A Mind-Body Physical Activity Program for Chronic Pain With or Without a Digital Monitoring Device: Proof-of-Concept Feasibility Randomized Controlled Trial

"Alone in the dark": A qualitative study of treatment experiences among young adults with a recent concussion and anxiety

PURPOSE

Young adults with anxiety are vulnerable to developing persistent symptoms following concussions. In order to develop psychosocial interventions to prevent persistent post-concussion symptoms, we need to understand patients' 1) experiences with treatments offered by health care providers; 2) experiences with attempted concussion management strategies; and 3) needs after their injury.

METHODS

We conducted in-depth interviews with 17 young adults with recent (≤ 10 weeks) concussions who have at least mild anxiety (Generalized Anxiety Disorder Assessment-7 ≥ 5). We used a hybrid deductive-inductive approach to thematic analysis.

RESULTS

Findings provide insight into recommended treatments (e.g., active/avoidant strategies, accommodations, referrals), attempted strategies (e.g., lifestyle changes, pacing, relationships, acceptance-based coping skills), and patient needs (e.g., education, accommodations, referrals for cognitive and emotional skills). Participants frequently expressed that treatment recommendations were confusing and difficult to implement. They initiated non-prescribed strategies that helped promote recovery and expressed a desire for more interdisciplinary treatment and education on concussions.

CONCLUSION

Patients' perceptions of health care provider recommendations after concussions did not fully meet patients' perceived needs. Young adults with concussions and anxiety would benefit from more education, guidance, and psychosocial and rehabilitation services. Addressing these gaps may help align treatments with patients' needs and therefore help optimize their recovery.

Feasibility and preliminary effects of a mindfulness-based physical exercise (MBPE) program for community-dwelling older people with sarcopenia: A protocol for a parallel, two-armed pilot randomised controlled trial

INTRODUCTION

Physical exercise (PE) is essential for alleviating the symptoms of sarcopenia. Low motivation is a major barrier to PE. Mindfulness-based intervention (MBI) has the potential to improve motivation. However, few studies have used a mindfulness-based PE (MBPE) intervention among older people with sarcopenia.

OBJECTIVES

To assess the feasibility, acceptability and preliminary effects of the MBPE program among community-dwelling older people with sarcopenia.

METHODS AND ANALYSIS

A two-arm pilot randomised controlled trial will be conducted to assess the feasibility, acceptability and preliminary effects of an MBPE program among community-dwelling older people with sarcopenia. A total of 60 participants will be randomised into the intervention group, receiving the MBPE intervention twice a week over 12 weeks, or the control group, receiving health education with the same duration, number of sessions and frequency as the intervention group. Each session of the MBPE program will last about 60 min, including 5-10- min introduction, 20-min MBI, 30-min PE and 5-10-min sharing and discussion. The primary outcomes will be the feasibility (i.e., the time spent recruiting participants, the eligibility rate and the recruitment rate) and acceptability (i.e., the attendance rate, completion rate and attrition rate) of the MBPE program. The secondary outcomes will be the preliminary effects of the MBPE program on symptoms of sarcopenia, motivation for PE, psychological well-being, mindfulness level, physical activity level and quality of life. Individual interviews will be conducted to identify the strengths, limitations and therapeutic components of the intervention. The quantitative data will be analysed by generalised estimating equations. The qualitative data will be analysed by Braun and Clarke's thematic approach.

CONCLUSION

The findings of this study will be able to provide evidence for the health professionals in adopting MBPE as a supportive intervention for the older adults with sarcopenia and the groundworks for the researchers in developing non-pharmacological intervention for older adults. The positive effects could facilitate healthy ageing and relief the burden of the medical system, especially in the countries facing the ageing population.

TRIAL REGISTRATION NUMBER

NCT05982067; ClinicalTrials.gov.

Improving multimodal physical function in adults with heterogeneous chronic pain; Protocol for a multisite feasibility RCT

BACKGROUND

Chronic pain is associated with substantial impairment in physical function, which has been identified as a top concern among persons with pain. GetActive-Fitbit, a mind-body activity program, is feasible, acceptable, and associated with improvement in physical function among primarily White, sedentary individuals with pain. In preparation for a multisite efficacy trial, we must examine feasibility across multiple sites with diverse patient populations. Here we describe the protocol of a multisite, feasibility RCT comparing GetActive-Fitbit with a time- and attention-matched educational comparison (Healthy Living for Pain). We aim to 1) test multisite fidelity of clinician training; 2) evaluate multisite feasibility benchmarks, including recruitment of chronic pain patients taking <5000 steps/day and racial and ethnic minorities; and 3) optimize fidelity and study protocol in preparation for a future multisite efficacy trial.

METHODS

Clinician training fidelity was assessed via roleplays and mock group sessions. Feasibility (i.e., recruitment, acceptability, credibility, adherence, satisfaction), multimodal physical function (e.g., self-report, 6-Minute Walk Test, step-count), and other psychosocial outcomes are assessed at baseline, posttest, and 6 months. Protocol optimization will be assessed using exit interviews and cross-site meetings.

RESULTS

The trial is ongoing. Clinician training is complete. 87 participants have been recruited. 54 completed baseline assessments and randomization, 44 are mid-intervention, and 9 have completed the intervention and posttest.

CONCLUSIONS

This study addresses the critical need for feasible, acceptable mind-body-activity interventions for chronic pain that follow evidence-based guidelines and improve all aspects of physical function across diverse populations. Results will inform a future fully-powered multisite efficacy trial.

CLINICAL TRIAL REGISTRATION

NCT05700383.

Feasibility of wearable activity tracking devices to measure physical activity and sleep change among adolescents with chronic pain-a pilot nonrandomized treatment study

Purpose

Personal informatics devices are being used to measure engagement in health behaviors in adults with chronic pain and may be appropriate for adolescent use. The aim of this study was to evaluate the utilization of a wearable activity tracking device to measure physical activity and sleep among adolescents attending a three-week, intensive interdisciplinary pain treatment (IIPT) program. We also assessed changes in physical activity and sleep from baseline to the treatment phase.

Methods

Participants (57.1% female, average age 15.88, SD = 1.27) wore an activity tracking device three weeks prior to starting and during the treatment program.

Results

Of 129 participants contacted, 47 (36.4%) agreed to participate. However, only 30 (64%) complied with the instructions for using the device prior to programming and during program participation. Preliminary analyses comparing averages from 3-weeks pre-treatment to 3-weeks during treatment indicated increases in daily overall activity minutes, daily step counts, and minutes of moderate to vigorous physical activity (by 353%), as well as a corresponding decrease in sedentary minutes. There was more missing data for sleep than anticipated.

Conclusions

Wearable activity tracking devices can be successfully used to measure adolescent physical activity in-person, with more difficulty obtaining this information remotely. Adolescents with chronic pain experience improvements in objective measurements of physical activity over the course of a 3-week IIPT program. Future studies may want to spend more time working with pediatric patients on their understanding of how to use trackers for sleep and physical activity.

Improving Health for Older Adults With Pain Through Engagement: Protocol for Tailoring and Open Pilot Testing of a Mind-Body Activity Program Delivered Within Shared Medical Visits in an Underserved Community Clinic

BACKGROUND

Chronic musculoskeletal pain is prevalent and disabling among older adults in underserved communities. Psychosocial pain management is more effective than pharmacological treatment in older adults. However, underserved community clinics often lack psychosocial treatments, in part because of a lack of trained providers. Shared medical appointments, in which patients undergo brief medical evaluation, monitoring, counseling, and group support, are an efficacious and cost-effective method for chronic disease management in underserved clinics, reducing the need for specialized providers. However, shared medical visits are often ineffective for chronic pain, possibly owing to lack of inclusion of skills most relevant for older adults (eg, pacing to increase engagement in daily activities).

OBJECTIVE

We have described the protocol for the development and initial pilot effectiveness testing of the GetActive+ mind-body activity intervention for older adults with chronic pain. GetActive+ was adapted from GetActive, an evidence-based intervention that improved pain outcomes among mostly affluent White adults. We aim to establish the initial feasibility, acceptability, fidelity, and effectiveness of GetActive+ when delivered as part of shared medical appointments in a community clinic.

METHODS

We conducted qualitative focus groups and individual interviews with providers (n=25) and English-speaking older adults (aged ≥55 y; n=18) with chronic pain to understand the pain experience in this population, perceptions about intervention content, and barriers to and facilitators of intervention participation and implementation in this setting. Qualitative interviews with Spanish-speaking older adults are in progress and will inform a future open pilot of the intervention in Spanish. We are currently conducting an open pilot study with exit interviews in English (n=30 individuals in total). Primary outcomes are feasibility (≥75% of patients who are approached agree to participate), acceptability (≥75% of patients who enrolled complete 8 out of 10 sessions; qualitative), and fidelity (≥75% of session components are delivered as intended). Secondary outcomes include physical function-self-reported, performance based (6-minute walk test), and objective (step count)-and emotional function (depression and anxiety). Other assessments include putative mechanisms (eg, mindfulness and pain catastrophizing).

