Assessing physical functioning on pain management programmes: the unique contribution of directly assessed physical performance measures and their relationship to self-reports

An investigation of the associations between stigma, self-compassion, and pain outcomes during treatment based on Acceptance and Commitment Therapy for chronic pain

Introduction

Stigma adversely affects people with chronic pain. The qualities within self-compassion may be particularly useful for buffering the impact of stigma on people with pain. In the context of an Acceptance and Commitment Therapy-based (ACT) treatment for chronic pain, this study investigated the association between changes in stigma and self-compassion and pain outcomes, and the potential moderating role of self-compassion on the association between stigma and pain outcomes.

Materials and methods

Five-hundred and nineteen patients completed standardized self-report questionnaires of stigma, self-compassion, psychological flexibility, pain intensity and interference, work and social adjustment, and depression symptoms at the start of an interdisciplinary ACT-based treatment for chronic pain. The same measures were completed at post-treatment (n = 431).

Results

The results indicated that key pain outcomes and self-compassion significantly improved during treatment, but stigma did not. Changes in stigma and self-compassion were significantly negatively correlated and changes in these variables were associated with improvements in treatment outcomes. There were significant main effects of stigma and self-compassion for many of the pre- and post-treatment regression models when psychological flexibility was not controlled for, but self-compassion did not moderate the association between stigma and pain outcomes. Stigma remained significant when psychological flexibility variables were controlled for, while self-compassion did not.

Discussion

The findings add to our conceptual understanding of the inter-relationships between stigma, self-compassion, and psychological flexibility and can contribute to treatment advancements to optimally target these variables.

Do baseline patient reported outcome measures predict changes in self-reported function, following a chronic pain rehabilitation programme?

Background

Interdisciplinary pain management programmes, based on cognitive-behavioural principles, aim to improve physical and psychological functioning and enhance self-management in people living with chronic pain. Currently there is insufficient evidence about whether psychological, biological or social factors are predictive of positive outcomes following pain rehabilitation. This study aims to evaluate predictors of change in Brief Pain Inventory - pain interference score (BPI) in a clinical data set to determine whether age, sex and baseline outcome measures are predictive of improvement in pain interference following pain rehabilitation.

Methods

A retrospective, pragmatic observational analysis of routinely collected clinical data in two pain rehabilitation programmes, Balanced Life Programme (BLP) and Get Back Active (GBA) was conducted. Standard regression and hierarchical regression analyses were used to identify predictors of change to assess temporal changes in BPI. Responder analysis was also conducted.

Results

Standard regression analyses of 208 (BLP) and 310 (GBA) patients showed that higher baseline BPI and better physical performance measures predicted better improvement in BPI across both programmes. Hierarchical regression showed that age and sex accounted for 2.7% (BLP) and 0.002% (GBA) of the variance in change in BPI. After controlling for age and sex, the other measures explained an additional 23% (BLP) and 19% (GBA) of the variance, p = < .001 where BPI and physical performance measures were consistently statistically significant predictors, p < .05. Responder analysis also showed that pain interference and physical performance were significantly associated with improvement (p = < .0005).

Conclusions

The combination of high self-reported pain interference and better physical performance measures may be a useful indicator of who would benefit from interdisciplinary rehabilitation. Further validation of the results is required.

Agreement between self-reported and observed functioning in patients with rheumatoid arthritis, osteoarthritis, and fibromyalgia, and the influence of pain and fatigue: a cross-sectional study

Objective: To evaluate the relationship between self-reported and performance-based measures of functioning in rheumatoid arthritis (RA), knee osteoarthritis (OA), and fibromyalgia (FM), and the influence of pain and fatigue.Method: Self-reported functioning was assessed by the Stanford Health Assessment Questionnaire, Fibromyalgia Impact Questionnaire, and Knee injury and Osteoarthritis Outcome Score. Performance-based measures of task-related physical activity included grip strength and Six-Minute Walk Test (6MWT). Assessment of Motor and Process Skills (AMPS) was used to obtain performance-based measures of activities of daily living (ADL) ability. Pain and fatigue were assessed by 100 mm visual analogue scales. Spearman's rho correlation and regression modelling were applied.Results: Correlations between self-reported functioning and performance-based measures of ADL ability were weak to moderate, and strongest in OA (r = 0.57, p = 0.002), and AMPS ADL ability measures did not enter regression models as explanatory factors for self-reported functioning. Correlations between AMPS ADL ability measures and measures of task-related physical activity were weak, except for a strong correlation between AMPS ADL motor ability and 6MWT in OA (r = 0.63, p = 0.000). The 6MWT was the only performance-based test explaining variance in AMPS motor ability (OA = 42%; FM = 11%). Pain explained variance in self-reported ability and contributed to variance in AMPS ADL motor ability measures in OA.Conclusion: Self-reported and observed measures of functioning assess partly different aspects of functioning, and both approaches may therefore be relevant in a structured assessment of patients with musculoskeletal disorders.

