Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review

Senior WISE intervention: Gender differences in bodily pain and trait anxiety

PURPOSE

In this secondary analysis we tested whether 12 h of Senior WISE (Wisdom Is Simply Exploration) memory or health training with older adults would produce better outcomes by gender in perceptions of anxiety and bodily pain and whether the effects of the Senior WISE training on pain were mediated by anxiety.

DESIGN

An implemented Phase III randomized clinical trial with follow up for 24 months in Central Texas. The sample was mostly female (79%), 71% Caucasian, 17% Hispanic, and 12% African American with an average age of 75 and 13 years of education.

RESULTS

The effects of the memory intervention on anxiety were consistent across time, with effects present for males but not females at post-treatment and end-of-study. Although males had more anxiety in the health promotion group, the memory training reduced males' anxiety such that no gender difference was present in this group. The Senior WISE intervention reduced pain for both males and females at post-intervention but not at end-of-study. Although gender differences did not depend on the treatment group for pain, females reported somewhat, but not significantly, less pain at post-treatment and end-of-study. Mediation analysis indicated that, for males, the memory intervention indirectly affected pain at post-treatment, in part, by reducing anxiety, which lowered pain. However, at end-of-study, no indirect effect was present. Males responded to memory training. Training tailored to gender may increase the efficacy of the programs and "buy-in" from male participants, especially if tailored to anxiety and pain.

Bringing chronic-pain care to rural veterans: A telehealth pilot program description

Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic-pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive-behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encounters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Military veterans with and without post-traumatic stress disorder: results from a chronic pain management programme

BACKGROUND AND AIMS

There is very little published evaluation of the treatment of military veterans with chronic pain, with or without post-traumatic stress disorder. Few clinical services offer integrated treatment for veterans with chronic pain and PTSD. Such veterans experience difficulty in accessing treatment for either condition: services may consider each condition as a contraindication to treatment of the other. Veterans are therefore often passed from one specialist service to another without adequate treatment. The veteran pain management programme (PMP) in the UK was established to meet the needs of veterans suffering from chronic pain with or without PTSD; this is the first evaluation.

METHODS

The PMP was advertised online via veteran charities. Veterans self-referred with accompanying information from General Practitioners. Veterans were then invited for an inter-disciplinary assessment and if appropriate invited onto the next PMP. Exclusion criteria included; current severe PTSD, severe depression with active suicidal ideation, moderate to severe personality disorder, or who were unable to self-care in the accommodation available. Treatment was by a team of experienced pain management clinicians: clinical psychologist, physiotherapist, nurse, medical consultant and psychiatrist. The PMP was delivered over 10 days: five residential days then five single days over the subsequent 6 months. The PMP combines cognitive behavioural treatment, which has the strongest evidence base, with more recent developments from mindfulness-based CBT for pain and compassion-focused therapy. Standard pain management strategies were adapted to meet the specific needs of the population, recognising the tendency to use demanding activity to manage post-traumatic stress symptoms. Domains of outcome were pain, mood, function, confidence and changes in medication use.

RESULTS

One hundred and sixty four military veterans started treatment in 19 programmes, and 158 completed. Results from those with high and low PTSD were compared; overall improvements in all domains were statistically significant: mood, self-efficacy and confidence, and those with PTSD showed a reduction (4.3/24 points on the IES-6). At the end of the programme the data showed that 17% reduced opioid medication and 25% stopped all opioid use.

CONCLUSIONS

Veterans made clinically and statistically significant improvements, including those with co-existing PTSD, who also reduced their symptom level. This serves to demonstrate the feasibility of treating veterans with both chronic pain and PTSD using a PMP model of care.

IMPLICATIONS

Military veterans experiencing both chronic pain and PTSD can be treated in a PMP adapted for their specific needs by an experienced clinical team.

A Brief Psychological Intervention for Chronic Pain in Primary Care: A Pilot Randomized Controlled Trial

OBJECTIVE

Although evidence-based psychological interventions improve chronic pain, many patients do not engage in behavioral health services. Offering a brief intervention in a medical setting may provide benefits to patients with chronic pain. The purpose of this study was to examine preliminary outcomes of a brief psychological intervention for chronic pain delivered in primary care.

DESIGN

Pilot randomized controlled trial.

SETTING

Primary care clinic.

SUBJECTS

Sixty participants with chronic pain were randomized to a 5-session psychological intervention or treatment-as-usual control group.

METHODS

Participants completed pre- and post-intervention measures assessing pain severity, pain interference, pain catastrophizing, depression, and anxiety.

RESULTS

Most participants (76.7%) randomized to the intervention completed all sessions. Compared to the control group, those in the intervention had decreases in pain severity (P = .048), pain catastrophizing (P = .04), and depression (P = .01) from pre- to post-intervention. Within the intervention group, there was a significant improvement in pain interference scores (P = 0.02). Within the intervention group, effect sizes were medium to large for changes in pain severity, pain interference, pain catastrophizing, and depression scores. There were no significant changes in anxiety scores.

CONCLUSION

Results suggest that delivery of a brief psychological intervention for chronic pain in primary care appears to offer improvements in pain severity, pain interference, pain catastrophizing, and depression. Findings suggest that shorter-term psychological interventions may offer similar benefits as longer-term ones. Furthermore, offering a brief intervention in primary care may increase access and engagement in behavioral pain management services. Future research should examine this through a fully-powered trial with longer-term outcomes.

Do quality of life, anxiety, depression and acceptance improve after interdisciplinary pain rehabilitation? A multicentre matched control study of acceptance and commitment therapy-based versus cognitive-behavioural therapy-based programmes

OBJECTIVE

Interdisciplinary pain rehabilitation (IPR) usually employs a cognitive-behavioural therapeutic (CBT) approach. However, there is growing support for chronic pain treatments based on acceptance and commitment therapy (ACT). Most studies of ACT and CBT for chronic pain have evaluated their effects after psychological interventions, not after IPR. We compared the results of an ACT-based IPR programme with two CBT-based IPR programmes.

METHODS

We used a retrospective multicentre pretest-posttest design with matched patient groups at three centres. Data were collected from the Swedish Quality Registry for Pain Rehabilitation before and after IPR participation. Participants completed the EQ-5D health-related quality of life questionnaire, the Chronic Pain Acceptance Questionnaire, (CPAQ) and the Hospital Anxiety and Depression Scale (HADS). Analyses were performed to compare the effects of the different interventions.

RESULTS

Neither EQ-5D nor HADS depression scores were affected by the psychological approach used. The score changes on both CPAQ subscales (activity engagement and pain willingness) indicated significant improvements between admission and discharge at all centres.

CONCLUSIONS

These findings indicate the effectiveness of using psychological approaches to manage chronic pain. Both CBT and ACT had a beneficial effect on most of the assessed health-related parameters.

New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials

BACKGROUND

There is a need to regularly update the evidence base on the effectiveness of online mindfulness-based interventions (MBIs), especially considering how fast this field is growing and developing.

OBJECTIVE

This study presents an updated meta-analysis of randomized controlled trials assessing the effects of online MBIs on mental health and the potential moderators of these effects.

METHODS

We conducted a systematic literature search in PsycINFO, PubMed, and Web of Science up to December 4, 2020, and included 97 trials, totaling 125 comparisons. Pre-to-post and pre-to-follow-up between-group effect sizes (Hedges g) were calculated for depression, anxiety, stress, well-being, and mindfulness using a random effects model.

RESULTS

The findings revealed statistically significant moderate pre-to-post effects on depression (g=0.34, 95% CI 0.18-0.50; P<.001), stress (g=0.44, 95% CI 0.32-0.55; P<.001), and mindfulness (g=0.40, 95% CI 0.30-0.50; P<.001) and small effects on anxiety (g=0.26, 95% CI 0.18-0.33; P<.001). For well-being, a significant small effect was found only when omitting outliers (g=0.22, 95% CI 0.15-0.29; P<.001) or low-quality studies (g=0.26, 95% CI 0.12-0.41; P<.001). Significant but small follow-up effects were found for depression (g=0.25, 95% CI 0.12-0.38) and anxiety (g=0.23, 95% CI 0.13-0.32). Subgroup analyses revealed that online MBIs resulted in higher effect sizes for stress when offered with guidance. In terms of stress and mindfulness, studies that used inactive control conditions yielded larger effects. For anxiety, populations with psychological symptoms had higher effect sizes. Adherence rates for the interventions ranged from 35% to 92%, but most studies lacked clear definitions or cut-offs.