RESULTS

We began enrolling participants for the qualitative phase in November 2022 and the open pilot phase in May 2023. We completed the qualitative phase with providers and English-speaking patients, and the results are being analyzed using a hybrid, inductive-deductive approach. We conducted rapid analysis of these data to develop GetActive+ before the open pilot in English, including increasing readability and clarity of language, reducing the number of skills taught to increase time for individual check-ins and group participation, and increasing experiential exercises for skill uptake.

CONCLUSIONS

We provide a blueprint for the refinement of a mind-body activity intervention for older adults with chronic pain in underserved community clinics and for incorporation within shared medical visits. It will inform a future, fully powered, effectiveness-implementation trial of GetActive+ to help address the chronic pain epidemic among older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05782231; https://clinicaltrials.gov/study/NCT05782231.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52117.

Behavioral Mechanisms That Mediate Mental and Physical Health Improvements in People With Chronic Pain Who Receive a Digital Health Intervention: Prospective Cohort Pilot Study

BACKGROUND

Preliminary evidence suggests that digital mental health intervention (Wysa for Chronic Pain) can improve mental and physical health in people with chronic musculoskeletal pain and coexisting symptoms of depression or anxiety. However, the behavioral mechanisms through which this intervention acts are not fully understood.

OBJECTIVE

The purpose of this study was to identify behavioral mechanisms that may mediate changes in mental and physical health associated with use of Wysa for Chronic Pain during orthopedic management of chronic musculoskeletal pain. We hypothesized that improved behavioral activation, pain acceptance, and sleep quality mediate improvements in self-reported mental and physical health.

METHODS

In this prospective cohort, pilot mediation analysis, adults with chronic (≥3 months) neck or back pain received the Wysa for Chronic Pain digital intervention, which uses a conversational agent and text-based access to human counselors to deliver cognitive behavioral therapy and related therapeutic content. Patient-reported outcomes and proposed mediators were collected at baseline and 1 month. The exposure of interest was participants' engagement (ie, total interactions) with the digital intervention. Proposed mediators were assessed using the Behavioral Activation for Depression Scale-Short Form, Chronic Pain Acceptance Questionnaire, and Athens Insomnia Scale. Outcomes included Patient-Reported Outcomes Measurement Information System Anxiety, Depression, Pain Interference, and Physical Function scores. A mediation analysis was conducted using the Baron and Kenny method, adjusting for age, sex, and baseline mediators and outcome values. P<.20 was considered significant for this pilot study.

RESULTS

Among 30 patients (mean age 59, SD 14, years; 21 [70%] female), the mediation effect of behavioral activation on the relationship between increased intervention engagement and improved anxiety symptoms met predefined statistical significance thresholds (indirect effect -0.4, 80% CI -0.7 to -0.1; P=.13, 45% of the total effect). The direction of mediation effect was generally consistent with our hypothesis for all other proposed mediator or outcome relationships, as well.

CONCLUSIONS

In a full-sized randomized controlled trial of patients with chronic musculoskeletal pain, behavioral activation, pain acceptance, and sleep quality may play an important role in mediating the relationship between use of a digital mental health intervention (Wysa for Chronic Pain) and improved mental and physical health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05194722; https://clinicaltrials.gov/ct2/show/NCT05194722.

Effects of a Mind-Body Program for Chronic Pain in Older versus Younger Adults

Purpose

Improving physical function is key to decreasing the burden of chronic pain across the lifespan. Although mind-body interventions show promise in increasing physical function in chronic pain, very little is known about whether older and younger adults derive similar benefit. Indeed, older adults experience higher rates of chronic pain and greater impacts of pain on physical function compared to younger adults. Therefore, additional work is needed to determine the extent of benefit older versus younger adults receive from a mind-body intervention. Here, we examined age differences in the effects of two mind-body and walking programs on pain and multimodal physical function.

Participants and Methods

Participants were 82 individuals with heterogenous chronic musculoskeletal pain (66% female, 57% aged ≥50 years) who participated in a feasibility randomized controlled trial of two mind-body interventions. They completed self-reported (WHODAS 2.0), performance-based (6-minute walk test), and objective (accelerometer-measured step count) measures of physical function, as well as self-report measures of pain intensity, before and after the intervention.

Results

Results indicated that adults aged ≥50 (vs adults aged <50) demonstrated greater improvements in performance-based physical function (6-minute walk test) and reductions in pain during activity. No age differences in the effects of the intervention on self-reported or objectively measured physical function were observed.

Conclusion

Collectively, these findings suggest that older adults can achieve equivalent or greater benefits from mind-body programs for chronic pain, despite facing unique challenges to chronic pain management (eg, multimorbidity, greater sedentary behavior).

The relationship between mindfulness and enduring somatic threat severity in long-term cardiac arrest survivors

BACKGROUND

Cardiac arrest (CA) survivors experience continuous exposures to potential traumas though chronic cognitive, physical and emotional sequelae and enduring somatic threats (ESTs) (i.e., recurring somatic traumatic reminders of the event). Sources of ESTs can include the daily sensation of an implantable cardioverter defibrillator (ICD), ICD-delivered shocks, pain from rescue compressions, fatigue, weakness, and changes in physical function. Mindfulness, defined as non-judgmental present-moment awareness, is a teachable skill that might help CA survivors cope with ESTs. Here we describe the severity of ESTs in a sample of long-term CA survivors and explore the cross-sectional relationship between mindfulness and severity of ESTs.

METHODS

We analyzed survey data of long-term CA survivors who were members of the Sudden Cardiac Arrest Foundation (collected 10-11/2020). We assessed ESTs using 4 cardiac threat items from the Anxiety Sensitivity Index-revised (items range from 0 "very little" to 4 "very much") which we summed to create a score reflecting total EST burden (range 0-16). We assessed mindfulness using the Cognitive and Affective Mindfulness Scale-Revised. First, we summarized the distribution of EST scores. Second, we used linear regression to describe the relationship between mindfulness and EST severity adjusting for age, gender, time since arrest, COVID-19-related stress, and loss of income due to COVID.

RESULTS

We included 145 CA survivors (mean age: 51 years, 52% male, 93.8% white, mean time since arrest: 6 years, 24.1% scored in the upper quarter of EST severity). Greater mindfulness (β: -30, p = 0.002), older age (β: -0.30, p = 0.01) and longer time since CA (β: -0.23, p = 0.005) were associated with lower EST severity. Male sex was also associated with greater EST severity (β: 0.21, p = 0.009).

CONCLUSION

ESTs are common among CA survivors. Mindfulness may be a protective skill that CA survivors use to cope with ESTs. Future psychosocial interventions for the CA population should consider using mindfulness as a core skill to reduce ESTs.

Feasibility of using remotely delivered Spring Forest Qigong to reduce neuropathic pain in adults with spinal cord injury: a pilot study

Introduction: Approximately 69% of 299,000 Americans with spinal cord injury (SCI) suffer debilitating chronic neuropathic pain, which is intractable to treatment. The aim of this study is to determine feasibility, as the primary objective, and estimates of efficacy of a remotely delivered Qigong intervention in adults with SCI-related neuropathic pain, as the secondary objective. Methods: We recruited adults with SCI-related neuropathic pain, with SCI ≥3 months, with complete or incomplete SCI, and highest neuropathic pain level of >3 on the Numeric Pain Rating Scale (NPRS), using nationwide volunteer sampling. Using a non-randomized controlled trial design, participants practiced Spring Forest Qigong's "Five Element Qigong Healing Movements" (online video) by combining movement to the best of their ability with kinesthetic imagery, at least 3x/week for 12 weeks. Adherence was automatically tracked through the Spring Forest Qigong website. Outcomes of neuropathic pain intensity (NPRS) were assessed weekly, and SCI-related symptoms were assessed at baseline, 6, and 12 weeks of Qigong practice and at 6-week and 1-year follow-ups. Results: We recruited 23 adults with chronic SCI (7/2021-2/2023). In total, 18 participants started the study and completed all study components, including the 6-week follow-up. Twelve participants completed the 1-year follow-up assessment. Feasibility was demonstrated through participants' willingness to participate, adherence, and acceptability of the study. Mean age of the 18 participants was 60 ± 12 years, and they were 15 ± 11 years post-SCI with the highest baseline neuropathic pain of 7.94 ± 2.33, which was reduced to 4.17 ± 3.07 after 12 weeks of Qigong practice (Cohen's d = 1.75). This pain relief remained at 6-week and 1-year follow-ups. Participants reported reduced spasm frequency (change score 1.17 ± 1.20, d = 0.98) and severity (0.72 ± 1.02, d = 0.71), reduced interference of neuropathic pain on mood (3.44 ± 2.53, d = 1.36), sleep (3.39 ± 2.40, d = 1.41), daily activities (3.17 ± 2.77, d = 1.14), greater ability to perform functional activities (6.68 ± 3.07, d = 2.18), and improved mood (2.33 ± 3.31, d = 0.70) after Qigong. Discussion: Remote Spring Forest Qigong's "Five Element Qigong Healing Movements" practice is feasible in adults with SCI-related neuropathic pain, with promising prolonged results of neuropathic pain relief and improvement in SCI-related symptoms after Qigong practice. Clinical trial registration: https://www.clinicaltrials.gov/ct2/show/NCT04917107, identifier NCT04917107.