Assessing the Functional Status of Patients with Chronic Pain-Cross Cultural Adaptation and Psychometric Properties of the Serbian Version of the Pain Disability Questionnaire

The Pain Disability Questionnaire (PDQ) has established itself as a leading patient-reported outcome measure for assessing both mental and physical components of pain-related disability. The current study aimed to translate the PDQ into Serbian and validate its psychometric properties. Following a standard translation process, a total of 554 chronic pain patients (average age 55.37 ± 12.72 years; 375 (67.5%) females) completed the PDQ-Serb, Oswestry Disability Index (ODI), Short Form-36 (SF-36), pain intensity rating and a six-minute walk test (6MWT). Responsiveness was examined in a subsample of 141 patients who completed an inpatient rehabilitation program. The internal consistency of the PDQ-Serb was excellent (Cronbach α = 0.92) and test-retest reliability was favorable (ICC = 0.87). Factor analyses found a bifactor model to be the best fit (CFI = 0.97: TLI = 0.96: RMSEA = 0.05; SRMR = 0.03). Statistically significant Pearson’s coefficient correlations (p < 0.001) were found between the PDQ-Serb and ODI (r = 0.786), SF-36 Physical Components summary (r = −0.659), SF-36 Mental Components summary (r = −0.493), pain intensity rating (r = 0.572), and 6MWT (r = −0.571). Significant post-treatment improvements following inpatient rehabilitation were found with the PDQ-Serb (p < 0.001; effect size 0.431) and other clinical variables (p < 0.001; effect sizes from 0.367 to 0.536). The PDQ-Serb was shown to be a reliable and valid self-report instrument for the evaluation of pain-related disability.

Pharmacist-led intervention on chronic pain management: A systematic review and meta-analysis

AIMS

Pharmacists have been contributing to the management of chronic pain, ensuring the quality use of medicine. However, there is diversity in the interventions provided by pharmacists and their impact.

METHODS

Six electronic databases were searched from inception until June 2020 for articles published in English examining the intervention provided by the pharmacist in chronic pain management. Studies investigating the impact of pharmacist intervention individually or multidisciplinary teams including pharmacists for chronic pain management were included.

RESULTS

Fourteen studies (2365 participants) were included in the current review. Six studies were randomized controlled trials while the remainder were observational studies in which pharmacists provided intervention individually or in collaboration with other healthcare professionals. Medication review was the most common intervention provided by the pharmacist. The pooled analysis found that pharmacist-led interventions reduced the pain intensity (-0.22; 95% confidence interval [CI]: -0.35 to -0.09; moderate certainty) among participants with chronic pain. Opiate stewardship provided by pharmacists was effective; however, mixed results were noted on the impact of the intervention on physical functioning, anxiety, depression and quality of life. Pharmacist intervention was more expensive than treatment as usual.

CONCLUSIONS

Pharmacists contribute substantially to chronic pain management, ensuring the quality use of medicine, resulting in reduced pain intensity. Further studies with rigorous design are needed to measure the impact of pharmacist-provided intervention individually or in a multidisciplinary team on the economic benefit and other health outcomes.

Psychosocial Correlates of Objective, Performance-Based, and Patient-Reported Physical Function Among Patients with Heterogeneous Chronic Pain

BACKGROUND

Improving all aspects of physical function is an important goal of chronic pain management. Few studies follow recent guidelines to comprehensively assess physical function via patient-reported, performance-based, and objective/ambulatory measures.

PURPOSE

To test 1) the interrelation between the 3 types of physical function measurement and 2) the association between psychosocial factors and each type of physical function measurement.

METHODS

Patients with chronic pain (N=79) completed measures of: 1) physical function (patient-reported disability; performance-based 6-minute walk-test; objective accelerometer step count); 2) pain and non-adaptive coping (pain during rest and activity, pain-catastrophizing, kinesiophobia); 3) adaptive coping (mindfulness, general coping, pain-resilience); and 4) social-emotional dysfunction (anxiety, depression, social isolation and emotional support). First, we tested the interrelation among the 3 aspects of physical function. Second, we used structural equation modeling to test associations between psychosocial factors (pain and non-adaptive coping, adaptive coping, and social-emotional dysfunction) and each measurement of physical function.

