Changes in pain, daily occupations, lifestyle, and health following an occupational therapy lifestyle intervention: a secondary analysis from a feasibility study in patients with chronic high-impact pain

OBJECTIVES

This study explored changes in pain-related parameters, occupational function, occupational balance, lifestyle factors, and self-perceived health status in adults with chronic high-impact pain participating in an occupational therapy lifestyle intervention.

METHODS

This one-group longitudinal feasibility study was performed in three continuous feasibility rounds. The occupational therapists-led intervention targeted meaningful occupations, regular physical activity, and a healthy diet. The intervention contained individual and group sessions and was added to the standard multidisciplinary chronic pain treatment. Outpatients (n=40, 85 % females, 46.6 ± 10.9 years old) participated in the study between April 2019 and December 2021. The analysis includes data for 31 participants. Analysis of pre-post changes assessed after each feasibility round were performed for the outcomes: pain intensity, pain sensitivity and pain modulation (pressure pain threshold and tolerance, temporal summation of pain and conditioned pain modulation), pain self-efficacy, pain catastrophizing, motor and process skills, occupational balance, daily wake-time movement, daily walking steps, body mass index, waist circumference, blood pressure, and self-perceived health status.

RESULTS

Improvements in motor skills (assessment of motor and process skills score=0.20 (1.37; 1.57), 95 % CI 0.01; 0.38) and temporal summation of pain (-1.19 (2.86; -1.67), 95 % CI -2.16; -0.22), but a decrease in pain tolerance (-7.110 (54.42; 47.32), 95 % CI -13.99; -0.22) were observed. Correlation analysis suggested moderate-to-very strong statistically significant relationships in several outcomes related to pain, health, pain coping, occupational balance, occupational functioning, body anthropometrics, and pain sensitivity.

CONCLUSIONS

This study suggested that the lifestyle intervention would benefit motor skills while effects on other outcomes were unclear in adults with chronic pain. To confirm the findings, a randomized trial evaluating effectiveness is needed. Ethical committee number: SJ-307 Reg. Clinicaltrials.gov: NCT03903900.

Acute exercise of painful muscles does not reduce the hypoalgesic response in young healthy women - a randomized crossover study

OBJECTIVES

Exercise-induced hypoalgesia (EIH) is characterized by an increase in pain threshold following acute exercise. EIH is reduced in some individuals with chronic musculoskeletal pain, although the mechanisms are unknown. It has been hypothesized that this may relate to whether exercises are performed in painful or non-painful body regions. The primary aim of this randomized experimental crossover study was to investigate whether the presence of pain per se in the exercising muscles reduced the local EIH response. The secondary aim was to investigate if EIH responses were also reduced in non-exercising remote muscles.

METHODS

Pain-free women (n=34) participated in three separate sessions. In session 1, the maximal voluntary contraction (MVC) for a single legged isometric knee extension exercise was determined. In sessions 2 and 3, pressure pain thresholds (PPT) were assessed at the thigh and shoulder muscles before and after a 3-min exercise at 30 % of MVC. Exercises were performed with or without thigh muscle pain, which was induced by either a painful injection (hypertonic saline, 5.8 %) or a non-painful injection (isotonic saline, 0.9 %) into the thigh muscle. Muscle pain intensity was assessed with an 11-point numerical rating scale (NRS) at baseline, after injections, during and after exercises.

RESULTS

PPTs increased at thigh and shoulder muscles after exercise with painful (14.0-24.9 %) and non-painful (14.3-19.5 %) injections and no significant between-injection EIH differences were observed (p>0.30). Muscle pain intensity was significantly higher following the painful injection compared to the non-painful injection (p<0.001).

CONCLUSIONS

Exercising painful muscles did not reduce the local or remote hypoalgesic responses, suggesting that the pain-relieving effects of isometric exercises are not reduced by exercising painful body regions.

ETHICAL COMMITTEE NUMBER

S-20210184.

TRIAL REGISTRATION NUMBER

NCT05299268.

Occupational therapy lifestyle intervention added to multidisciplinary treatment for adults living with chronic pain: a feasibility study

OBJECTIVES

To evaluate the feasibility and outcomes of an occupational therapy lifestyle intervention for adults living with chronic pain.

DESIGN

This one-group pre-post interventional study investigated the feasibility and outcomes of the Redesign Your Everyday Activities and Lifestyle with Occupational Therapy (REVEAL(OT)) intervention targeting meaningful activities and lifestyle.