Using remotely delivered Spring Forest Qigong™ to reduce neuropathic pain in adults with spinal cord injury: protocol of a quasi-experimental feasibility clinical trial

BACKGROUND

About 69% of Americans living with spinal cord injury (SCI) suffer from long-term debilitating neuropathic pain, interfering with the quality of daily life. Neuropathic pain is refractory to many available treatments-some carrying a risk for opioid addiction-highlighting an urgent need for new treatments. In this study, we will test our hypothesis that Spring Forest Qigong™ will reduce SCI-related neuropathic pain by improving body awareness. We will determine whether remotely delivered Qigong is feasible and we will collect data on neuropathic pain, and other reported associations with pain such as spasms frequency and/or severity, functional performance, mood, and body awareness.

METHODS

In this quasi-experimental pilot clinical trial study, adults with SCI will practice Qigong at home with a 45-min video, at least 3 × /week for 12 weeks. The Qigong practice includes movements with guided breathing and is individualized based on functional abilities, i.e., the participants follow along with the Qigong movements to the level of their ability, with guided breathing, and perform kinesthetic imagery by focusing on the feeling in the whole body as if doing the whole-body Qigong movement while standing. The highest, average, and lowest neuropathic pain ratings perceived in the prior week will be recorded weekly until the 6-week follow-up. The other outcomes will be collected at 5 time points: at baseline, midway during the Qigong intervention (6 weeks), after the Qigong intervention (12 weeks), after a 6-week and 1-year follow-up. Rate parameters for the feasibility markers will be estimated based on the participants who achieved each benchmark.

DISCUSSION

The University of Minnesota (UMN)'s Institutional Review Board (IRB) approved the study (IRB #STUDY00011997). All participants will sign electronic informed consent on the secure UMN REDCap platform. The results will be presented at academic conferences and published in peer-reviewed publications.

TRIAL REGISTRATION

ClinicalTrial.gov registration number: NCT04917107 , (this protocol paper refers to the substudy), first registered 6/8/2021.

Protective positive psychology factors and emotional distress after cardiac arrest

BACKGROUND

There is a critical need to identify factors that can prevent emotional distress post-cardiac arrest (CA). CA survivors have previously described benefitting from utilizing positive psychology constructs (mindfulness, existential well-being, resilient coping, social support) to cope with distress. Here, we explored associations between positive psychology factors and emotional distress post-CA.

METHODS

We recruited CA survivors treated from 4/2021-9/2022 at a single academic medical center. We assessed positive psychology factors (mindfulness [Cognitive and Affective Mindfulness Scale-Revised], existential well-being [Meaning in Life Questionnaire Presence of Meaning subscale], resilient coping [Brief Resilient Coping Scale], perceived social support [ENRICHD Social Support Inventory]) and emotional distress (posttraumatic stress [Posttraumatic Stress Checklist-5], anxiety and depression symptoms [PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a]) just before discharge from the index hospitalization. We selected covariates for inclusion in our multivariable models based on an association with any emotional distress factor (p < 0.10). For our final, multivariable regression models, we individually tested the independent association of each positive psychology factor and emotional distress factor.

RESULTS

We included 110 survivors (mean age 59 years, 64% male, 88% non-Hispanic White, 48% low income); 36.4% of survivors scored above the cut-off for at least one measure of emotional distress. In separate adjusted models, each positive psychology factor was independently associated with emotional distress (β: -0.20 to -0.42, all p < 0.05).

CONCLUSIONS

Higher levels of mindfulness, existential well-being, resilient coping, and perceived social support were each associated with less emotional distress. Future intervention development studies should consider these factors as potential treatment targets.

Identifying body awareness-related brain network changes after Spring Forest Qigong™ practice or P.Volve low-intensity exercise in adults with chronic low back pain: a feasibility Phase I Randomized Clinical Trial

Background

Chronic low back pain (cLBP) affects the quality of life of 52 million Americans and leads to an enormous personal and economic burden. A multidisciplinary approach to cLBP management is recommended. Since medication has limited efficacy and there are mounting concerns about opioid addiction, the American College of Physicians and American Pain Society recommend non-pharmacological interventions, such as mind and body approaches (e.g., Qigong, yoga, Tai Chi) before prescribing medications. Of those, Qigong practice might be most accessible given its gentle movements and because it can be performed standing, sitting, or lying down. The three available Qigong studies in adults with cLBP showed that Qigong reduced pain more than waitlist and equally well than exercise. Yet, the duration and/or frequency of Qigong practice were low (<12 weeks or less than 3x/week). The objectives of this study were to investigate the feasibility of practicing Spring Forest Qigong™ or performing P.Volve low intensity exercises 3x/week for 12 weeks, feasibility of recruitment, data collection, delivery of the intervention as intended, as well as identify estimates of efficacy on brain function and behavioral outcomes after Qigong practice or exercise. To our knowledge, this is the first study investigating the feasibility of the potential effect of Qigong on brain function in adults with cLBP.

Methods

We conducted a feasibility Phase I Randomized Clinical Trial. Of the 36 adults with cLBP recruited between January 2020 and June 2021, 32 were enrolled and randomized to either 12 weeks of remote Spring Forest Qigong™ practice or remote P.Volve low-intensity exercises. Participants practiced at least 3x/week for 41min/session with online videos. Our main outcome measures were the Numeric Pain Rating Scale (highest, average, and lowest cLBP pain intensity levels in the prior week), assessed weekly and fMRI data (resting-state and task-based fMRI tasks: pain imagery, kinesthetic imagery of a Qigong movement, and robot-guided shape discrimination). We compared baseline resting-state connectivity and brain activation during fMRI tasks in adults with cLBP with data from a healthy control group (n=28) acquired in a prior study. Secondary outcomes included measures of function, disability, body awareness, kinesiophobia, balance, self-efficacy, core muscle strength, and ankle proprioceptive acuity with a custom-build device.

Results

Feasibility of the study design and methods was demonstrated with 30 participants completing the study (94% retention) and reporting high satisfaction with the programs; 96% adherence to P.Volve low-intensity exercises, and 128% of the required practice intensity for Spring Forest Qigong™ practice. Both groups saw promising reductions in low back pain (effect sizes Cohen's d =1.01-2.22) and in most other outcomes ( d =0.90-2.33). Markers of ankle proprioception were not significantly elevated in the cLBP group after the interventions. Brain imaging analysis showed weaker parietal operculum and insula network connectivity in adults with cLBP (n=26), compared to data from a healthy control group (n=28). The pain imagery task elicited lower brain activation of insula, parietal operculum, angular gyrus and supramarginal gyrus at baseline in adults with cLBP than in healthy adults. Adults with cLBP had lower precentral gyrus activation than healthy adults for the Qigong movement and robot task at baseline. Pre-post brain function changes showed individual variability: Six (out of 13) participants in the Qigong group showed increased activation in the parietal operculum, angular gyrus, supramarginal gyrus, and precentral gyrus during the Qigong fMRI task.

Interpretation

Our data indicate the feasibility and acceptability of using Spring Forest Qigong™ practice or P.Volve low-intensity exercises for cLBP relief showing promising results in terms of pain relief and associated symptoms. Our brain imaging results indicated brain function improvements after 12 weeks of Qigong practice in some participants, pointing to the need for further investigation in larger studies.

Trial registration number

ClinicalTrials.gov: NCT04164225 .

Using remotely delivered Spring Forest Qigong™ to reduce neuropathic pain in adults with spinal cord injury: A non-randomized controlled trial

Importance

The manuscript proposes the feasibility and potential of a remote Qigong intervention to reduce neuropathic pain in adults with spinal cord injury (SCI)-related neuropathic pain.

Objective

We determined the feasibility and estimates of efficacy of a remotely delivered Qigong intervention in adults with SCI-related neuropathic pain.