RESULTS

Performance-based and objective physical function were significantly interrelated (r=0.48, p<0.001) but did not correlate with patient-reported disability. Pain and non-adaptive coping (β=0.68, p<0.001), adaptive coping (β=-0.65, p<0.001) and social-emotional dysfunction (β=0.65, p<0.001) were associated with patient-reported disability but not to performance-based or objective physical function (ps>0.1).

CONCLUSION

Results suggest that patient-reported physical function may provide limited information about patients' physical capacity or ambulatory activity. While pain and non-adaptive reactions to it, adaptive coping, and social-emotional dysfunction may potentially improve patient-reported physical function, additional targets may be needed to improve functional capacity and ambulatory activity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03412916.

Reliability and validity of Five Times Sit to Stand Test in pregnancy-related pelvic girdle pain

BACKGROUND

Pelvic girdle pain (PGP) is a common musculoskeletal disorder during pregnancy, and functional mobility evaluation is very important in reflecting the treatment effects.

OBJECTIVES

To investigate reliability and validity of Five Times Sit-to-Stand (5TSS) test in pregnant women with and without PGP.

DESIGN

A cross-sectional observational study.

METHODS

One hundred sixty-seven women in the second or third trimester of pregnancy participated in two assessments one week apart. The 5TSS and Timed Up & Go (TUG) tests were used to assess functional mobility, in a randomized sequence, by two independent raters. Time to complete the tests were recorded. Perceived pain and difficulty during functional mobility tests were marked on two Visual Analogue Scales. Following tests of functional mobility, seven clinical tests were used to classify the subjects as with or without PGP.

RESULTS

The 25% of subjects had PGP. Inter-rater reliability of 5TSS was excellent for subjects with and without PGP (ICC = 0.999, 95% CI = 0.999-1.000; ICC = 0.999, 95% CI = 0.999-0.999, respectively). Test-retest reliability of 5TSS was also very high for subjects with and without PGP (ICC = 0.986, 95% CI = 0.959-0.995; ICC = 0.828, 95% CI = 0.632-0.920, respectively). The 5TSS scores were positively correlated with TUG scores (r = 0.420, p = 0.006 and r = 0.404, p = 0.000, respectively). The subjects reported higher pain (95% CI = 0.322-0.824) and difficulty (95%Cl = 0.500-1.042) during 5TSS than the TUG test.

CONCLUSIONS

The 5TSS test is a reliable and valid functional mobility outcome measure in pregnant women with and without PGP. Further psychometric properties of the measure such as responsiveness, should be investigated in the future.

Task-Contingent Persistence is Related to Better Performance-Based Measures in Patients with Chronic Musculoskeletal Pain

Purpose

Pacing, avoidance, and overdoing are considered the three main behavioral strategies, also labeled activity patterns. Their relationship with functioning of patients with chronic pain is debated. The purpose of this study was to measure the influence of activity patterns on lifting tasks commonly used in daily life.

Method

We performed a monocentric observational study and included patients performing Functional Capacity Evaluation (FCE). Avoidance, pacing, and persistence were assessed with using the Patterns of Activity Measures-Pain (POAM-P). Maximal safe performance was measured for floor-to-waist, waist-to-overhead, horizontal lift, and carrying with dominant-hand tests according to the FCE guidelines. Descriptive statistics, associations of POAM-P subscales with various sociodemographic variables, and correlations are presented. Standard multiple linear regression models were applied to measure the associations between FCE tests and POAM-P subscales, adjusting for the following potential confounders: age, gender, body mass index (BMI), pain severity, trauma severity, localization of injury, and education.

Results

Persistence was significantly positively associated with performance on the 4 FCE tests: floor-to-waist (coefficient = 0.20; p=0.001), waist-to-overhead (coefficient = 0.13; p=0.004), horizontal lift (coefficient = 0.31; p ≤ 0.001), and dominant-handed lifting (coefficient = 0.19; p=0.001). Pacing was found to have a negative influence on the carrying dominant-hand test (coefficient = -0.14; p=0.034), and avoidance was not found to have an influence on the 4 FCE tests.

Conclusion

This study shows that task-persistence pattern is positively associated with physical performance in FCE, whereas pacing can have a negative influence on some tests.