CONCLUSIONS

Our findings not only demonstrate that online MBIs are booming but also corroborate previous findings that online MBIs are beneficial for improving mental health outcomes in a broad range of populations. To advance the field of online MBIs, future trials should pay specific attention to methodological quality, adherence, and long-term follow-up measurements.

Randomized Controlled Trials of Mindfulness and Acceptance-Based Interventions Over the Past Two Decades: A Bibliometric Analysis

Introduction: The past several years have witnessed a significant increase in interest among the public in mindfulness with an unmistakable growth in the scientific literature investigating mindfulness-based therapies. A myriad of therapeutic uses of mindfulness have been studied. Given this burgeoning interest, the authors' objective was to conduct a broad-sweeping bibliometric analysis over the past two decades to describe overarching trends in the publications of randomized controlled trials (RCTs) investigating mindfulness to broadly identify both strengths and gaps in this field and inform a strategic plan for further advancing this research area. Materials and Methods: The authors retrieved mindfulness-focused RCTs available on PubMed in the past two decades (2000-2019). They synthesized the literature with respect to publication numbers, countries of publication, journal type, areas of research focus, characteristics of study designs, sample size, and trends in remote intervention delivery. Results: The resulting 1389 publications represent a near exponential growth trend over the past 20 years. Publications from the top three countries (the United States, the United Kingdom, and the Netherlands) with the highest productivity accounted for 60% of total number of publications. The most published modalities include acceptance-based therapy (n = 260), mindfulness-based stress reduction (n = 238), mindfulness-based cognitive therapy (n = 174), and dialectical behavior therapy (n = 82). Stress, depression, anxiety, pain, cancer, diet/healthy eating, and sleep were the most common major areas of focus. Studies included active (46%) or inactive controls (44%), and increasingly more studies with both types of controls (10%). The top 10 journals that published the most mindfulness RCTs were from behavioral sciences and psychiatry or psychology. There were 187 RCTs utilizing remote delivery, with 146 (87.1%) in the most recent 5 years. Conclusion: Publications of mindfulness-focused RCTs show a continuous increasing trend. Mindfulness research from non-Western countries and studies published in biomedical journals were less prevalent and potentially represent future opportunities. Trends of studies with both inactive and active controls support an overall advancement in research methodology. There has been a significant expansion of studies of remotely delivered mindfulness interventions. Future research might consider evaluation of a broader range of modalities and further examine optimal delivery formats.

Psychological Interventions for Women with Persistent Pelvic Pain: A Survey of Mental Health Clinicians

Objective

To establish which psychological therapies mental health professionals use with reference to the treatment of women with persistent pelvic pain conditions. This research investigates overall therapies and specific techniques that clinicians believe are the most effective with this patient group, and the challenges mental health clinicians face in administering interventions. The study aims to suggest improvements to clinical practice and establish directions for targeted future research.

Design

Cross-sectional survey design.

Methods

An online survey was developed to ask mental health clinicians questions regarding the therapies and techniques they use with women experiencing persistent pelvic pain, their perspective on their practice in this area. The survey was advertised on relevant social media and professional websites. Survey results were tabled, and chi-square statistical analyses were undertaken to examine differences in therapy use according to country and profession.

Results

Mental health clinicians predominantly utilized cognitive behavioral therapy, acceptance and commitment therapy and associated techniques for women with persistent pelvic pain conditions. The results of the chi-square analyses showed that psychologists were more likely to use cognitive behavioral therapy or acceptance and commitment therapy, than counsellors who preferred counselling interventions. Chi-square analyses showed that Australian clinicians used acceptance and commitment therapy with a higher frequency than mental health clinicians in other countries. Clinicians provided multiple insights into their experiences working with women affected by persistent pelvic pain and their opinions as to valuable future research directions.

Conclusion

Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness therapies were most commonly used by mental health clinicians working with women with persistent pelvic pain conditions, despite severely limited evidence for the use of these psychological interventions in this client group.

Validity of Current Assessment Tools Aiming to Measure the Affective Component of Pain: A Systematic Review

The objective of this study was to identify patient-reported outcome measures (PROMs), which aim to measure the affective component of pain and to assess their content validity, unidimensionality, measurement invariance, and Internal consistency in patients with chronic pain. The study was reported according to the PRISMA guidelines. A protocol of the review was submitted to PROSPERO before data extraction. Eligible studies were any type of study that investigated at least one of the domains: PROM development, content validity, dimensionality, internal consistency, or measurement invariance of any type of scale that claimed to measure the affective component of pain among patients with chronic pain. The databases Medline, Embase, PsycINFO, and the Cochrane Library were searched for eligible studies. The database search was supplemented by looking for relevant articles in the reference list of included studies, ie backtracking. All included studies were assessed independently by two authors according to the “COSMIN methodology on Systematic Reviews of Patient-Reported Outcome Measures”. Descriptive data synthesis of the identified PROMs was conducted. The search yielded 11,242 titles of which 283 were assessed at the full-text level. Full-text screening led to the inclusion of 11 studies and an additional 28 studies were identified via backtracking, leading to the inclusion of 39 studies in total in the review. Included studies described the development and validity of 10 unique PROMs, all of which we assessed to have potentially inadequate content validity and doubtful psychometric properties. No studies reported whether the PROMs possessed invariant measurement properties. The existing PROMs measuring affective components of chronic pain potentially lack content validity and have inadequate psychometric measurement properties. There is a need for new PROMs measuring the affective component of chronic pain that possess high content validity and adequate psychometric measurement properties.

Effects of Mindfulness-Based Cognitive Therapy for Chronic Pain: A Multicenter Study

The prevalence of chronic pain in Spain is 15%. The objective of this study was to evaluate the efficacy of mindfulness-based cognitive therapy on patients with chronic pain. A quasi-experimental design of repeated measures pre- and post-test (N = 57) was carried out at three hospitals from the province of Alicante. Self-reported assessment measurements of pain intensity, anxiety-depression symptoms, perception of health status, interference of pain on sleep, self-efficacy in pain, acceptance, and mindfulness attitude were included. The T-test indicates significant differences in intensity of present pain, mental quality of life, and depression (medium effect sizes), as well as in self-efficacy: total score, symptom management and pain control (medium effect sizes), sleep disturbances and quantity of sleep (large effect sizes). MBCT is effective in reducing many symptoms in patients with chronic pain, although its maintenance needs to be further investigated.

Mindfulness-based and acceptance-based programmes in the treatment of obsessive-compulsive disorder: a study protocol for a systematic review and meta-analysis

INTRODUCTION

Cognitive-behavioural therapy (CBT) with exposure and response prevention is the recommended standard for the treatment of obsessive-compulsive disorder (OCD). However, a high proportion of patients refuse this treatment, do not respond or relapse shortly after treatment. Growing evidence suggests that mindfulness-based and acceptance-based programmes (MABPs) are an effective option for the treatment of OCD. This systematic review and meta-analysis will examine the effectiveness of MABPs in treating OCD. We also aimed to explore potential moderators of the programmes' effectiveness.

METHODS AND ANALYSIS

We will systematically search MEDLINE, Embase, PsycINFO, PSYINDEX, Web of Science, CINAHL and Cochrane Register of Controlled Trials (no language restrictions) for studies that evaluate the effect of MABPs on patients with OCD. We will conduct backward and forward citation searches of included studies and relevant reviews and contact corresponding authors. The primary outcome will be pre-post intervention change in symptom severity. A secondary outcome will be change in depressive symptoms. Two reviewers will independently screen the records, extract the data and rate the methodological quality of the studies. We will include both controlled and uncontrolled trials. Randomised controlled trials will be meta-analysed, separately assessing between-group effects. A second meta-analysis will assess the within-group effect of all eligible studies. We will explore moderators and sources of heterogeneity such as the specific programme, study design, changes in depressive symptoms, hours of guided treatment, control condition and prior therapy (eg, CBT) using metaregression and subgroup analyses. We will perform sensitivity analyses using follow-up data. A narrative synthesis will also be pursued. We will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to assess the quality of the evidence.

ETHICS AND DISSEMINATION

Ethical approval is not required. Results will be published in peer-reviewed journals and presented at international conferences.

Effectiveness of Acceptance and Commitment Therapy in Central Pain Sensitization Syndromes: A Systematic Review

OBJECTIVES

Acceptance and commitment therapy (ACT) is considered by the American Psychological Association as an evidence-based treatment for a variety of disorders, including chronic pain. The main objective of the present systematic review was to determine the effectiveness of ACT in patients with central pain sensitization syndromes (CPSS).