Design

This is a non-randomized controlled trial with outcomes assessed at baseline-, 6- and 12-weeks of Qigong practice, and at 6-weeks and 1-year follow-up.

Setting

Completely remote clinical trial.

Participants

Adults with SCI-related neuropathic pain, with SCI ≥3 months, with complete or incomplete SCI, and highest neuropathic pain level of >3 on the Numeric Pain Rating Scale (NPRS). We used nationwide volunteer sampling.We recruited 23 adults with chronic SCI (7/2021-2/2022). Eighteen participants started the study and completed all study components, including the 6-week follow-up. Twelve participants completed the 1-year follow-up assessment.

Intervention

Participants practiced the Spring Forest Qigong™ "Five Element Healing Movements" with an online video by combining movement with kinesthetic imagery, at least 3x/week for 12 weeks.

Main Outcomes and Measures

To address the feasibility outcome and track adherence, the website automatically monitored the days and duration that the Qigong video was played. Self-report neuropathic pain intensity and SCI-related symptoms such as spasms, functional performance, mood, and body appreciation were also collected.

Results

Eighteen participants, 60±12 years of age, 15±11 years post-SCI had a highest baseline neuropathic pain of 7.94±2.33 on the NPRS, which was reduced to 4.17±3.07 after 12 weeks of Qigong practice (Cohen's d =1.75). This pain relief remained at 6-week and 1-year follow-ups. Participants reported reduced spasm frequency (change score 1.17±1.20, d =0.98) and severity (0.72±1.02, d =0.71), and reduced interference of neuropathic pain on mood (3.44±2.53, d =1.36), sleep (3.39±2.40, d =1.41), and daily activities (3.17±2.77, d =1.14). They had a greater ability to perform functional activities (Patient Specific Functional Scale, 6.68±3.07, d =2.18) and had improved mood (Patient Health Questionnaire-9, 2.33±3.31, d =0.70).

Conclusions and Relevance

Our preliminary data demonstrate the feasibility of Qigong practice in adults with SCI-related neuropathic pain and promising results of neuropathic pain relief and improvement in SCI-related symptoms after Qigong practice.

Trial Registration this manuscript refers to the quasi-experimental substudy

CREATION: A Clinical Trial of Qigong for Neuropathic Pain Relief in Adults with Spinal Cord Injury, NCT04917107 , https://www.clinicaltrials.gov/ct2/show/NCT04917107 .

Conscious connected breathing with breath retention intervention in adults with chronic low back pain: protocol for a randomized controlled pilot study

BACKGROUND

Chronic pain is a major source of human suffering, and chronic low back pain (cLBP) is among the most prevalent, costly, and disabling of pain conditions. Due to the significant personal and societal burden and the complex and recurring nature of cLBP, self-management approaches that can be practiced at home are highly relevant to develop and test. The respiratory system is one of the most integrated systems of the body, and breathing is bidirectionally related with stress, emotion, and pain. Thus, the widespread physiological and psychological impact of breathing practices and breathwork interventions hold substantial promise as possible self-management strategies for chronic pain. The primary aim of the current randomized pilot study is to test the feasibility and acceptability of a conscious connected breathing with breath retention intervention compared to a sham control condition.

METHODS

The rationale and procedures for testing a 5-day conscious connected breathing with breath retention intervention, compared to a deep breathing sham control intervention, in 24 adults (18-65 years) with cLBP is described. Both interventions will be delivered using standardized audio recordings and practiced over 5 days (two times in-person and three times at-home), and both are described as Breathing and Attention Training to reduce possible expectancy and placebo effects common in pain research. The primary outcomes for this study are feasibility and acceptability. Feasibility will be evaluated by determining rates of participant recruitment, adherence, retention, and study assessment completion, and acceptability will be evaluated by assessing participants' satisfaction and helpfulness of the intervention. We will also measure other clinical pain, psychological, behavioral, and physiological variables that are planned to be included in a follow-up randomized controlled trial.

DISCUSSION

This will be the first study to examine the effects of a conscious connected breathing with breath retention intervention for individuals with chronic pain. The successful completion of this smaller-scale pilot study will provide data regarding the feasibility and acceptability to conduct a subsequent trial testing the efficacy of this breathing self-management practice for adults with cLBP.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier NCT04740710 . Registered on 5 February 2021.

The Impact of a Recent Concussion on College-Aged Individuals with Co-Occurring Anxiety: A Qualitative Investigation

College-aged individuals with anxiety are vulnerable to developing persistent concussion symptoms, yet evidence-based treatments for this population are limited. Understanding these individuals' perspectives is critical for developing effective interventions. We conducted qualitative interviews with 17 college-aged individuals (18-24 years old) with a recent (≤10 weeks) concussion and at least mild anxiety (≥5 on the GAD-7 questionnaire) to understand the life impact of their concussion. We identified 5 themes: (1) disruption to daily activities (e.g., reduced participation in hobbies and physical activity); (2) disruption to relationships (e.g., reduced social engagement, feeling dismissed by others, stigma, and interpersonal friction); (3) disruptions in school/work (e.g., challenges participating due to light sensitivity, cognitive or sleep disturbance, and related emotional distress); (4) changes in view of the self (e.g., feeling "unlike oneself", duller, or more irritable), and (5) finding "silver linings" after the injury (e.g., increased motivation). Concussions impact the lives of college-aged individuals with co-occurring anxiety in a broad range of domains, many of which remain largely neglected in standard concussion clinical assessment and treatment. Assessing and addressing these issues has the potential to limit the negative impact of concussion, promote recovery, and potentially help prevent persistent concussion symptoms in this at-risk population.

Early feasibility testing of a web-based mind-body resiliency program for adults with neurofibromatosis: The NF-Web study

Objectives

We aimed to test early feasibility, acceptability, and signals of improvement after the 8-week individually delivered asynchronous, web-based mind-body program (NF-Web) modeled after the synchronous group-based live video program (Relaxation Response Resiliency Program for NF; 3RP-NF).

Methods

Two cohorts (cohort 1 n = 14, cohort 2 n = 14) completed baseline and posttest (feasibility markers, t-tests).

Results

Enrolled participants (N = 28; 80% of those eligible) completed baseline (N = 28; 100% of sample) and posttests (N = 25; 89.3%). Video lesson (58.0%) and homework (70.9%) completion were fair to good. Satisfaction (M = 8.85/10; SD = 2.35), credibility (M = 7.07/10; SD = 1.44), and expectancy (M = 6.68/10; SD = 2.10) were good to excellent. Participation was associated with statistically significant pre-to-post positive changes in quality of life (QoL; Physical, Psychological, Social, and Environmental,; p < 0.05) and emotional distress (depression, anxiety, and stress; p < 0.05). Pain intensity and interference did not improve significantly (p > 0.05) after participation.

Conclusions

NF-Web demonstrates initial feasibility, acceptability, and signals of improvement. Results support future trials to ascertain efficacy.

Innovation

Web-based programs may be valuable for individuals with rare illness who prefer to learn skills on their own timeline, have barriers to live video participation, and who also have apprehensions about interacting with others during treatment.

A systematic review and meta-analysis of digital application use in clinical research in pain medicine

IMPORTANCE

Pain is a silent global epidemic impacting approximately a third of the population. Pharmacological and surgical interventions are primary modes of treatment. Cognitive/behavioural management approaches and interventional pain management strategies are approaches that have been used to assist with the management of chronic pain. Accurate data collection and reporting treatment outcomes are vital to addressing the challenges faced. In light of this, we conducted a systematic evaluation of the current digital application landscape within chronic pain medicine.

OBJECTIVE

The primary objective was to consider the prevalence of digital application usage for chronic pain management. These digital applications included mobile apps, web apps, and chatbots.

DATA SOURCES

We conducted searches on PubMed and ScienceDirect for studies that were published between 1st January 1990 and 1st January 2021.

STUDY SELECTION

Our review included studies that involved the use of digital applications for chronic pain conditions. There were no restrictions on the country in which the study was conducted. Only studies that were peer-reviewed and published in English were included. Four reviewers had assessed the eligibility of each study against the inclusion/exclusion criteria. Out of the 84 studies that were initially identified, 38 were included in the systematic review.

DATA EXTRACTION AND SYNTHESIS

The AMSTAR guidelines were used to assess data quality. This assessment was carried out by 3 reviewers. The data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

Before data collection began, the primary outcome was to report on the standard mean difference of digital application usage for chronic pain conditions. We also recorded the type of digital application studied (e.g., mobile application, web application) and, where the data was available, the standard mean difference of pain intensity, pain inferences, depression, anxiety, and fatigue.