SETTINGS

The occupational therapist-led intervention was added to standard multidisciplinary chronic pain treatment at a Danish pain centre.

PARTICIPANTS

Of the 40 adult participants aged 18-64 (mean 46.6±10.9 years old, 85% females, chronic pain duration ≥3 months), there were 31 completers.

INTERVENTION

Three feasibility rounds were carried out in 2019-2021. The intervention focused on meaningful activities, healthy eating habits and daily physical activity. Methods of didactical presentations, group discussions, personal reflection and experiential learning were used in the intervention composed both of individual and group sessions.

OUTCOMES

Primary outcomes were predefined research progression criteria evaluated by the red-amber-green method. Secondary outcomes measured pre-post changes in health-related quality of life and occupational performance and satisfaction.

RESULTS

The study demonstrated satisfactory programme adherence (77.5%), patients' self-perceived relevance (97%), timing and mode of delivery (97%) and assessment procedure acceptance (95%). No adverse events causing discontinuation occurred. Recruitment rate (n=5.7 monthly), retention (77.5%) and the fidelity of delivery (83.3%) needed improvement. We observed no improvement in health-related quality of life (mean=0.04, 95% CI -0.03 to 0.12) but positive change in occupational performance (mean=1.80, 95% CI 1.25 to 2.35) and satisfaction (mean=1.95, 95% CI 1.06 to 2.84). The participants reached the minimal clinically important difference for occupational performance (≥3.0 points in 13.8%) and satisfaction (≥3.2 points in 24.0%).

CONCLUSIONS

The REVEAL(OT) intervention was feasible to deliver and beneficial for the participants' occupational performance and satisfaction. The interventions' recruitment, retention and delivery strategies need optimisation in a future definitive trial.

TRIAL REGISTRATION NUMBER

NCT03903900.

Cryoneurolysis for the management of chronic pain in patients with knee osteoarthritis; a double-blinded randomized controlled sham trial

Objective

Pain is the principal symptom in knee osteoarthritis (OA). Current non-operative treatment options have only moderate effects and often patients experience persistent pain or side-effects. Novel advances in the field of cryoneurolysis applies low temperatures to disrupt nerve signaling at the painful area, providing pain relief. The primary aim of this randomized controlled trial (RCT) is to investigate if cryoneurolysis is superior to sham at decreasing pain intensity 2 weeks after the intervention in patients with knee OA. Secondary aims are to explore effects on pain, quality of life and functional performance over 24 months.

Methods

This two-arm, parallel-group RCT, approved by the Regional Ethics Committee, will randomly allocate patients (n = 94) to a cryoneurolysis intervention group + standardized education and exercise (CRYO) or a sham group + standardized education and exercise (SHAM) (1:1 ratio). Both groups will be assessed at baseline, 2 weeks post intervention, post education and exercise and at 6, 12 and 24 months after cryoneurolysis. The primary outcome is the NRS knee pain intensity score assessed 2 weeks post the intervention. Secondary outcome measures include functional performance (chair-stand test, 40 m walk, stair test and maximum voluntary contraction of the knee), patient reported outcomes (quality of life (EQ5D), Knee and osteoarthritis outcome scores (KOOS), among others), use of analgesics, and adverse events over 24 months.

Impact statement

Cryoneurolysis could potentially provide an effective, safe and non-pharmacological therapeutic option to treat pain in OA patients. The potential benefits include increased functional capacity and quality of life as a result of significant pain relief and improved benefits of physical exercise.

Trial registration

Clinicaltrials.gov, NCT03774121, registered 3 March 2018, http://www.clinicaltrials.gov

Validation of the Danish International Trauma Questionnaire for posttraumatic stress disorder in chronic pain patients using clinician-rated diagnostic interviews