METHODS

This systematic review was conducted according to the guidelines of the Cochrane Collaboration and PRISMA statements. The protocol was registered in advance in the Prospective Register of Systematic Reviews (PROSPERO) international database. The selected articles were evaluated using the Cochrane risk of bias (ROB) assessment tool. The PubMed, Scopus, and Web of Science databases were searched.

RESULTS

The literature search identified 21 studies (including investigations of fibromyalgia syndrome, irritable bowel syndrome, and migraine) eligible for the systematic review. There were no studies regarding the effectiveness of ACT for chronic tension-type headache (CTTH), interstitial cystitis (IC), or temporomandibular disorder (TMD). The evaluation of ROB showed that 12 of the selected studies were of low quality, 5 were of moderate quality, and 4 were high quality. ACT reduces some clinical symptoms, such as anxiety, depression, and pain. This positive effect of ACT might be mediated by pain acceptance, psychological flexibility, optimism, self-efficacy, or adherence to values. ACT showed better results in comparison to non-intervention (e.g., "waiting list") conditions, as well as pharmacological and psychoeducational interventions. It is not entirely clear whether extended ACT treatments are more advantageous than briefer interventions.

CONCLUSIONS

There are few studies about the effectiveness of ACT on CPSS. However, ACT seems to reduce subjective CPSS symptoms and improve the health-related quality of life of these patients. The absence of studies on the effectiveness of ACT in CTTH, IC, and TMD, indicate the pressing need for further ACT studies in these CPSS.

Pain and QOL in Pediatric Sickle Cell Disease: Buffering by Resilience Processes

OBJECTIVE

Sickle cell disease (SCD) is a group of inherited blood disorders. The central feature of this chronic condition is pain. Several identified risk factors exacerbate the impact of pain on quality of life (QOL) in SCD; however, there are relatively fewer investigations of strengths-based resilience variables that might buffer the influence of pain on living with SCD. The purpose of this study was to examine strength-based resilience processes in youth with SCD and their parents. Grounded in an ecological resilience-risk model, we evaluated whether adolescent and parent protective factors (pain acceptance, mindfulness, and psychological flexibility) moderated the relation between adolescent-reported pain burden and QOL.

METHODS

Ninety-three 12- to 18-year-old adolescents with SCD and their parents participated. Adolescents completed assessments of pain characteristics, pain acceptance, mindfulness, and QOL. Parents completed instruments measuring demographic and disease variables and parent psychological flexibility.

RESULTS

Pain variables were associated with protective factors in predicted directions. Adolescent acceptance and mindfulness were positively correlated with QOL. Parent psychological flexibility and adolescent QOL were not related. After controlling for demographic, pain, and disease variables, moderation analyses indicated that adolescent pain acceptance buffered the relation between SCD pain burden and QOL. Moderation analyses were not significant for adolescent mindfulness or parent psychological flexibility.

CONCLUSIONS

Results suggest that strengths-based factors may play an important role for adolescents' QOL within the context of SCD pain. Interventions that enhance teenagers' ability to accept pain might be particularly useful to improve QOL in adolescents living with SCD pain.

Brief mindfulness training can mitigate the influence of prior expectations on pain perception

BACKGROUND

Recent neuroimaging evidence suggests that mindfulness practice may mitigate the biasing influence of prior cognitive and emotional expectations on pain perception. The current study tested this hypothesis using a pain-cueing paradigm, which has reliably been shown to elicit conditioned hypoalgesic and hyperalgesic effects. Specifically, we aimed to investigate whether the instructed use of a mindfulness compared to a suppression strategy differentially modulates the magnitudes of conditioned hypoalgesia and hyperalgesia.

METHODS

Sixty-two healthy non-meditators were assigned to listen to either brief mindfulness or suppression instructions, in between the conditioning and testing phases of a pain-cueing task. Participants provided ratings of anticipatory anxiety, pain intensity and pain unpleasantness throughout the task. They also completed trait and state self-report measures of mindfulness and pain catastrophizing.

RESULTS

Results indicated that the paradigm was successful in inducing conditioned hyperalgesic and hypoalgesic effects. Importantly, while we found evidence of cue-induced hyperalgesia in both groups, only the suppression group reported cue-induced hypoalgesia. No group differences in pain ratings were found for unconditioned (novel-cued) stimuli.

CONCLUSIONS

These findings provide partial support for recently proposed predictive processing models, which posit that mindfulness may lead to a prioritization of current sensory information over previous expectations. We explore potential explanations for the asymmetrical group differences in conditioned hypoalgesia versus conditioned hyperalgesia, and discuss our results in light of recent neuroimaging insights into the neuropsychological mechanisms of mindfulness and expectancy-driven pain modulation.

SIGNIFICANCE

The current study provides novel insights into the working mechanisms of mindfulness-driven pain modulation. Our data suggest that brief mindfulness training may reduce the influence of prior beliefs and expectations on pain perception. This finding adds to growing evidence suggesting that mindfulness may alleviate pain via neuropsychological mechanisms opposite to those typically observed in conditioning/placebo procedures and other cognitive manipulations. These unique mechanisms underline the potential of mindfulness as an alternative to traditional cognitive pain regulatory strategies.

Cognitive therapy, mindfulness-based stress reduction, and behavior therapy for the treatment of chronic pain: randomized controlled trial

ABSTRACT

Trials of cognitive therapy (CT), mindfulness-based stress reduction (MBSR), and behavior therapy (BT) suggest that all 3 treatments produce reductions in pain and improvements in physical function, mood, and sleep disturbance in people with chronic pain conditions. Fewer studies have compared the relative efficacies of these treatments. In this randomized controlled study, we compared CT, MBSR, BT, and treatment as usual (TAU) in a sample of people with chronic low back pain (N = 521). Eight individual sessions were administered with weekly assessments of outcomes. Consistent with the prior work, we found that CT, MBSR, and BT produced similar pretreatment to posttreatment effects on all outcomes and revealed similar levels of maintenance of treatment gains at 6-month follow-up. All 3 active treatments produced greater improvements than TAU. Weekly assessments allowed us to assess rates of change; ie, how quickly a given treatment produced significant differences, compared with TAU, on a given outcome. The 3 treatments differed significantly from TAU on average by session 6, and this rate of treatment effect was consistent across all treatments. Results suggest the possibility that the specific techniques included in CT, MBSR, and BT may be less important for producing benefits than people participating in any techniques rooted in these evidence-based psychosocial treatments for chronic pain.

The Effect of 5-Min Mindful Breathing on Pain in Palliative Care Cancer Patients: A Randomized Controlled Study

Context:

While pain is a common complaint among palliative cancer patients, there is little research looking into nonpharmacological methods for the reduction of pain in the palliative setting.

Aim:

This study aims to study the efficacy of 5-min mindful breathing for rapid reduction of pain in a palliative care setting.

Methods:

This is a sub-analysis of the previous randomized controlled study on distress reduction. Sixty patients were recruited and randomly assigned to either the intervention (5-min mindful breathing) or the control (5-min normal listening) group. Participants reported their pain on a 10-item analog scale at baseline, immediately after intervention and 10 min postintervention. Changes in pain scores were further analyzed.

Results:

Pain scores decreased for both the intervention and control groups. However, the reduction of pain did not reach statistical difference in both groups (P > 0.05).

Conclusion:

Five-minute mindful breathing is a quick and easy to administer therapy but does not have significant effects in terms of pain reduction in palliative settings. Future research and directions are nonetheless suggested and encouraged to look for short-term mindfulness-based therapies on pain reduction for this population.

Fibromyalgia as a Heterogeneous Condition: Subgroups of Patients Based on Physical Symptoms and Cognitive-Affective Variables Related to Pain

Fibromyalgia (FM) is a chronic syndrome characterized by heterogeneous clinical manifestations, and knowing this variability can help to develop tailored treatments. To understand better the heterogeneity of FM the present cross-sectional study analyzed the role of several physical symptoms (pain, fatigue and poor sleep quality) and cognitive-affective variables related to pain (pain catastrophizing, pain vigilance, self-efficacy in pain management, and pain acceptance) in the configuration of clinical profiles. A sample of 161 women with FM fulfilled an interview and several self-report measures to explore physical symptoms, cognitive-affective variables, disability and psychopathology. To establish FM groups a hierarchical cluster analysis was performed. The findings revealed three clusters that differed in the grouping variables, Wilks' λ = .17, F(14, 304) = 31.50, p < .001, ηp2 = .59. Group 1 (n = 72) was characterized by high physical and psychological affectation, Group 2 (n = 19) by low physical affectation and high pain self-efficacy, and Group 3 (n = 70) by moderate physical affectation and low pain catastrophizing. The external validation of the clusters was confirmed, Wilks' λ = .72, F(4, 314) = 14.09, p < .001, ηp2 = .15, showing Group 1 the highest levels of FM impact and psychopathological distress. Considering the distinctive clinical characteristics of each subgroup therapeutic strategies addressed to the specific needs of each group were suggested. Assessing FM profiles may be key for a better understanding and approach of this syndrome.