RESULTS

38 studies were included in the systematic review and 22 studies were included in the meta-analysis. The digital interventions were categorised to web and mobile applications and chatbots, with pooled standard mean difference of 0.22 (95% CI: -0.16, 0.60), 0.30 (95% CI: 0.00, 0.60) and -0.02 (95% CI: -0.47, 0.42) respectively. Pooled standard mean differences for symptomatologies of pain intensity, depression, and anxiety symptoms were 0.25 (95% CI: 0.03, 0.46), 0.30 (95% CI: 0.17, 0.43) and 0.37 (95% CI: 0.05, 0.69), respectively. A sub-group analysis was conducted on pain intensity due to the heterogeneity of the results (I ² = 82.86%; p = 0.02). After stratifying by country, we found that digital applications were more likely to be effective in some countries (e.g., United States, China) than others (e.g., Ireland, Norway).

CONCLUSIONS AND RELEVANCE

The use of digital applications in improving pain-related symptoms shows promise, but further clinical studies would be needed to develop more robust applications.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021228343.

Fitbit Activity, Quota-Based Pacing, and Physical and Emotional Functioning Among Adults With Chronic Pain

Physical activity can improve function in patients with chronic pain, however, adherence is low, in part due to inconsistent activity patterns. Smart wearable activity trackers, such as Fitbits, may help promote activity. In our program for chronic pain, we examined: 1) Fitbit activity patterns (ie, step count, moderate-to-vigorous physical activity (MVPA), sedentary behavior), and 2) whether achievement of weekly, individualized Fitbit step goals was associated with functional outcomes. We conducted a secondary analysis of Fitbit data from our 10-week mind-body activity program for chronic pain (GetActive-Fitbit arm, N = 41). Participants self-reported emotional and physical function and completed performance-based and accelerometer-based assessments. From week 1 to week 10, 30% of participants increased >800 steps; 32.5% increased MVPA; and 30% decreased sedentary behavior. Only step count significantly changed across time with mean steps peaking at week 8 (M = +1897.60, SD = 467.67). Fitbit step goal achievement was associated with improvements in anxiety (ß = -.35, CI [-2.80, -.43]), self-reported physical function (ß = -.34, CI [-5.17, 8.05]), and performance-based physical function (ß = .29, CI [-71.93, 28.38]), but not accelerometer-based physical function or depression. Adhering to individualized Fitbit step goals in the context of a mind-body activity program may improve anxiety and self-reported and performance-based physical function. PERSPECTIVE: We examine Fitbit activity patterns and the association between quota-based pacing and functional outcomes within a mind-body activity program for adults with chronic pain. Complementing quota-based pacing and coping skills with Fitbits may be a useful approach to promote activity engagement and behavior change in chronic pain populations.

Prospective feasibility study of a mindfulness-based program for breast cancer patients in the southeastern US

BACKGROUND

Mindfulness interventions can improve psychological distress and quality of life (QoL) in cancer survivors. Few mindfulness programs for cancer recovery exist in Southeastern U.S. The primary objective of this study was to assess the feasibility of a modified mindfulness-based stress reduction (MBSR) program for breast cancer patients in Birmingham, Alabama. The secondary objective was to explore potential program effects on mindfulness skills and QoL.

METHODS

This study was a prospective, quasi-experimental feasibility study conducted over 10 months at a university hospital. Feasibility was achieved if 80% of eligible patients screened enrolled in the study and 70% of enrolled patients attended all 8 program sessions. Effectiveness was estimated by changes in mindfulness and QoL indicators measured with validated scales administered at 3 time points and assessed with a non-parametric Friedman test. Sessions included meditation, yoga, and an attention practice called body scan. There were 3 groups of 2-5 patients.

RESULTS

The sample totaled 12 patients. Forty-four percent (12/27) of eligible patients enrolled in the study, and two out of 12 enrolled patients completed 8 program sessions, resulting in 16.7% (2/12) retention. However, more than half (66.7%) of participants completed at least 7 sessions. Between baseline and 8-week follow-up, patients demonstrated statistically significant improvements in distress, general wellbeing, and fatigue-related QoL.

CONCLUSIONS

Feasibility objectives were not achieved. However, a majority of participants (66.7%) completed 7 of 8 program sessions. Program effects were promising for distress, fatigue, and wellbeing. Results warrant further research on MBSR-like programs for breast cancer patients in Alabama.

“I Still Suffer Every Second of Every Day”: A Qualitative Analysis of the Challenges of Living with Chronic Orofacial Pain

Objective

Chronic orofacial pain is prevalent and debilitating. Psychological and social factors place a heavy burden on this population but are often overlooked. Here, we offer the first comprehensive qualitative conceptualization of the challenges of living with chronic orofacial pain through a biopsychosocial perspective to inform multifaceted care for this population.

Design

We employed a qualitative thematic analysis of open text responses using a hybrid inductive-deductive approach and a biopsychosocial framework.

Methods

Two hundred and sixty participants with chronic orofacial pain responded to an open-ended question: “What is the biggest challenge you face in managing your condition?” by typing their responses into a text box as part of an online survey. We mapped responses onto biomedical, psychological, and social themes (deductive) and concurrently identified findings within each theme that emerged directly from the data (inductive).

Results

Subthemes within the biomedical theme included challenges with biomedical pain management, medication side effects, sensory triggers, physical symptoms of stress/tension, and biological functions and related activities of daily living. Subthemes within the psychological theme included anxiety, depression, emotional symptoms of stress, unpredictability/uncertainty of pain, and psychological and cognitive aspects of medication management. Subthemes within the social theme included social relational, experience with providers, socioeconomics and access to care, and roles and responsibilities.

Conclusion

Chronic orofacial pain is associated with multifaceted challenges. Consideration of individuals’ experiences of biomedical, psychological, and social challenges in the assessment, referral, and treatment of chronic orofacial pain holds the potential to promote more comprehensive, patient-centered care for this population.

“Practice Makes Perfect”? Associations Between Home Practice and Physical and Emotional Function Outcomes Among Patients with Chronic Pain Enrolled in a Mind–Body Program

Objectives: To summarize the characteristics of home practice adherence in patients with chronic pain randomized to a 10-week group mind-body activity program with (GetActive-Fitbit) and without (GetActive) a digital monitoring device, and test the association between home practice adherence and improvement in physical and emotional treatment outcomes. Methods: Data were collected in a pilot randomized controlled trial (RCT) of the GetActive (n = 41) and GetActive-Fitbit (n = 41) programs. Participants submitted weekly home practice logs depicting their daily physical activity and practice of relaxation and gratitude skills. Participants completed assessments of physical (patient-reported, performance-based, and accelerometer-measured) and emotional function outcomes both before and after the programs. Participants in both programs were combined due to the identical session and home practice content. Results: Participants reported engaging in physical activity on average 30.62 days (SD = 20.28, 48.6% of intervention days), relaxation skill practice on average 29.87 days (SD = 21.16, 47.4% of intervention days), and gratitude practice on average 32.10 days (SD = 22.12, 51.0% of intervention days). The average duration of physical activity and relaxation skill practice were 44.40 min a day (SD = 59.44) and 11.15 min a day (SD = 12.00), respectively. The duration of physical activity was significantly associated with decrease depression symptoms (p = 0.049, η² = 0.056). No other association was found between home practice and change in outcomes. Conclusions: Patients with chronic pain are generally able and willing to engage in home practice during a mind-body activity intervention. Emphasizing longer duration of physical activity practice may contribute to an improvement in depression. Future fully powered RCTs with rigorous assessment of home practice adherence and dose-response designs may further elucidate the role of home practice in improvements in treatment outcomes. ClinicalTrials.gov identifier: NCT03412916.

Delivery of a Mental Health Intervention for Chronic Pain Through an Artificial Intelligence-Enabled App (Wysa): Protocol for a Prospective Pilot Study

BACKGROUND

Patients with chronic pain often suffer from coexisting, long-term and debilitating mental health comorbidities such as depression and anxiety. Artificial Intelligence Supported Cognitive Behavioral Therapy or AI-CBT interventions could offer cost-effective, accessible, and potentially effective resources to tackle this problem. However, there is not enough research conducted about the efficacy of AI-CBT interventions for chronic pain.

OBJECTIVE

This prospective cohort study aims to examine the efficacy and usage of an AI-CBT intervention for chronic pain (Wysa for Chronic Pain app), using a conversational agent (with no human intervention). To the best of our knowledge, this is the first such study for chronic pain using a fully-automated, free-text-based conversational agent (CA).