Body mass in adolescents with chronic pain: observational study

OBJECTIVE

In a paediatric chronic pain population, to determine whether higher body mass was associated with poorer functioning, mood or treatment outcome.

DESIGN

Cross-sectional study with examination of treatment outcomes.

SETTING

Tertiary specialist adolescent pain rehabilitation unit.

PATIENTS

355 adolescents with relatively severe non-malignant chronic pain.

INTERVENTIONS

Intensive 3-week pain rehabilitation programme.

MAIN OUTCOME MEASURES

Objective physical measures (walk, sit-to-stand); self-reported functioning and mood RESULTS: Average body mass index (BMI) in the sample was relatively high (24.2 (SD 5.6)) with 20.5% being classified as obese. However, there were no relationships between body mass and objective physical measures, physical or social functioning, depression or anxiety (all p>0.05). There was a small relationship between higher body mass and greater pain-related fear (r=0.17, p<0.01). Treatment improved all variables (p<0.001) apart from pain intensity. There were no relationships between higher body mass and poorer treatment outcome; in fact, patients with higher BMI showed slightly greater decreases in depression (r=0.12, p<0.05) and pain-specific anxiety (r=0.18, p<0.01) during treatment.

CONCLUSIONS

Higher body mass does not worsen functioning, mood or treatment response in adolescents with disabling chronic pain. Childhood obesity and chronic pain are both stigmatised conditions; clinicians should avoid implying that high body mass alone is a causal factor in the struggles of a young person with chronic pain.

The Timed Up & Go test in pregnant women with pelvic girdle pain compared to asymptomatic pregnant and non-pregnant women

BACKGROUND

The Timed Up and Go (TUG) test, a standardized functional mobility test, has been proposed as a physical performance-based measure in pregnant women with pelvic girdle pain (PGP).

OBJECTIVES

This cross-sectional study aimed to investigate physical function by the use of TUG in pregnant women with PGP compared to asymptomatic pregnant and non-pregnant women, and to identify factors associated with increased TUG.

METHODS

In total, 25 pregnant women with PGP, 24 asymptomatic pregnant and 25 asymptomatic non-pregnant women participated. One-way analysis of variance was used to explore difference in TUG between the groups and multiple linear regression analyses to explore associations between TUG and potential explanatory variables.

RESULTS

The time on TUG varied among pregnant women with PGP, and was significantly higher (mean (95% CI) 6.9 (6.5, 7.3) seconds) than for asymptomatic pregnant (5.8 (5.5, 6.0), p < 0.001) and non-pregnant (5.5 (5.4, 5.6), p < 0.001) women. In the total study sample, group, increased BMI and sick leave were significantly associated with increased TUG (p-values≤0.02). In pregnant women with PGP, pain intensity was the only significant clinical factor associated with increased TUG (p = 0.002).

CONCLUSION

Pregnant women with PGP used longer time and showed larger variation in TUG than asymptomatic pregnant and non-pregnant women, this underpins that TUG targets activities relevant to PGP. Our results provide new knowledge about factors influencing TUG time. Importantly, multivariable analyses suggest that pain intensity should be considered when interpreting TUG time in pregnant women with PGP.

Comparison of STarT Back Screening Tool and Simmonds Physical Performance Based Test Battery in Prediction of Disability Risks Among Patients with Chronic Low-Back Pain