Using a Narrative Practice Approach to Understand In-Depth Experiences of Individuals Coping with Chronic Pain

OBJECTIVE

Current psychological interventions to enhance management of chronic pain report small to moderate effects. There is a need to explore the experiences and coping of individuals with chronic pain in depth and expand beyond current knowledge paradigms to enhance psychological interventions. The current literature recommends narrative practice as a qualitative approach in a group to facilitate sharing of knowledge on coping with chronic pain. Therefore, we conducted group sessions incorporating narrative practice to explore the experiences of individuals coping with chronic pain.

DESIGN

We explored the experiences of 11 individuals coping with chronic pain from two group sessions that incorporated narrative practice. Themes emerging from participants' sharing were triangulated from interview transcripts, field notes, and participants' response worksheets. Data analysis adopted thematic analysis and narrative practice approaches.

RESULTS

Themes on coping found include "refocusing," "distraction," "inspiration and perspective taking," and "acknowledgement of skills, knowledge, and attitude." "Distraction" and "refocusing" complimented one another. This provided a new perspective, in contrast to current research that views both as mutually exclusive. Social environmental factors were found to help participants share existing coping methods of "connection," "deepen perspective," "inspiration and perspective taking," and "acknowledgement of skill, knowledge and attitude." The possible relationships between the themes also provided support to the theoretical foundations of Acceptance and Commitment Therapy. Results suggest that adopting a narrative practice sequence helped individuals to acknowledge chronic pain experiences and facilitated their identification of ways to cope.

CONCLUSIONS

Narrative practice identified themes of coping that can inform clinical practice. Narrative practice is indicated as a feasible and acceptable research and clinical approach for individuals with chronic pain.

Pain Anxiety as a Mechanism Linking Pain Severity and Opioid Misuse and Disability Among Individuals With Chronic Pain

OBJECTIVE

Chronic pain affects a significant number of individuals in the United States and is associated with several negative health-related outcomes, including possibility of opioid misuse and disability. The identification of factors associated with both opioid misuse and disability is of critical public health importance, and significant research suggests that pain severity has been shown to be associated with both. Pain-related anxiety has been uniquely associated with both opioid misuse and disability, yet little research has examined pain-related anxiety as a potential mechanism linking pain severity with opioid misuse and disability.

METHOD

Therefore, the current study examined whether pain-related anxiety explains, in part, the relationship between pain severity, opioid misuse, and disability among 396 adults with chronic pain (55.8% female, Mage 36.61, SD 11.40).

RESULTS

Cross-sectional analyses indicated that pain-related anxiety significantly mediated the relationship between pain severity, opioid misuse outcomes, and psychosocial disability, but not physical disability.

CONCLUSIONS

These results build upon the literature indicating the importance of pain-related anxiety in those with chronic pain by suggesting this construct may account, in part, for the relation of pain intensity to opioid misuse and psychosocial disability. Future research should longitudinally examine these associations.

A qualitative study of the experience and impact of neuropathic pain in people living with HIV

Painful distal symmetrical polyneuropathy is common in HIV and is associated with reduced quality of life. Research has not explored the experience of neuropathic pain in people with HIV from a person-centred perspective. Therefore, a qualitative interview study was conducted to more deeply understand the experience and impact of neuropathic pain in this population. Semistructured interviews were conducted with 26 people with HIV and peripheral neuropathic pain symptoms. Interviews explored the impact of pain and participants' pain management strategies. Interviews were transcribed verbatim and analysed using thematic analysis. Four themes and 11 subthemes were identified. Theme 1 reflects the complex characterisation of neuropathic pain, including the perceived unusual nature of this pain and diagnostic uncertainty. Theme 2 centred on the interconnected impacts of pain on mood and functioning and includes how pain disrupts relationships and threatens social inclusion. Theme 3 reflects the struggle for pain relief, including participants' attempts to "exhaust all options" and limited success in finding lasting relief. The final theme describes how pain management is complicated by living with HIV; this theme includes the influence of HIV stigma on pain communication and pain as an unwanted reminder of HIV. These data support the relevance of investigating and targeting psychosocial factors to manage neuropathic pain in HIV.

Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis

Acceptance and Commitment Therapy (ACT) has been widely tested for chronic pain, with demonstrated efficacy. Nevertheless, although there is meta-analytical evidence on the efficacy of face-to-face ACT, no reviews have been performed on online ACT in this population. The aim of this meta-analysis is to determine the efficacy of online ACT for adults with chronic pain, when compared with controls. PubMed, PsycINFO, CENTRAL, and Web of Knowledge were searched for randomized controlled trials (RCTs) of online-delivered ACT for chronic pain. Effects were analyzed at post-treatment and follow-up, by calculating standardized mean differences. Online-delivered ACT was generally favored over controls (5 RCTs, N = 746). At post-treatment, medium effects for pain interference and pain acceptance, and small effects for depression, mindfulness, and psychological flexibility were found. A medium effect for pain interference and acceptance, and small effects for pain intensity, depression, anxiety, mindfulness, and psychological flexibility were found at follow-up. ACT-related effects for pain interference, pain intensity, mindfulness, and anxiety increased from post-treatment to follow-up. Nevertheless, the current findings also highlight the need for more methodologically robust RCTs. Future trials should compare online ACT with active treatments, and use measurement methods with low bias. PERSPECTIVE: This is the first meta-analytical review on the efficacy of online ACT for people with chronic pain. It comprises 5 RCTs that compared online ACT with active and/or inactive controls. Online ACT was more efficacious than controls regarding pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.

The Development of Mindful-Based Dance Movement Therapy Intervention for Chronic Pain: A Pilot Study With Chronic Headache Patients

Chronic pain is of significant global concern. There is growing evidence that body–mind therapies and psychological approaches can contribute toward changing chronic pain perceptions. This is the first model described in the literature that combines a mindfulness-based approach with dance movement therapy and explores the potential psychological and pain-related changes for this client population. In this paper, the results from the pilot study are presented involving patients with chronic headache recruited in an outpatient rehabilitation setting.

Methods: In this pilot study, 29 patients (n = 29) with chronic headache were randomized to either the Mindful-Based Dance Movement Therapy (MBDMT) group or the waiting list control group (treatment as usual, TAU). The MBDMT group was offered 10 sessions in a clinical outpatient rehabilitation setting for 5 weeks. Data were collected pre- and post-intervention and 16 weeks after the intervention was finished. The Hospital Anxiety and Depression Scale (HADS), Patient Health Questionnaire−9 (PHQ-9), Five Facet Mindfulness Questionnaire (FFMQ), and Numeric Rating Scale (NRS) were used as outcome measures.

Results: The working model of MBDMT identifies nine therapeutic mechanisms (safe therapeutic environment, mindfulness skills, body awareness, relaxation/releasing, distancing and staying with discomfort, meaning making, self-regulation, acceptance and integration, creative process). Per-protocol analysis reveals statistically significant reduction of pain intensity and depression scores in favor of the MBDMT group, and these improvements were maintained in the follow-up assessment.

Conclusions: The results suggest that MBDMT is a feasible and promising therapy approach for chronic pain patients. The pilot study offered sufficient information and preliminary results in the desirable direction to enable the researchers to move to a randomized controlled trial (RCT) stage in order to establish the efficacy of the intervention.

Clinical Trial Registration: The study was registered in the www.researchregistry.com, registry (5483).

Background factors for chronic low back pain resistant to cognitive behavioral therapy

This study examined the factors that inhibit the therapeutic effects of cognitive behavioral therapy (CBT) and clarify the adaptation judgment criteria of CBT. We included patients with chronic low back pain and allocated them to the adaptation (with visual analog scale [VAS] improvement) or non-adaptation group (without VAS improvement). The patients were analyzed using various psychological tests. CBT improved depressive symptoms and catastrophic thinking; however, they were not correlated with the VAS and did not directly affect low back pain improvement. The non-adaptation group showed an unexplainable/vague sense of anxiety; an excessive focus on searching for pain; a strong intimacy desire; a strong tendency of medical dependency; and fantasy or distortion of the actual experience, especially self-image. Moreover, the patients showed a low ability to objectively express or attribute meaning to pain due to poor language skills, attention-deficit hyperactivity disorder, and emotional value judgment. Individuals with the aforementioned characteristics of pre-CBT psychological tests should select a different treatment approach given the high poor-adaption possibility. Even patients with depressive or anxious symptoms are not necessarily adaptable for CBT. Therefore, pre-CBT tests for treatment suitability are necessary. Future studies should establish a protocol for psychotherapy suitable for the non-adaptation group.