METHODS

Participants with self-reported chronic pain (N = 500) will be recruited online on a rolling basis from April 2022 through posts on US-based internet communities within this prospective cohort. Informed consent is taken from the participants within the app and the Wysa intervention is delivered remotely for 8 weeks. Outcome measures including NPRS (Numeric Pain Rating Scale), PROMIS PI (Patient-Reported Outcomes Measurement Information System Pain Interference), GAD-7 (Generalized Anxiety Disorder), and PHQ-9 (Patient Health Questionnaire) questionnaires will be administered to test the effectiveness of the intervention on reducing levels of pain interference, depression, and anxiety. The therapeutic alliance created with the conversational agent will be assessed through the WAI-SR (Working Alliance Inventory-Short Revised). Retention and usage statistics will be observed for adherence and engagement.

RESULTS

The study will open for recruitment in April 2022 and data collection is expected to be completed by August 2022. The results for the primary outcomes are expected to be published by late-2022.

CONCLUSIONS

Mental health conversational agents driven by artificial intelligence (AI) could be effective in helping patients with chronic pain learn to self-manage their pain and deal with common comorbidities like depression and anxiety. The Wysa for Chronic Pain app is one such digital intervention that can potentially serve as a solution to the problems of affordability and scalability associated with interventions with a human therapist in loop. This prospective study examines the efficacy of the app as a treatment solution for chronic pain. It aims to inform future practices and digital mental health interventions for individuals with chronic pain.

CLINICALTRIAL

Mindfulness is inversely associated with psychological symptoms in long-term cardiac arrest survivors

Identifying correlates of psychological symptoms in cardiac arrest (CA) survivors is a major research priority. In this longitudinal survey study, we evaluated associations between mindfulness, baseline psychological symptoms, and 1-year psychological symptoms in long-term CA survivors. We collected demographic and CA characteristics at baseline. At both timepoints, we assessed posttraumatic stress symptoms (PTS) through the PTSD Checklist-5 (PCL-5) and depression and anxiety symptoms through the Patient Health Questionnaire-4 (PHQ-4). At follow-up, we assessed mindfulness through the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). We used adjusted linear regression to predict 1-year PCL-5 and PHQ-4 scores, with particular consideration of the CAMS-R as a cross-sectional correlate of outcome. We included 129 CA survivors (mean age: 52 years, 52% male, 98% white). At 1-year follow-up, in adjusted models, CAMS-R (β: −0.35, p < 0.001) and baseline PCL-5 scores (β: 0.56, p < 0.001) were associated with 1-year PCL-5 scores. CAMS-R (β: −0.34, p < 0.001) and baseline PHQ-4 scores were associated with 1-year PHQ-4 scores (β: 0.37, p < 0.001). In conclusion, mindfulness was inversely associated with psychological symptoms in long-term CA survivors. Future studies should examine the longitudinal relationship of mindfulness and psychological symptoms after CA.

The role of mindfulness and relaxation in improved sleep quality following a mind-body and activity program for chronic pain

Objectives

Poor sleep quality is prevalent among individuals with chronic pain and contributes to increased physical and emotional dysfunction. However, treatments that improve sleep quality among individuals with chronic pain are scant. A previously developed mind-body activity program for chronic pain has been shown to be feasible and associated with improvements in pain and physical and emotional function. Using secondary data-analysis, the purpose of this study was to understand whether participants also experienced significant and sustained improvements in sleep quality over time and whether these improvements were explained by change in two core treatment targets, relaxation and mindfulness.

Methods

Participants with heterogenous chronic pain (N = 82) were randomized to a mind-body activity intervention with (GetActive-Fitbit; n=41) or without (GetActive; n=41) a Fitbit device. Sleep quality was measured with the PSQI, mindfulness with the CAMS-R, and relaxation with the relaxation subscale of the MOCS-A. Mediation was tested via mixed-models analysis.

Results

Both intervention groups experienced significant and comparable improvements in sleep quality from baseline to post-treatment, which were sustained through a 3-month follow-up. Mindfulness and relaxation also improved significantly over time and these improvements were associated with improved sleep quality. Mindfulness and relaxation fully mediated improvement in sleep quality (medium to large effect sizes).

Conclusions

Results suggest that, despite not targeting sleep explicitly, the two mind-body activity programs hold promise for sustainably improving sleep quality among patients with chronic pain. Targeting mindfulness and relaxation may facilitate these improvements.

Getting Active Mindfully: Rationale and Case Illustration of a Group Mind-body and Activity Program for Chronic Pain

Chronic pain is associated with substantial decreases in physical and emotional health. Psychosocial and physical restoration interventions, although potentially helpful, typically show small-to-moderate improvements that are limited to the short term, and often exhibit problematic adherence. Here, we present GetActive-Fitbit, a novel 10-week group program that integrates mind-body skills, pain coping and gradual increases in activity reinforced by a commercially available digital monitoring device (Fitbit). We illustrate the program among a group of 4 adults with heterogeneous chronic pain. We also highlight pre to post-program improvements in physical function (objective, performance-based and self-report), emotional function (depression and anxiety) and other relevant outcomes targeted by the program (e.g., pain intensity, catastrophizing, mindfulness, coping, kinesiophobia, emotional support, social isolation, pain resilience, program satisfaction and impression of change). Group participants' experiences suggest that GetActive-Fitbit is credible, useful, and shows potential to improve physical and emotional function among this challenging population.Clinical trial number: NCT03412916.

Virtual Mind-Body Program for Obese Knee Osteoarthritis Patients with Comorbid Depression: Development and Feasibility Pilot (Preprint)

Background

Knee osteoarthritis (KOA) is the most common joint disorder in the United States and a leading cause of disability. Depression and obesity are highly comorbid with KOA and accelerate knee degeneration and disability through biopsychosocial mechanisms. Mind-body physical activity programs can engage biological, mechanical, and psychological mechanisms to improve outcomes in KOA, but such programs are not currently available.

Objective

This mixed methods study aims to adapt a mind-body activity program for the unique needs of patients with KOA, depression, and obesity (GetActive-OA) delivered via live video.

Methods

Participants were adults (aged ≥45 years) from rural Kentucky with obesity (BMI≥30 kg/m²), idiopathic KOA with mild to moderate radiographic changes, and elevated depressive symptoms (9-item Patient Health Questionnaire ≥10) recruited from 2 orthopedic centers. In phase 1, we developed GetActive-OA and the study protocol using qualitative focus group feedback from the study population (N=9; 2 focus groups, 90 minutes) and multidisciplinary expertise from clinical psychologists and orthopedic researchers. In phase 2, we explored the initial feasibility, credibility, and acceptability of GetActive-OA, live video delivery, and study procedures via an open pilot with exit interviews (N=5; 1 group). This research was guided by National Institutes of Health (NIH) model stage IA.

Results

Phase 1 qualitative analyses revealed nuanced information about challenges with coping and increasing activity, high interest in a mind-body activity program, program participation facilitators (flexibility with technology) and barriers (amotivation and forgetfulness), and perceived challenges with data collection procedures (blood and urine samples and homework). Phase 2 quantitative analyses showed that GetActive-OA met most a priori feasibility markers: acceptability (80%), expectancy (100%), credibility (100%), clinician adherence (90%), homework adherence (80%), questionnaire data collection (100%), program satisfaction (100%), and safety (100%). Adherence to ActiGraph wear (80% baseline, 20% posttest) and collection of blood samples (60%) were low. Participation in GetActive-OA was associated with signals of improvements in general coping (Cohen d=2.41), pain catastrophizing (Cohen d=1.24), depression (Cohen d=0.88), anxiety (Cohen d=0.78), self-efficacy (Cohen d=0.73), pain (Cohen d=0.39), and KOA symptoms (Cohen d=0.36). Qualitative exit interviews confirmed quantitative findings and provided valuable information to optimize the program and protocol.

Conclusions

Patients with KOA, depression, and obesity from rural Kentucky were interested in a live video mind-body activity program. GetActive-OA shows promise; however, the program and protocol require further NIH stage I refinement before formal efficacy testing (NIH model stage II).

International Registered Report Identifier (IRRID)

RR2-10.1016/j.conctc.2021.100720

Feasibility randomized controlled trial of a mind-body activity program for older adults with chronic pain and cognitive decline: The virtual "Active Brains" study

BACKGROUND AND OBJECTIVES

Chronic pain (CP) and cognitive decline (CD) are highly co-morbid and debilitating among older adults. We iteratively developed Active Brains-Fitbit (AB-F), a group mind-body activity program aided by a Fitbit that is feasible and associated with improvements in physical, cognitive, and emotional functioning when delivered in person to older adults with CP and CD. We adapted our intervention and methodology for remote delivery to bypass barriers to participation. Here we report on a feasibility randomized controlled trial of the virtual AB-F versus a Health Enhancement Program (HEP) educational control followed by qualitative exit interviews.