Objectives This study identified disability sub-groups of patients with chronic low back pain (LBP) using the Subgroup for Targeted Treatment (or STarT) Back Screening Tool (SBST) and Simmonds Physical Performance Tests Battery (SPPTB). In addition, the study investigated the divergent validity of SBST, and compared the predictive validity of SBST and SPPTB among the patients with the aim to enhance quick and accurate prediction of disability risks among patients with chronic LBP. Methods This exploratory cross-sectional study involved 70 (52.0% female and 47.1% male) consenting patients with chronic non-specific LBP attending out-patient physiotherapy and Orthopedic Clinics at the Obafemi Awolowo University Teaching Hospitals, Ile-Ife and Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria. Disability risk subgrouping and prediction were carried out using the SBST and SPPTB (comprising six functional tasks of repeated trunk flexion, sit-to-stand, 360-degree rollover, Sorenson fatigue test, unloaded reach test, and 50 foot walk test). Pain intensity was assessed using the Quadruple Visual Analogue Scale. Data on age, sex, height, weight and BMI were also collected. Descriptive and inferential statistics were used to analyze data at p<0.05 Alpha level. Results The mean age, weight, height and body mass index of the participants were 51.4 ±8.78 years, 1.61 ±0.76 m and 26.6 ±3.18 kg/m2 respectively. The mean pain intensity and duration were 5.37 ±1.37 and 21.2 ±6.68 respectively. The divergent validity of SBST with percentage overall pain intensity was r = 0.732; p = 0.001. Under SBST sub-grouping the majority of participants were rated as having medium disability risk (76%), whilst SPPTB sub-grouped the majority as having high disability risk (71.4%). There was a significant difference in disability risk subgrouping between SBST and SPPTB (χ²=12.334; p=0.015). SBST had no floor and ceiling effects, as less than 15% of the participants reached the lowest (2.9%) or highest (1.4%) possible score. Conversely, SPPBT showed both floor and ceiling effects, as it was unable to detect ‘1’ and ‘9’, the lowest and highest obtainable scores. The ‘Area Under Curve’ for sensitivity (0.83) and specificity (0.23) of the SBST to predict ‘high-disability risk’ was 0.51. The estimated prevalence for ‘high-disability risk’ prediction of SBST was 0.76. The estimate for true positive, false positive, true negative and false negative for prediction of ‘high-disability risk’ for SBST were 0.77, 0.23, 0.31, and 0.69 respectively. Conclusion The Start Back Screening Tool is able to identify the proportion of patients with low back pain with moderate disability risks, while the Simmonds Physical Performance Tests Battery is better able to identify high disability risks. Thus, SBST as a self-report measure may not adequately substitute physical performance assessment based disability risks prediction. However, SBST has good divergent predictive validity with pain intensity. In contrast to SPBBT, SBST exhibited no floor or ceiling effects in our tests, and demonstrated high sensitivity but low specificity in predicting ‘high-disability risk’.

Avoidance, pacing, or persistence in multidisciplinary functional rehabilitation for chronic musculoskeletal pain: An observational study with cross-sectional and longitudinal analyses

Background

Three main activity patterns have been distinguished in describing chronic pain (avoidance, pacing and persistence). However, their influence on patient outcomes remains a question of debate. This observational study aimed to measure the associations between the avoidance, pacing, and persistence (labelled overdoing) scales of the Patterns of Activity Measure–Pain (POAM-P), self-reported outcomes (pain-interference, depression, functional ability), and observational outcomes (walking, lifting test, physical fitness).

Methods

We conducted an observational study with cross-sectional and longitudinal analyses. The data were collected prospectively before and after treatment, which was a 5-week functional rehabilitation including vocational aspects. In addition to self-reported and observational outcomes, patients were asked if they thought they would be able to return to work at 6 months. Analyses were conducted with treatment effect sizes, correlations, and multiple regression models.

Results

In this sample (891 patients), we found on average small to moderate improvements for pain-interference and observational outcomes (Cohen’s d: 0.37 to 0.64). According to the multivariable models, overdoing was associated with most of the beneficial psychosocial and observational outcomes (β -0.13 to 0.17; all p<0.01). Avoidance was related to negative psychosocial outcomes before treatment (β -0.09 to 0.17; all p<0.015). Pacing, which had moderate correlation with avoidance (r = 0.46), was not associated with most of the outcomes. The feeling that the goal of returning to work was attainable was associated with lower avoidance scores (adjusted OR 0.97; p = 0.024).

Conclusions

The overdoing POAM-P scale probably measures a task-contingent persistence, which appears appropriate in the setting of this study. Persistent behavior was indeed related to small or moderate positive biopsychosocial outcomes, before and after treatment. Moreover feeling able to return to work was related to lower avoidance. Further studies should test the efficacy of motivational strategies that may promote functional task-contingent persistence and reduce avoidance of painful tasks.

Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change

Long-term use of opioid medication is associated with a host of negative effects on health and quality of life. Guidelines state that people with chronic pain taking high doses of opioids without benefit should be supported to discontinue them. Little research has investigated psychological processes associated with analgesic use and tapering. This study investigated (1) analgesic use pre- and post-participation in an interdisciplinary pain management programme and its relationship to functioning and (2) psychological processes associated with analgesic use. Opioid use was associated with poorer functioning at baseline. Participating in an interdisciplinary pain management programme was associated with reductions in opioid dose and number of classes of analgesics used. Reductions in analgesic use were associated with improvements in functioning. Psychological inflexibility was associated with using higher doses of opioid medication and with using a greater number of classes of analgesics. Psychological flexibility appears relevant in explaining analgesic use. Future research could focus on targeting this process to improve tapering outcomes.