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

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

Systematic evaluation of content and quality of English and German pain apps in European app stores

BACKGROUND AND OBJECTIVE

Pain spans a broad spectrum of diseases and types that are highly prevalent and cause substantial disease burden for individuals and society. Up to 40% of people affected by pain receive no or inadequate treatment. Providing a scalable, time-, and location-independent way for pain diagnostic, management, prevention and treatment mobile health applications (MHA) might be a promising approach to improve health care for pain. However, the commercial app market is rapidly growing and unregulated, resulting in an opaque market. Studies investigating the content, privacy and security features, quality and scientific evidence of the available apps are highly needed, to guide patients and clinicians to high quality MHA.Contributing to this challenge, the present study investigates the content, quality, and privacy features of pain apps available in the European app stores.

METHODS

An automated search engine was used to identify pain apps in the European Google Play and Apple App store. Pain apps were screened and checked for systematic criteria (pain-relatedness, functionality, availability, independent usability, English or German). Content, quality and privacy features were assessed by two independent reviewers using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality on four objectives (engagement, functionality, aesthetics, information quality) and two subjective scales (perceived impact, subjective quality).

RESULTS

Out of 1034 identified pain apps 218 were included. Pain apps covered eight different pain types. Content included basic information, advice, assessment and tracking, and stand-alone interventions. The overall quality of the pain apps was average M = 3.13 (SD = 0.56, min = 1, max = 4.69). The effectiveness of less than 1% of the included pain apps was evaluated in a randomized controlled trial. Major problems with data privacy were present: 59% provided no imprint, 70% had no visible privacy policy.

CONCLUSION

A multitude of pain apps is available. Most MHA lack scientific evaluation and have serious privacy issues, posing a potential threat to users. Further research on evidence and improvements privacy and security are needed. Overall, the potential of pain apps is not exploited.

Feasibility randomized-controlled trial of online acceptance and commitment therapy for painful peripheral neuropathy in people living with HIV: The OPEN study

BACKGROUND

Neuropathic pain negatively affects quality of life among people living with HIV (PLWH). This study examined the feasibility of conducting a full-scale randomized-controlled trial of online acceptance and commitment therapy ("ACT OPEN") for neuropathic pain in PLWH.

METHODS

Using a parallel-groups design, thirty-eight participants were randomized to ACT OPEN or a waitlist control (2:1). Participants completed standard self-report outcome measures at baseline, and two- and five-months post-randomization. Participants were aware of their allocation, but assessment was blinded.

RESULTS

Twenty-five participants were randomized to ACT OPEN and 13 to the control (of 133 referrals). ACT OPEN completion was 69% and two-month trial retention was 82%. Treatment credibility and satisfaction scores for ACT OPEN were comparable to scores reported in previous trials of cognitive-behavioural treatments for pain. Four adverse events were reported during the study, including one serious adverse event; all of these were unrelated to the research procedures. Small to moderate effects and 95% confidence intervals suggest that the true effect may favour ACT OPEN for improvements in pain intensity/interference and depression.

CONCLUSIONS

A full-scale RCT of online ACT for pain management in PLWH may be feasible with refinements to trial design to facilitate recruitment.

SIGNIFICANCE

Research on pain management in people living with HIV has primarily focused on pharmacological treatments with limited success. This is the first study to show the potential feasibility of a psychological treatment based on acceptance and commitment therapy delivered online and tailored for pain management in people with HIV ("ACT OPEN"). ACT OPEN may be a promising treatment in this population and further evaluation in a full-scale randomized-controlled trial appears warranted.

TRIAL REGISTRATION

The trial was registered (clinicaltrials.gov; NCT03584412).

Health care providers' experiences of pain management and attitudes towards digitally supported self-management interventions for chronic pain: a qualitative study

BACKGROUND

Chronic pain constitutes a significant burden for the individuals affected, and is a frequent reason why patients seek health care services. While in-person psychosocial interventions can be of support to people living with chronic pain, such interventions are not always accessible. eHealth interventions may provide greater accessibility, but the evidence and use of digital self-management solutions for chronic pain are still limited and the lack of health care provider input in the development process of such solutions a concern. Therefore, the aim of the current study was to investigate health care providers' experiences of treating patients with chronic pain, their attitudes towards, and use of, digital solutions in pain management, and their suggestions for content and design elements for a potential digital pain self-management intervention.

METHODS

Twelve health care providers representing a variety of health care disciplines participated in semi-structured interviews. The interviews were analyzed using thematic analysis.

RESULTS

The material was analyzed into three main themes: [1] Patients with chronic pain and their current use of the health care services, [2] Health care providers' own motivation and impression of patient prerequisites for use of digital self-management interventions, and [3] Suggestions for content and design elements in a digital self-management intervention for people living with chronic pain. The challenges faced by patients living with chronic pain were described as numerous. Despite interest and positive attitudes, few of the health care providers had used or recommended eHealth solutions to their patients. A range of potential content and functionality elements were identified, including aspects of motivation and engagement and providers also emphasized the importance of easy access and positive, personal content to support existing treatment.

CONCLUSIONS

This study offers insights into health care providers' considerations for the potential of digital self-management interventions supporting patients living with chronic pain. Findings indicate the need for change and a more comprehensive treatment approach to pain management. eHealth solutions may contribute to such change, and providers pointed to a need for health care provider involvement, timely support and follow-up as important factors for integrating digital pain self-management interventions into clinical care.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03705104.

Communication skills in the context of psychological flexibility: training is associated with changes in responses to chronic pain in physiotherapy students in Spain

Introduction

The aim of this study is to explore the effectiveness of a training programme aimed at managing patients' chronic pain in physiotherapy students in Spain. The programme addressed providing them with efficient skills to manage patients' chronic pain from psychological flexibility (PF) perspective.

Methods

The programme integrates communication skills training into PF-based training. It sought to contribute to better recognise the role of psychosocial factors in chronic pain and to better promote adherence to treatment. This is an observational study with a pre- and post-training programme design and a 2-month follow-up. A total of 35 physiotherapy students, divided into three groups, participated in a 10-hour training course. Training focused on three areas: (1) communication skills, (2) therapeutic adherence and (3) managing distress and pain. The three areas were addressed from the PF point of view. Impact of training was measured through standardised questionnaires that assessed attitudes towards chronic pain, an ad hoc questionnaire that assessed responses to difficult communicative situations and a training satisfaction scale.

Results

Final analyses showed that attitudes changed significantly after training, biomedical attitude scores decreased and biopsychosocial attitude increased, while pain was considered less disabling, and informed empathic responses in communication situations increased. These changes were maintained at 2-month follow-up. Satisfaction with the training was high.

Conclusion

We conclude that a brief training programme based on the PF model may help students develop a more comprehensive approach and improve their skills for managing chronic pain.

Effect of Mindfulness-Based Stress Reduction Program on Psychological Symptoms, Quality of Life, and Symptom Severity in Patients with Somatic Symptom Disorder

Background:

Patients with somatic symptom disorder (SSD) had a poor quality of life and suffered from depression, anxiety, and stress. Mindfulness-based stress reduction (MBSR) is a psychological treatment with remarkable effects on several psychological disorders. This study aimed to evaluate the effect of the MBSR program on psychological symptoms, quality of life, and symptom severity in patients with SSD.

Materials and Methods:

The patients with SSD were randomly divided into two groups of receiving venlafaxine alone and venlafaxine with an 8-week MBSR program. Depression, anxiety, and stress with their severities were assessed along with the quality of life, the number of physical symptoms and their severities, as well as SSD severity before and after the intervention. Subsequently, the results were compared between the two groups.

Results:

This study included 37 patients with SSD who referred to Shariati Psychosomatic Clinic, Isfahan, Iran, with a mean age of 37.08 ± 8.26 years. It should be noted that 37.8% of the participants were male. The intervention group obtained significantly lower scores in depression, anxiety, stress, and their severities, compared to the control group. Moreover, the number of physical symptoms, their severity, and the severity of SSD were significantly decreased more in the intervention group rather than the controls.