Background: The estimated prevalence rate of comorbid posttraumatic stress disorder (PTSD) is high in trauma-exposed chronic pain patients. At the same time, self-report measures of PTSD tend to be over-inclusive within this specific population due to the high symptom overlap resulting in potential false positives. There is a need for an updated PTSD screening tools with a proper validation against clinical interviews according to the recently published 11^th revision of the World Health Organization's International Classification of Diseases (ICD-11). Objective: The present study aimed to validate the Danish International Trauma Questionnaire (ITQ) PTSD part in a sample of trauma-exposed chronic pain patients. Method: The ITQ was validated using a clinician-rated diagnostic interview of ICD-11 PTSD among chronic pain patients exposed to accident or work-related trauma (N = 40). Construct validity, concurrent and discriminant validity was investigated using confirmatory factor analyses (CFA) and correlation analysis, respectively. Three CFA models of ITQ PTSD part were tested in a sample of trauma-exposed chronic pain patients (N = 1,017) and a subsample of chronic pain patients exposed to accident or work-related trauma only (n = 367). Results: Diagnostic consistency between the six ICD-11 PTSD symptoms derived from the ITQ and the clinical interview (κ = .59) and the overall accuracy of the scale (AUC = .90) were good. The Danish ITQ showed excellent construct, concurrent and discriminant validity. The ICD-11 three factor PTSD model had excellent fit in both the full sample and the subsample of traffic and work-related accidents. Conclusions: The results indicate that the ITQ also has good psychometric properties in patients with chronic pain.

Multiple physical symptoms and individual characteristics - A cross-sectional study of the general population

OBJECTIVE

Multiple physical symptoms not attributable to known organic disease are common in all medical fields and associated with major personal and social consequences. This study investigated multiple physical symptoms according to the construct of bodily distress syndrome (BDS) and associated individual characteristics in the general adult population.

METHODS

A nationwide, population-based study of 100,000 randomly selected individuals aged 20 years and older, conducted in 2012. A web-based questionnaire formed the basis of the study and was combined with Danish national registry data on socioeconomic factors and medication and healthcare use.

RESULTS

49,706 individuals completed the questionnaire. After exclusion of women indicating pregnancy, respondents reporting chronic disease and respondents over 65 years of age, 23,331 remained for analysis. Of these 23,331 individuals, 15.5% fulfilled the criteria for BDS. BDS positives were more often younger (20-40 years) and female. Self-rated health and self-reported functional capacity were impaired among these individuals. Fulfilling the BDS criteria was significantly associated with current or former smoking, overweight and obesity, low educational level and income, and unemployment. Moreover, individuals with BDS were more often from ethnic minorities and had higher use of healthcare and medication.

CONCLUSION

Multiple physical symptoms, as captured by the concept of BDS, are common in the general adult population, especially among younger women. Fulfilling the BDS criteria is associated with substantial negative impact on self-perceived health and socioeconomic parameters. Fulfilling BDS criteria is positively associated with health risk behaviors (smoking, overweight and obesity) and higher use of healthcare and medication.

A 13-Weeks Mindfulness Based Pain Management Program Improves Psychological Distress in Patients with Chronic Pain Compared with Waiting List Controls

BACKGROUND

Eradication of pain is seldom an option in chronic pain management. Hence, mindfulness meditation has become popular in pain management.

OBJECTIVE

This pilot study compared the effect of a 13-weeks cognitive behavioural therapy program with integrated mindfulness meditation (CBTm) in patients with chronic non-malignant pain with a control condition. It was hypothesised that the CBTm program would reduce pain intensity and psychological distress compared to the control condition and that level of mindfulness and acceptance both would be associated with the reduction in pain intensity and psychological distress.

METHODS

A case-control design was used and data were collected from a convenience sample of 70 patients with chronic non-malignant pain. Fifty patients were consecutively recruited to the CBTm intervention and 20 patients matched waiting list controls. Assessments of clinical pain and psychological distress were performed in both groups at baseline and after 13 weeks.

RESULTS

The CBTm program reduced depression, anxiety and pain-catastrophizing compared with the control group. Increased level of mindfulness and acceptance were associated with change in psychological distress with the exception of depression, which was only associated with change in level of mindfulness. Surprisingly, changes in level of mindfulness did not correlate with changes in acceptance.

CONCLUSIONS

The results indicate that different mechanisms are targeted with cognitive behavioural therapy and mindfulness. The finding that changes in level of mindfulness did not correlate with changes in acceptance may indicate that acceptance is not a strict prerequisite for coping with pain related distress.

[Low dose naltrexone for treatment of pain]

Recent years have seen an increasing interest in the use of low dose naltrexone (LDN) for off-label treatment of pain in diseases as fibromyalgia, multiple sclerosis and morbus Crohn. The evidence is poor, with only few randomized double-blind placebo-controlled studies. The studies currently available are reviewed in this paper. LDN could be a potentially useful drug in the future for the treatment of pain in fibromyalgia, but more studies are needed to verify that it is superior to placebo, and currently it cannot be recommended as first-line therapy.