RESEARCH DESIGN AND METHODS

Older adults (age ≥ 60) with CP and CD (2 cohorts) completed eight weeks of AB-F (n = 8) or HEP (n = 11). Study procedures were fully remote via live video. Quantitative analyses explored feasibility and acceptability markers and within group improvements in outcomes. Qualitative analyses were primarily deductive using the Framework Method.

RESULTS

AB-F met a-priori set feasibility benchmarks, similar to our in-person pilot. Participation in AB-F was associated with preliminary signals of improvement in multimodal physical function, emotional function (anxiety), cognitive function, pain intensity, and coping (e.g., pain self-efficacy, catastrophizing). Participation in HEP was associated with smaller or negligible improvements. Exit interviews confirmed feasibility and satisfaction with our completely remote interventions and methodology.

DISCUSSION AND IMPLICATIONS

Results provide evidence for the feasibility of our completely remote study, and for initial markers of improvement after AB-F. The results will inform a fully powered remote efficacy trial.

Mechanisms of change in depression and anxiety within a mind-body activity intervention for chronic pain

BACKGROUND

Chronic pain is challenging and costly to treat. Depression and anxiety co-occur with chronic pain. Identifying psychosocial mechanisms contributing to emotional outcomes among chronic pain patients can inform future iterations of this intervention.

METHODS

We examined explanatory mechanisms of change in emotional distress following a mind-body and activity intervention among 82 participants (21 - 79 years old, 65.85% female, 80.48% White). With depression and anxiety as outcomes, we hypothesized that potential mediators would include pain catastrophizing, mindfulness, and pain resilience. We used mixed-effects modeling to assess the indirect effects of time on each outcome variable through hypothesized mediators simultaneously.

RESULTS

Improvements in depression from baseline to post-treatment were most explained by pain catastrophizing (b = -2.53, CI = [-3.82, -1.43]), followed by mindfulness (b = -1.21, CI = [-2.15, -0.46]), and pain resilience (b = -0.76, CI = [-1.54, -1.66]). Improvements in anxiety from baseline to post-treatment were most explained by pain catastrophizing(b = -2.16, CI = [-3.45, -1.08]) and mindfulness (b = -1.51, CI = [-2.60, -0.65]), but not by pain resilience, (b = -0.47, CI = [-1.26, 0.17]).

LIMITATIONS

Findings are limited by the lack of a control group, relatively small sample, and two timepoints. However, findings can guide future mind-body intervention efficacy testing trials.

CONCLUSIONS

Pain catastrophizing and mindfulness appear to be important intervention targets to enhance emotional functioning for chronic pain patients, and should be considered simultaneously in interventions for chronic pain.

A qualitative investigation of activity measurement and change following a mind-body activity program for chronic pain

Increasing activity is important yet challenging among people with chronic pain. Objective assessment of activity using accelerometers (i.e., ActiGraph) has gained popularity, but reactivity to assessment and non-adherence to wearing the ActiGraph may bias data. We explored: 1) experiences of wearing the ActiGraph to identify ways to increase adherence and facilitate accurate assessment of activity; and 2) barriers and facilitators to increasing activity following two mind-body activity programs to optimize future interventions. We conducted semi-structured exit interviews with 13 participants with heterogenous chronic pain who completed a randomized controlled trial of two mind-body activity programs. We analyzed transcripts using a framework approach to generate themes. Participants indicated that receiving reminders increased ActiGraph wear adherence and reported that program skills such as gratitude, pacing, mindfulness, and deep breathing were facilitators to increasing activity, while medical problems were barriers. Interventions aiming to increase activity may benefit from emphasizing mind-body skills and sending ActiGraph wear reminders.

Development of a Novel Mind-Body Activity and Pain Management Program for Older Adults With Cognitive Decline

BACKGROUND AND OBJECTIVES

Chronic pain (CP) and cognitive decline (CD) often co-occur in older adults, which can reinforce a "disability spiral." Early interventions teaching pain coping skills and gradual increases in activity (walking) are needed to promote overall well-being and potentially delay further decline of cognition and daily functioning. The goal of this mixed-methods study was to guide the development of two mind-body activity programs for CP and CD which focus on increasing walking using time goals (Active Brains) or step count reinforced by a Fitbit (Active Brains-Fitbit).

RESEARCH DESIGN AND METHODS

Older adults with CP and CD (N = 23) participated in a one-time focus group (four total) and completed measures of physical, emotional, and cognitive functioning. Qualitative analyses identified population-specific needs, preferences, and perceptions of proposed program skills. Quantitative analysis compared clinical characteristics to population norms and explored intercorrelations among treatment targets.

RESULTS

Thematic analyses revealed six main themes: (1) challenges living with CP and (2) CD, (3) current walking, (4) technology (Fitbit) to increase walking, (5) perceptions of proposed program skills (e.g., mind-body, pain, and increased walking), and (6) program barriers and facilitators. Quantitative analyses showed that (a) participants had physical function below reference values and (b) higher self-efficacy correlated with higher cognitive, emotional, and physical functioning.

DISCUSSION AND IMPLICATIONS

Focus group participants were enthusiastic about the proposed program skills. Current work includes open pilot testing, qualitative interviews, and a small randomized controlled trial to optimize the programs and methodology in preparation for efficacy testing against an educational control.

Sustainability of Improvements in Adaptive Coping Following Mind-Body and Activity Training for Chronic Pain

BACKGROUND

The strategies patients use to cope with chronic pain are key determinants of pain-related treatment outcomes and are often targeted in psychosocial interventions for chronic pain. However, improvements in coping often fade after intervention completion. Here, we test whether previously reported improvements in coping following two novel mind-body and activity interventions are maintained 3 months after completion.

METHODS

Eighty-two patients with heterogeneous chronic pain were randomized to two identical mind-body and activity interventions, one with the addition of a Fitbit device (GetActive-Fitbit) and one without it (GetActive; n = 41 each). Participants completed measures of pain-catastrophizing, kinesiophobia, mindfulness, adaptive coping, and pain-resilience at baseline, post-intervention, and at 3-month follow-up.

RESULTS

At follow-up, participants in both groups exhibited sustained improvements in all five coping measures compared to baseline (significant in both groups for all measures except for p = .05 in kinesiophobia in GetActive and p = .07 in pain resilience in GetActive-Fitbit).

CONCLUSIONS

Overall, GetActive and GetcActive-Fitbit are promising interventions to sustainably improve coping with chronic pain.

TRIAL REGISTRATION

This trial is registered under ClinicalTrials.gov identifier NCT03412916.

Development of a mind body program for obese knee osteoarthritis patients with comorbid depression

Knee osteoarthritis (OA) is the most common joint disorder in the U.S. and a leading cause of disability. Depression and obesity are highly comorbid among knee OA patients, and the combination of obesity and depression is associated with decreased physical activity, higher pain and disability, and more rapid cartilage degradation. Depression, obesity and OA exacerbate one another and share a common pathophysiology involving systemic inflammation and pro-inflammatory cytokines, reflecting a complex mind-body interaction. Current treatments for knee OA offer little to no benefit over placebo, and do not emphasize mind-body practices or physical activity to target the underlying pathophysiology. Mind-body interventions to lessen depressive symptoms and increase physical activity offer the ability to target biological, mechanical and psychological mechanisms of OA progression. Our long-term goals are to evaluate the mechanisms by which the Relaxation Response Resiliency Program (3RP) delivered via secure telehealth, and adapted for patients with depression, obesity and knee OA (GetActive-OA) promotes increases in physical activity and improved knee health. We hypothesize that the synergistic interaction between mindfulness, adaptive thinking, positive psychology and healthy living skills of the GetActive-OA will slow the progression of symptomatic knee OA by reducing pro-inflammatory cytokine expression and promoting optimal mechanical loading of the cartilage. Here we present the protocol for a mixed methods study that will adapt the 3RP for the needs of knee OA patients with depression and obesity with a focus on increasing physical activity (GetActive-OA), and iteratively maximize the feasibility, credibility and acceptability of the programs and research procedures.

Mind-Body Activity Program for Chronic Pain: Exploring Mechanisms of Improvement in Patient-Reported, Performance-Based and Ambulatory Physical Function

BACKGROUND

Improving physical function among patients with chronic pain is critical for reducing disability and healthcare costs. However, mechanisms underlying improvement in patient-reported, performance-based, and ambulatory physical function in chronic pain remain poorly understood.

PURPOSE

To explore psychosocial mediators of improvement in patient-reported, performance-based, and objective/accelerometer-measured physical function among participants in a mind-body activity program.