Conclusion:

The MBSR accompanied by prescribing venlafaxine can significantly reduce the severity of SSD, as well as the number and severity of physical symptoms. Moreover, it can reduce depression, anxiety, stress, and their severity. The MBSR can be used as complementary medicine for the treatment of patients with SSD.

ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain-A Pilot Trial

BACKGROUND

Acceptance and commitment therapy (ACT) is a behavioral health intervention with strong empirical support for chronic pain but, to date, widespread dissemination is limited. Digital solutions improve access to care and can be integrated into patients' everyday lives.

OBJECTIVE

ACTsmart, a guided smartphone-delivered ACT intervention, was developed to improve the accessibility of an evidence-based behavioral treatment for chronic pain. In the present study, we evaluated the preliminary efficacy of ACTsmart in adults with chronic pain.

METHODS

The study was an open-label pilot trial. The treatment lasted for 8 weeks, and participants completed all outcome measures at pretreatment and posttreatment and at 3-, 6-, and 12-month follow-ups, with weekly assessments of selected measures during treatment. The primary outcome was pain interference. The secondary outcomes were psychological flexibility, values, insomnia, anxiety, depressive symptoms, health-related quality of life, and pain intensity. All outcomes were analyzed using linear mixed-effects models.

RESULTS

The sample consisted of 34 adults (88% women) with long-standing chronic pain (M=20.4 years, SD=11.7). Compliance to treatment was high, and at the end of treatment, we observed a significant improvement in the primary outcome of pain interference (d = -1.01). All secondary outcomes significantly improved from pretreatment to posttreatment with small to large effect sizes. Improvements were maintained throughout 12 months of follow-up.

CONCLUSION

The results of this pilot study provide preliminary support for ACTsmart as an accessible and effective behavioral health treatment for adults with chronic pain and warrant a randomized controlled trial to further evaluate the efficacy of the intervention.

Description of content, structure and theoretical model of a group-based pain management programme in the treatment of patients with persistent non-specific low back pain and psychological risk factors in a secondary sector setting

OBJECTIVE

To present the theoretical foundation and methodological considerations for a group-based pain management programme for patients with persistent non-specific low back pain and psychosocial risk factors.

METHOD

The Template for Intervention Description and Replication (TIDieR) checklist was used as a framework for describing the content, structure and context of the program. The theoretical rationale underlying the pain management programme was described using the first three steps of the Intervention Mapping framework. The Fear-avoidance model and the Self-efficacy Theory were identified as the two main theories. These were used to establish specific factors addressed by the pain management programme as well as expected outcomes.

INTERVENTION DESCRIPTION

A multidisciplinary, group-based programme using a cognitive-behavioural approach was developed. The programme consisting of six sessions of two hours duration, took place at a spine clinic at a regional hospital in Denmark. Psychoeducation and cognitive restructuring were specific strategies hypothesised to induce changes in outcome measures. The outcomes expected to change as a result of the intervention were disability, quality of life, sick leave and physical activity. A pilot study was performed, subsequent adjustments made and the final content and educational materials completed by January 2017.

CONCLUSION

The theoretical foundation and underlying evidence for the hypothesised change mechanisms in the use of a cognitive-behavioural approach was presented. A theoretically sound and practically feasible intervention has been developed and its effectiveness is being determined in a randomised controlled trial, including 130 low back pain patients, which is currently underway.

COPAHS Study: protocol of a randomised experimental study comparing the effects of hypnosis, mindfulness meditation, and spiritual practices on experimental pain in healthy adults

BACKGROUND

There has been an increasing interest in studying the potential benefits of so-called complementary and alternative approaches for pain management, such as hypnosis and mindfulness-based interventions. More recently, researchers have been interested in studying the effects of spiritual practices on pain experience as well. These practices may increase pain tolerance, result in a positive re-appraisal of pain and influence other psychological variables that are known to be associated with pain experience. The purpose of this study is to evaluate and compare the immediate effects of self-hypnosis, mindfulness meditation, and a spiritual intervention relative to a control condition for increasing pain tolerance and reducing pain intensity and pain-related stress, in response to experimental painful stimulation.

METHODS AND ANALYSIS

Recruitment is anticipated to start in November 2020. This is a randomised quantitative experimental mixed-design repeated-measures study with three assessment points: baseline (T0), pre-test (T1) and post-test (T2). Eligible healthy adults will be randomised to one of the four study conditions. Interventions will be a 20-minute audio-guided practice of either self-hypnosis, mindfulness meditation, or Christian prayer. Participants in the control group will not be instructed to use any specific strategy during the painful stimulation. Participants will be submitted to a first cycle of Cold Pressor Arm Wrap. They will then listen to a 20-minute audio recording inducing one of the three interventions, or, in the case of the control group, to a 20-minute audio recording of text from a natural history textbook. Primary outcomes are pain intensity and pain tolerance. Pain-related stress as measured by salivary cortisol level and heart rate variability are secondary outcomes.

ETHICS AND DISSEMINATION

This study was approved by ISPA-University Institute's internal Ethics Committee for Research on 3rd December 2018 (reference I/010/12/2018). Findings will be published in peer-reviewed indexed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov registry (NCT04491630). Stage: pre-results.

Neural Mechanisms of Acceptance and Commitment Therapy for Chronic Pain: A Network-Based fMRI Approach

Over 100 million Americans suffer from chronic pain (CP), which causes more disability than any other medical condition in the United States at a cost of $560-$635 billion per year (Institute of Medicine, 2011). Opioid analgesics are frequently used to treat CP. However, long term use of opioids can cause brain changes such as opioid-induced hyperalgesia that, over time, increase pain sensation. Also, opioids fail to treat complex psychological factors that worsen pain-related disability, including beliefs about and emotional responses to pain. Cognitive behavioral therapy (CBT) can be efficacious for CP. However, CBT generally does not focus on important factors needed for long-term functional improvement, including attainment of personal goals and the psychological flexibility to choose responses to pain. Acceptance and Commitment Therapy (ACT) has been recognized as an effective, non-pharmacologic treatment for a variety of CP conditions (Gutierrez et al., 2004). However, little is known about the neurologic mechanisms underlying ACT. We conducted an ACT intervention in women (n = 9) with chronic musculoskeletal pain. Functional magnetic resonance imaging (fMRI) data were collected pre- and post-ACT, and changes in functional connectivity (FC) were measured using Network-Based Statistics (NBS). Behavioral outcomes were measured using validated assessments such as the Acceptance and Action Questionnaire (AAQ-II), the Chronic Pain Acceptance Questionnaire (CPAQ), the Center for Epidemiologic Studies Depression Scale (CES-D), and the NIH Toolbox Neuro-QoLTM (Quality of Life in Neurological Disorders) scales. Results suggest that, following the 4-week ACT intervention, participants exhibited reductions in brain activation within and between key networks including self-reflection (default mode, DMN), emotion (salience, SN), and cognitive control (frontal parietal, FPN). These changes in connectivity strength were correlated with changes in behavioral outcomes including decreased depression and pain interference, and increased participation in social roles. This study is one of the first to demonstrate that improved function across the DMN, SN, and FPN may drive the positive outcomes associated with ACT. This study contributes to the emerging evidence supporting the use of neurophysiological indices to characterize treatment effects of alternative and complementary mind-body therapies.

Non-Pharmacological Approaches to Headaches: Non-Invasive Neuromodulation, Nutraceuticals, and Behavioral Approaches

Significant side effects or drug interactions can make pharmacological management of headache disorders very difficult. Non-conventional and non-pharmacological treatments are becoming increasingly used to overcome these issues. In particular, non-invasive neuromodulation, nutraceuticals, and behavioral approaches are well tolerated and indicated for specific patient categories such as adolescents and pregnant women. This paper aims to present the main approaches reported in the literature in the management of headache disorders. We therefore reviewed the available literature published between 2010 and 2020 and performed a narrative presentation for each of the three categories (non-invasive neuromodulation, nutraceuticals, and behavioral therapies). Regarding non-invasive neuromodulation, we selected transcranial magnetic stimulation, supraorbital nerve stimulation, transcranial direct current stimulation, non-invasive vagal nerve stimulation, and caloric vestibular stimulation. For nutraceuticals, we selected Feverfew, Butterbur, Riboflavin, Magnesium, and Coenzyme Q10. Finally, for behavioral approaches, we selected biofeedback, cognitive behavioral therapy, relaxation techniques, mindfulness-based therapy, and acceptance and commitment therapy. These approaches are increasingly seen as a valid treatment option in headache management, especially for patients with medication overuse or contraindications to drug treatment. However, further investigations are needed to consider the effectiveness of these approaches also with respect to the long-term effects.

