agenda and an educational agenda. The recommendations were categorised according to level and strength of evidence graded from A (highest) to D (lowest). Task force members rated their agreement with each recommendation from 0 (total disagreement) to 10 (total agreement).

RESULTS

Based on the SLR and expert opinions, eight recommendations were developed, four with strength A evidence. The recommendations addressed when and by whom PE should be offered, modes and methods of delivery, theoretical framework, outcomes and evaluation. A high level of agreement was achieved for all recommendations (mean range 9.4-9.8). The task force proposed a research agenda and an educational agenda.

CONCLUSIONS

The eight evidence-based and expert opinion-based recommendations for PE for people with inflammatory arthritis are intended to provide a core framework for the delivery of PE and training for health professionals in delivering PE across Europe.

Optimizing pain management through collaborations with behavioral and addiction medicine in primary care

Chronic noncancer pain (CNCP) affects many primary care patients, and carries a large human and economic burden. In response to the widespread perception that pain is underdiagnosed and undertreated, regulatory bodies have encouraged more comprehensive services to address pain syndromes. Significant hurdles exist in treating CNCP in primary care settings, and interventional therapies and pharmacotherapy often do not provide complete symptomatic relief. This article describes a multidimensional and interdisciplinary approach to the treatment of CNCP. The utility of collaborations with behavioral and addiction medicine specialists optimizes care and advances models of patient treatment within a primary care patient-centered medical home.

Randomised controlled trial of group cognitive behaviour therapy versus brief intervention for depression in cardiac patients

OBJECTIVE

To determine whether a six-session group cognitive behaviour therapy (CBT) programme results in a greater reduction in depression symptoms than a brief intervention alone in cardiac patients with clinically significant symptoms of depression.

METHOD

Fifty-seven community dwelling cardiac patients scoring >13 on the Beck Depression Inventory-II (BDI-II) received a single-session brief intervention. They were then block randomised to either six sessions of group CBT (n = 25) or no further intervention (BI; n = 32). All were re-assessed at 2, 6 and 12 months. Differences between treatment groups in the primary (BDI-II) and secondary [rates of depression; anxiety symptoms, as measured by the Hospital Anxiety and Depression Scale-Anxiety (HADS-A)] outcomes were examined using generalised linear mixed models with a random intercept term for the individual.

RESULTS

Significant improvements were seen for the total group from baseline to 12 months on BDI-II and HADS-A scores. However, no differences were found between the CBT and BI conditions on change in BDI-II score, rates of major depressive episode or HADS-A score. Post hoc analysis on the total group found 12-month symptom non-remission was associated with higher baseline BDI-II score (p = 0.03), more visits to health professionals 12 months prior to baseline (p = 0.05) and a greater likelihood of either drinking alcohol over recommended levels or smoking at baseline (p = 0.01).

CONCLUSIONS

Group CBT of up to six sessions did not result in greater reductions in depression or anxiety symptoms compared with a single-session brief intervention. Further work should focus on the efficacy and role of brief interventions, and addressing smoking and alcohol misuse in cardiac patients with depression.