METHODS

Individuals with chronic pain were randomized to one of two identical 10-week mind-body activity interventions aimed at improving physical function with (GetActive-Fitbit; N=41) or without (GetActive; N=41) a Fitbit device. They completed self-reported (WHODAS 2.0), performance-based (6-minute walk test), and objective (accelerometer-measured step-count) measures of physical function, as well as measures of kinesiophobia (Tampa Kinesiophobia Scale), mindfulness (CAMS-R), and pain resilience (Pain Resilience Scale) before and after the intervention. We conducted secondary data analyses to test mediation via mixed-effects modeline.

RESULTS

Improvements in patient-reported physical function were fully and uniquely mediated by kinesiophobia (Completely Standardized Indirect Effect (CSIE)=.18; CI=0.08, 0.30; medium-large effect size), mindfulness (CSIE=-.14; CI=-25, -.05; medium effect size) and pain resilience (CSIE=-.07; CI=-.16, -.005; small-medium effect size). Improvements in performance-based physical function were mediated only by kinesiophobia (CSIE=-.11; CI=-23, -.008; medium effect size). No measures mediated improvements in objective (accelerometer measured) physical function.

CONCLUSION

Interventions aiming to improve patient-reported physical function in patients with chronic pain may benefit from skills that target kinesiophobia, mindfulness, and pain resilience, while those focused on improving performance-based physical function should target primarily kinesiophobia. More research is needed to understand mechanisms of improvement in objective, accelerometer-measured physical function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03412916.

A Live Video Mind-Body Treatment to Prevent Persistent Symptoms Following Mild Traumatic Brain Injury: Protocol for a Mixed Methods Study

Background

Every year, approximately 42 million people sustain a mild traumatic brain injury (mTBI, also known as concussion), with particularly high rates among college-aged individuals. A substantial proportion of these people (44%-64%) develop persistent symptoms that are challenging to treat, costly, and associated with significant disability. Anxiety has emerged as a risk factor for progression from acute to persistent mTBI symptoms.

Objective

This study aims to develop, adapt, and establish the feasibility of the Toolkit for Optimal Recovery after Concussions (TOR-C), an innovative mind-body program aimed at preventing persistent symptoms among young adults with mTBI and comorbid anxiety. Here, we describe the proposed study design, methodology, measurement, and treatment manuals.

Methods

In phase 1, we will conduct individual, live video qualitative interviews (up to n=20) with college-aged individuals with mTBI and comorbid anxiety to inform adaptation of the intervention and study procedures. In phase 2, an open pilot of the live video TOR-C (n=5) with exit interviews will be conducted to explore the initial feasibility, acceptability, and credibility of the program and to refine the study procedures. Phase 3 will involve conducting a feasibility randomized controlled trial (N=50) of the TOR-C versus a health education control (Health Enhancement for Concussions; HE-C), both delivered via live video, to establish feasibility of recruitment procedures (screening, eligibility, and enrollment) and data collection; feasibility, credibility, and acceptability of the live video TOR-C and HE-C (adherence, retention, fidelity, and satisfaction) following prespecified benchmarks; and a signal of improvement in outcomes.

Results

Phase 1 of the study has been approved by the Massachusetts General Hospital Institutional Review Board. Study completion is anticipated by early 2025.

Conclusions

We will develop and test the first mind-body intervention focused on prevention of persistent symptoms following mTBI in young adults with comorbid anxiety problems. This will allow us to establish feasibility markers in postconcussive symptoms, anxiety, disability, and fear avoidance to inform a future efficacy trial of the TOR-C versus HE-C.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25746

Live Video Adaptations to a Mind-Body Activity Program for Chronic Pain and Cognitive Decline: Protocol for the Virtual Active Brains Study

BACKGROUND

Chronic pain (CP) and cognitive decline (CD) are costly, challenging to treat, prevalent among older adults, and worsen each other over time. We are iteratively developing Active Brains-Fitbit (AB-F), a live video program for older adults with CP and CD that teaches mind-body skills and gradual increases in step count. AB-F has demonstrated feasibility; acceptability; and signs of improvement in emotional, physical, and cognitive functions when delivered in person to older adults.

OBJECTIVE

We are conducting a feasibility randomized controlled trial (RCT) of AB-F versus a time- and dose-matched educational control (health enhancement program [HEP]) in older adults with CP and CD. Here, we describe virtual adaptions to our study protocol, manualized treatments, evaluation plan, and study design in response to feedback from former participants and COVID-19. We will evaluate the feasibility benchmarks and the potential of AB-F to improve physical, emotional, and cognitive functions.

METHODS

This is a single-blind pilot RCT. Participants are randomized to AB-F or HEP. Patients are recruited through pain clinic referrals, institutional registries, and flyers. Interested participants are screened for eligibility via telephone and provide electronic informed consent. After randomization, participants are mailed all study documents, including their treatment manual, an ActiGraph accelerometer, and a Fitbit (separate envelope for AB-F only). Both conditions are manualized and delivered over 8 weekly sessions via Zoom. Participants complete self-report and performance-based (6-min walk test and Montreal Cognitive Assessment) outcome measures via Zoom at baseline and post intervention. Primary outcomes are a priori set feasibility (recruitment, quantitative measures, and adherence), acceptability, credibility, expectancy, and satisfaction benchmarks. Secondary outcomes are physical, cognitive, and emotional functions as well as intervention targets (social function, pain intensity, pain-specific coping, and mindfulness).

RESULTS

The trial is ongoing. We have recruited 21 participants (10 AB-F and 11 HEP) across 2 rounds. Only 2 participants have withdrawn (1 before baseline and 1 before the first session). All 19 remaining participants have completed the baseline assessment. In the first round, attendance is high (11 out of 12 participants completed all 4 sessions so far), and AB-F participants are adherent to their Fitbit and step goals (5 out of 6 participants).

CONCLUSIONS

Preliminary findings are promising for the feasibility of our completely virtual AB-F intervention. However, these findings need to be confirmed at the trial conclusion. This study will answer important questions about the feasibility of delivering a completely virtual mind-body activity program to older adults with comorbid CP and CD, which, to our knowledge, is unprecedented. Details on integrating multiple digital platforms for virtual assessments and intervention delivery will inform treatment development for older adults and those with comorbid CP and CD, which is crucial during the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04044183; https://clinicaltrials.gov/ct2/show/NCT04044183.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/25351.

The role of social isolation in physical and emotional outcomes among patients with chronic pain

OBJECTIVE

Social isolation negatively impacts early-disease processes and long-term health. Individuals with chronic pain are more vulnerable to social isolation, which exacerbates symptoms. It is currently unclear whether: 1. group-based programs for chronic pain improve social isolation, 2. improvements in social isolation account for improvements in outcomes. This study involved secondary data analysis of participants in a 10-week mind-body physical activity program. We examined whether social isolation improved during treatment, and whether such improvements accounted for improvements in emotional and physical functioning.

METHODS

Participants (N = 82) with chronic pain were randomized to a group-based mind-body physical activity intervention with (GetActive-Fitbit; n = 41) or without a Fitbit device (GetActive; n = 41). Participants completed self-reported measures of social isolation, emotional functioning (depression and anxiety symptoms), and multimodal physical functioning (self-report, performance-based, and objective). We used linear mixed effects modeling to examine pre-post treatment changes in social isolation and whether these changes accounted for improvements in emotional and physical functioning.

RESULTS

Both interventions were associated with significant and comparable improvements in social isolation from baseline to end of treatment, and improvements in social isolation accounted for significant improvements in self-reported emotional and physical functioning.

CONCLUSION

Interventions may target social isolation in chronic pain to optimize treatment outcomes.

Feasibility Trial of a Mind-Body Activity Pain Management Program for Older Adults With Cognitive Decline

BACKGROUND AND OBJECTIVES

The relationship between chronic pain (CP) and cognitive decline (CD) is bidirectional among older adults. The CP-CD comorbidity can progressively worsen cognitive, physical, emotional, and social functioning with aging. We explored the feasibility and outcomes associated with two mind-body activity programs for CP and CD that focus on increasing walking using time goals (Active Brains) or step-count reinforced via Fitbit (Active Brains-Fitbit).

RESEARCH DESIGN AND METHODS

Older adults with CP and CD participated in a non-randomized open pilot of Active Brains (n = 6) and Active Brains-Fitbit (n = 6) followed by exit interviews. Quantitative analysis explored feasibility markers and signals of improvement on physical, cognitive, and emotional function, as well as additional program targets. Qualitative analyses were predominantly deductive and applied the Framework Method to enhance the programs and methodology.

RESULTS

Both programs met a-priori feasibility benchmarks. We found within-group improvements for pain intensity, pain-specific coping, physical function, and cognitive function in both programs. Exit interviews confirmed high satisfaction with both programs.

DISCUSSION AND IMPLICATIONS

Our mixed methods data provide preliminary evidence of feasibility, showed promise for improving outcomes, and yielded critical information to further enhance the programs. We discuss "lessons learned" and future directions.

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.