Barriers and Facilitators to the Prevention of Chronic Pain in the Subacute Phase After Cardiac Surgery

BACKGROUND

Although a transitional approach promoting continuity of care is warranted to prevent chronic post-surgical pain (CPSP) and opioid misuse, there is limited research examining interventions targeting the subacute phase after cardiac surgery. Contextual multi-level factors may explain this scarcity.

AIMS

The purpose of this study was to explore the potential implementation of a nursing intervention to prevent CPSP in the subacute phase by describing nurses' viewpoints of current barriers and facilitators.

DESIGN

A descriptive qualitative study was conducted using secondary data analysis.

SETTINGS

A Web-based survey was used along with in-person interviews.

PARTICIPANTS

75 perioperative nurses.

METHODS

Qualitative data from individual interviews (n=10) and open-ended responses to a survey (n=65) regarding the intervention's acceptability were used. Content analysis was conducted using a deductive approach.

RESULTS

The introduction of nurses from various clinical settings to a new intervention allowed reflection on current practice and represented a shift toward a preventive approach. The main barrier expressed was the lack of communication and continuity of care between clinical settings. Several policy implications were outlined such as increasing the involvement of rehabilitation programs and strengthening collaboration between pain specialists and primary care providers.

CONCLUSIONS

Based on perceptions of nurses involved at different stages of the continuum, the findings provide a preliminary picture of clinical challenges and potential avenues for the prevention of CPSP in the subacute phase after cardiac surgery. An expanded pain management nursing role in primary care would allow earlier interventions and contribute to the prevention of CPSP for a tremendous number of patients undergoing surgeries.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Acceptability of psychologically-based pain management and online delivery for people living with HIV and chronic neuropathic pain: a qualitative study

OBJECTIVES

Chronic neuropathic pain is common in people living with HIV. Psychological treatments can improve quality of life for people with chronic pain in general, and online delivery can increase access to these treatments. However, the acceptability of psychological treatment and online delivery have not been investigated in-depth in people living with HIV and chronic neuropathic pain. Therefore, a qualitative study was undertaken to explore views about a psychological treatment for pain management in this population and to investigate the acceptability of online treatment delivery.

METHODS

Qualitative interviews were conducted and analysed using inductive thematic analysis, adopting a critical realist perspective. Twenty-six people living with HIV and chronic neuropathic pain completed semi-structured interviews. Their views about a psychological treatment for pain management and online delivery were explored in-depth.

RESULTS

Three themes and 12 subthemes were identified. Theme one represents a desire for a broader approach to pain management, including not wanting to take more pills and having multidimensional goals that were not just focussed on pain relief. Theme two includes barriers to online psychologically-based pain management, including concerns about using the Internet and confidentiality. Theme three describes treatment facilitators, including accessibility, therapist support, social connection, and experiencing success.

CONCLUSIONS

A psychological treatment for chronic neuropathic pain management appears acceptable for people living with HIV. Therapist-supported online delivery of cognitive-behavioural pain management may be acceptable for people living with HIV given appropriate development of the treatment to address identified barriers to engagement. These data can inform developments to enhance engagement in online psychologically-informed pain management in people living with HIV and more broadly in remote delivery of psychological treatments.

Self-compassion predicting pain, depression and anger in people suffering from chronic pain: A prospective study

Self-compassion is associated with disability, pain-related anxiety as well as depression and anger in patients with chronic pain. However, the unique value of self-compassion versus other concepts such as psychological flexibility and self-esteem is unknown. The present study therefore aimed to clarify these relationships. Individuals with chronic pain (N_CP = 872) and without chronic pain (N_NP = 356) took part in a longitudinal study. Participants completed self-report instruments: Pain Disability Index (PDI), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptom Scale (PASS-20), Patient Health Questionnaire (PHQ-9), State Trait Anger Expression Inventory (STAXI), Self-Compassion Scale (SCS), Psychological Inflexibility in Pain Scale (PIPS) and Rosenberg Self-Esteem Scale (RSES). Assessments were repeated after 8 weeks. We found differences in baseline levels of all relevant variables except for anger-out and anger-control between people with and without chronic pain. Subsequently, we computed a path model analysis regarding individuals suffering from chronic pain (N_CP), addressing the predictive value of reduced uncompassionate self-responding (RUS), compassionate self-responding (CS), avoidance (PIPS), cognitive fusion (PIPS) and self-esteem (RSES) regarding pain-related (PDI, PCS, PASS) and emotional variables (PHQ-9, STAXI). Avoidance predicted disability, catastrophizing, anxiety and depression. RUS predicted catastrophizing and pain-related anxiety. Self-esteem predicted depression. CS and cognitive fusion had no unique predictive value. The model explained 65.4%-72.1% of the variance in pain-related variables, 68.7% of the variance in depression and 38.7%-60.7% in the variance of anger-related variables. In conclusion, psychological flexibility, in terms of avoidance, seems to be more relevant for chronic pain than self-compassion. Future research should focus on subgroups and tailored-treatment approaches. SIGNIFICANCE: Applying a longitudinal design, this study examined the predictive value of self-compassion regarding pain, depression and anger. The relevance of self-compassion was compared to psychological flexibility and self-esteem. We can conclude that psychological flexibility, in terms of avoidance behaviour, is the most relevant predictor concerning pain.

School-Based Mind–Body Interventions: A Research Review

This paper contains a narrative review of the literature in the field of school-based mind–body interventions (MBIs). The aim of the current review is to verify whether the school-based MBI programs implemented in primary and secondary schools over the past 5 years are effective in helping schoolchildren cope with stress-related, behavioral, and affective issues, as well as improve stress response and school performance. All articles were retrieved using a number of databases. Inclusion criteria comprised qualitative and quantitative, English language, and peer-reviewed studies among third graders (8–9 years old) to twelfth graders (17–18 years old), including special needs pupils. Qualitative studies were limited to pupils’ experience only. Ten studies meeting the criteria for this review were assessed. The school-based interventions included yoga-based programs and mindfulness training. Evidence was evaluated and summarized. Across the reviewed studies, we found support for MBIs as part of school curricula to reduce negative effects of stress and promote overall well-being with caveats to consider in choosing specific programs. The practical implications of the current review include considerations related to the incorporation of MBIs in school curricula, which would likely benefit schoolchildren.

Factors affecting body awareness in older adults with chronic musculoskeletal pain

INTRODUCTION

Chronic musculoskeletal pain (CMP) and cognitive impairment (CI) may reduce body awareness in older adults. The first aim of this study was to determine the impact of CMP and CI on body awareness in older adults. The second was to search for the factors most affecting body awareness using logistic regression analysis.

MATERIAL AND METHODS

Two hundred and 65 older adults (males: 138 and females: 127) aged 65 and over (mean age; 72.27 ±6.42 years) living in their own homes were included. We used the following evaluation methods: CMP intensity (Visual Analog Scale - VAS), cognitive status (Hodkinson's Abbreviated Mental Test - HAMT), and body awareness (Body Awareness Questionnaire - BAQ). Logistic regression analysis was used to determine the factor most affecting the BAQ score.

RESULTS

Eighty-five point two percent of participants (n = 265) reported CMP (lower extremity pain: 74.6%; spinal pain: 66.6%; upper extremities pain: 44.4%). CMP intensity was higher in lower extremities (mean VAS: 5.73 ±1.86 cm). Gender differences in terms of CMP were found in favor of males (p = 0.0001). Mean HAMT score was 8.16±1.65. Gender difference in favor of males was significant (p = 0.0001). Mean BAQ score was 77.61±20.90; there was no significant difference between the gender (p = 0.142). There was a significant moderate positive correlation between body awareness and cognitive status (r = 0.382, p = 0.0001). However, a weak negative correlation was found between body awareness and pain intensity (r = -0.234, p = 0.0001). Regression analysis showed that living environment (rural area), low education level, low cognition level and increased CMP intensity significantly predicted body awareness.

CONCLUSIONS

The results obtained from this study indicate that cognitive impairment and pain should be reduced by improving body awareness among older adults. That is why health professionals should evaluate all related factors affecting body awareness before planning the most suitable rehabilitation program.

Implementing an Interactive Introduction to Complementary Medicine for Chronic Pain Management Into the Medical School Curriculum

Introduction

In the setting of the opioid crisis, chronic pain management requires new approaches and open dialogue between physicians and patients to explore evidence-based nonpharmacologic treatments. We developed an educational session on the role of complementary and alternative medicine (CAM) for chronic pain management as part of our larger curriculum on health equity and social justice.

Methods

Students and faculty developed a novel educational session for second-year medical students consisting of a lecture and an experiential small-group session immersing the students in CAM. We conducted pre- and postsurveys to assess the students' self-reported learning and impressions of the session.

Results

Over the academic years of 2018-2019 and 2019-2020, 345 second-year medical students participated in this mandatory session. In matched pre-and postsession surveys, students rated their knowledge of the evidence behind CAM practices, and reported statistically significant increases in their understanding. When asked about the importance of physician familiarity with common CAM practices, students noted both a high baseline agreement and a statistically significant increase after the session concluded. Familiarity with financial costs of each of the practices also saw statistically significant increases after the session.

Discussion

Our results indicated that the session met the educational objectives. A critical part of improving our session between academic years involved gathering feedback and implementing changes based on these suggestions. Our model is easy to implement and replicate at medical schools across the country. Future studies should assess the effects of CAM-focused educational interventions on practices in the clinical setting.

Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management

Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

The Effects of Psychological Interventions on Diabetic Peripheral Neuropathy: A Systematic Review and Meta-Analysis

BACKGROUND

Psychological interventions are effective at ameliorating the experience of pain in conditions such as rheumatoid arthritis and chronic back pain. However, their effect on diabetic peripheral neuropathy (DPN) pain has yet to be established AIM: To assess the effectiveness of psychological interventions on pain and related outcomes in adults with DPN.

DESIGN

Systematic review.

SETTINGS

Community, hospital in-patient and out-patient.

PARTICIPANTS/SUBJECTS

Adults with diabetic peripheral neuropathy.

METHODS

Medline, Embase, PsychInfo, and CINAHL databases together with grey literature and trial registers were searched. A meta-analysis and narrative synthesis of included studies were undertaken.

RESULTS

Nine studies were selected from 1610 citations. At short-term follow-up psychological therapies showed a large effect on pain severity (SMD = -0.94, 95%CI [-1.50, -0.37], p = .001), a small effect on pain interference (SMD = -0.39, 95%CI [-0.73, -0.05], p = .02), and a moderate effect on depressive symptoms (SMD = -0.58, 95%CI [-0.95, -0.21], p = .002). Quality of life significantly improved in experimental subjects, (MD = -2.35, 95%CI [-3.99, -0.71], p = .005). At medium-term follow-up there was a large effect on pain severity (SMD = -1.26, 95%CI [-1.76, -0.77], p < .00001) and on pain interference (SMD = -0.91, 95%CI [-1.61, -0.21], p = .01) and a moderate effect on depressive symptoms (SMD = -0.76, 95%CI [-1.48, -0.05], p = .04). At long-term follow-up, improvements in pain interference, mood, and self-care behaviors were reported.

CONCLUSIONS

These findings demonstrate that the relationship between pain and perceived control identified in other groups who experience chronic pain may also be replicated in the DPN population. This is an important outcome that can guide further research and associated service developments.

Remote management of musculoskeletal pain: a pragmatic approach to the implementation of video and phone consultations in musculoskeletal practice

Video and phone consultations for musculoskeletal pain are effective, safe, and appreciated by patients. Implementation and execution require special consideration and such guidance is provided.

Introduction:

Remote consultations through phone or video are gaining in importance for the treatment of musculoskeletal pain across a range of health care providers. However, there is a plethora of technical options for practitioners to choose from, and there are various challenges in the adaptation of clinical processes as well as several special considerations regarding regulatory context and patient management. Practitioners are faced with a lack of high-quality peer-reviewed resources to guide the planning and practical implementation of remote consultations.

Objectives:

This Clinical Update seeks to provide practical guidance for the planning and implementation of remote consultations for the management and treatment of people with musculoskeletal pain.

Methods:

Recommendations are based on a brief overview of the relevant research regarding phone and video consultations for musculoskeletal practice and derived from the literature, relevant guidelines, and practical experience.

Results:

The technical feasibility of remote consultations for musculoskeletal complaints is good, patient satisfaction is high, and a growing body of evidence supports its comparative effectiveness to in-person consultations in some circumstances for improving pain and functioning. We consider in detail practical aspects such as the choosing of hardware and software, we touch on the legal and regulatory context, and we focus on the adaptation of clinical processes and communication.

Conclusion:

This Clinical Update draws together best-practice evidence in a practically applicable format, enabling therapists who are working with people with pain to directly apply this knowledge to their individual clinical settings and the requirements of their patients.

Depression, anxiety, pain and chronic opioid management in primary care: Type II effectiveness-implementation hybrid stepped wedge cluster randomized trial

Even though current prescribing trends reveal that high-dose opioid prescribing and opioid prescribing in general has decreased, sustained efforts are needed to help providers adopt and maintain safe prescribing behaviors. The purpose of this four-year type 2 effectiveness-implementation hybrid stepped wedge cluster randomized trial is to: (1) compare the clinical and cost effectiveness of electronic medical record-based clinical decision support [EMR-CDS] versus additional integrated, collaborative behavioral health [EMR-CDS + BHI-CCM] for opioid management of patients with co-morbid chronic non-cancer pain with depression or anxiety; and (2) examine facilitators and barriers to implementing these interventions within 35 primary care clinics in a integrated delivery health system. The EMR-CDS alerts providers to employ opioid risk mitigation and safe prescribing practices at the point of care. The BHI-CCM consists of primary care embedded community health workers for case management; licensed clinical social workers for cognitive behavioral therapy, and a clinical pharmacist for medication management who provide care management via telemedicine (virtual video or audio only visits) under the guidance of a consulting psychiatrist. The primary outcome is reduction in the percentage of patients with average daily opioid dose ≥50 mg morphine equivalent. Secondary outcomes include changes in service utilization, patient reported outcomes and processes of care. The investigators anticipate that study results will elucidate the role of technology versus care team optimization in changing opioid prescribing behaviors. The investigators further anticipate that integrated mental/behavioral health care will increase value-based care and the efficiency with which guideline concordant care is delivered.

Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Purpose

An estimated 2.2 billion people are visually impaired worldwide. Given that age-related vision loss is a primary cause of vision impairment, this number is projected to rise with increases in average lifespan. Vision loss often results in significant disability and is associated with a substantial economic burden, reduced quality-of-life, concurrent medical issues, and mental health problems. In this review, the mental health needs of people with vision impairment are examined.

Patients and methods

A review of recent literature on mental health outcomes and current treatments in people with visual impairment was conducted.

Results

Considerable data indicate that rates of depression and anxiety are elevated among people with visual impairments. Moreover, individuals of lower socioeconomic status may be at increased risk for vision impairment and subsequent mental health problems. Existing psychosocial interventions for improving mental health in people with visual impairment show some promise, but are limited by low adherence and lack generalizability.

Conclusion

In order to improve outcomes, a better understanding of the mechanisms linking visual impairment and poor mental health is needed. It will also be essential to develop more effective interventions and expand access to services to improve the detection and treatment of mental health problems in this population.

A systematic review and meta-analysis of mindfulness- and acceptance-based interventions for affect intolerance/sensitivity

Affect intolerance/sensitivity, defined as one's sensitivity to, or inability to tolerate, affective states, is a transdiagnostic process implicated in the development and maintenance of numerous forms of psychopathology. Mindfulness and acceptance interventions are posited to improve affect intolerance/sensitivity; however, there has been no quantitative synthesis of this research to date. Seven electronic databases were searched up until November 2018. Hedges' g values, 95% confidence intervals, p-values, and Q-values were calculated for a series of random-effects models. Twenty-five studies (pooled N = 1778) met eligibility criteria and were included in the qualitative synthesis (n = 22 included in the meta-analysis). There was a small, significant effect of mindfulness and acceptance interventions on improving affect intolerance/sensitivity from pre-to post-intervention (Hedges' g = -0.37, 95% CI = -0.52 to -0.23, p < .001), with effects maintained up to 6-months (Hedges' g = -0.35, 95% CI = -0.61 to -0.09, p < .01). There was a significantly larger effect for studies with inactive compared to active controls. No significant effect size differences were found for intervention length (<8 vs. ≥ 8 sessions), intervention type (mindfulness vs. acceptance) or sample type (clinical vs. non-clinical). Mindfulness and acceptance interventions modestly improve affect intolerance/sensitivity.