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

Cannabis Use and Anxiety Sensitivity in Relation to Physical Health and Functioning in post-9/11 Veterans

Frequency of cannabis use and cognitive vulnerabilities such as anxiety sensitivity (i.e., the fear of bodily sensations), have been independently linked with poor physical health, however the interplay between these health-mental health processes may compound poor physical health and functioning in cannabis users. Thus, the current study evaluated the direct and interactive effects of cannabis use frequency and anxiety sensitivity on physical health and functioning among cannabis-using veterans. Participants (N = 138) were post-9/11 United States veterans recruited from a Veterans Affairs hospital who reported cannabis use in the past six months. Cannabis use frequency in the past month and anxiety sensitivity were significantly negatively correlated with perceived overall physical health. There was a significant interaction between cannabis use frequency and anxiety sensitivity, such that more frequent cannabis use was associated with poorer overall health and role functioning due to health problems among veterans with higher anxiety sensitivity (but not lower). Findings suggest that anxiety sensitivity is a cognitive vulnerability linked to poor perceived physical health and impairment among frequent cannabis users and could be targeted, along with cannabis use, for health-promotion in cannabis users.

Acceptance and Commitment Therapy for Parental Management of Childhood Asthma: An RCT

BACKGROUND

Few trials have been conducted to address the psychological difficulties of parents in managing their child's asthma. Fostering parental psychological flexibility through Acceptance and Commitment Therapy (ACT) may help parents to accept these psychological difficulties and improve their management of childhood asthma.

METHODS

In this randomized controlled trial, a 4-session, group-based ACT plus asthma education (ACT group) was compared with an asthma education talk plus 3 telephone follow-ups (control group) to train parents of children diagnosed with asthma. The use of health care services due to asthma exacerbations in children and the psychological well-being of their parents were assessed before, immediately after, and at 6 months after the intervention.

RESULTS

A total of 168 parents and their children aged 3 to 12 years with asthma were consecutively recruited in a public hospital in Hong Kong. When compared with the control group, children whose parents were in the ACT group made significantly fewer emergency department visits (adjusted 6-month incidence rate ratio = 0.20; confidence interval [CI] 0.08 to 0.53; P = .001) due to asthma exacerbations at 6 months postintervention. These parents also reported a decrease in psychological inflexibility (mean difference = -5.45; CI -7.71 to -3.30; P = .014), less anxiety (mean difference = -2.20; CI -3.66 to -0.73; P = .003), and stress (mean difference = -2.50; CI -4.54 to -0.47; P = .016).

CONCLUSIONS

Integrating ACT into parental asthma education was effective at decreasing parental anxiety and stress and reducing the asthma-related emergency department visits of children at 6 months postintervention.

Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: A systematic review and network meta-analysis

QUESTION

This review compares mindfulness-based stress reduction (MBSR) to cognitive-behavioural therapy (CBT) in its ability to improve physical functioning and reduce pain intensity and distress in patients with chronic pain (CP), when evaluated against control conditions.

STUDY SELECTION AND ANALYSIS

Ovid MEDLINE, EmbaseClassic+Embase, PsycINFO and the Cochrane Library were searched to identify randomised controlled trials. The primary outcome measure was physical functioning. Secondary outcomes were pain intensity and depression symptoms. We used random and fixed effects (RE and FE) network meta-analyses (NMA) to compare MBSR, CBT and control interventions on the standardised mean difference scale.

FINDINGS

Twenty-one studies were included: 13 CBT vs control (n=1095), 7 MBSR vs control (n=545) and 1 MBSR vs CBT vs control (n=341). Of the 21 articles, 12 were determined to be of fair or good quality. Findings from RE NMA for change in physical functioning, pain intensity and depression revealed clinically important advantages relative to control for MBSR and CBT, but no evidence of an important difference between MBSR and CBT was found.

CONCLUSIONS

This review suggests that MBSR offers another potentially helpful intervention for CP management. Additional research using consistent measures is required to guide decisions about providing CBT or MBSR.

Personal resource profiles of individuals with chronic pain: Sociodemographic and pain interference differences

PURPOSE/OBJECTIVE

Previous studies have demonstrated important associations between personal resources and pain interference. Using latent profile analysis, the present study (a) identified subgroups of individuals with chronic pain who have different personal resource profiles; (b) explored sociodemographic differences among subgroups; and (c) examined how these subgroups differ in pain interference. Research Method/Design: Study 1 is based on daily diary and survey data from 220 individuals with fibromyalgia (FM). Study 2 is based on 4 annual surveys of 483 individuals with long-term neurological/neuromuscular disease or injury, and chronic pain. Modifiable personal resource variables including sense of resilience, social support, pain acceptance, and sleep quality were included in latent profile analyses.

RESULTS

Three subgroups were identified in both studies: High, Moderate, and Low Personal Resource groups. In both studies, annual income level was significantly different among subgroups. Study 1 results showed a significant between-groups difference in pain interference across 21-days only between High and Moderate Personal Resource groups controlling for the level of pain intensity and depressive symptoms. In Study 2, however, all subgroups were significantly different with respect to their levels of pain interference at baseline over and above various covariates, with the Low Personal Resource group reporting the highest level of pain interference at baseline. These baseline differences remained stable over 4 years.

CONCLUSIONS/IMPLICATIONS

The findings suggest a robust association between economic disparity and personal resource profiles among individuals with chronic pain. The role of different personal resource profiles in pain interference appears to differ by chronic pain condition. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Pilot Randomized Controlled Trial Comparing Mindfulness Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain

Objective

This pilot trial compared the feasibility, tolerability, acceptability, and effects of group-delivered mindfulness meditation (MM), cognitive therapy (CT), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP).

Setting

University of Queensland Psychology Clinic.

Subjects

Participants were N = 69 (intent-to-treat [ITT] sample) adults with CLBP.

Design

A pilot, assessor-blinded randomized controlled trial.

Methods

Participants were randomized to treatments. The primary outcome was pain interference; secondary outcomes were pain intensity, physical function, depression, and opioid medication use. The primary study end point was post-treatment; maintenance of gains was evaluated at three- and six-month follow-up.

Results

Ratings of acceptability, and ratios of dropout and attendance showed that MBCT was acceptable, feasible, and well tolerated, with similar results found across conditions. For the ITT sample, large improvements in post-treatment scores for pain interference, pain intensity, physical function, and depression were found (P < 0.001), with no significant between-group differences. Analysis of the follow-up data (N = 43), however, revealed that MBCT participants improved significantly more than MM participants on pain interference, physical function, and depression. The CT group improved more than MM in physical function. The MBCT and CT groups did not differ significantly on any measures.

Conclusions

This is the first study to examine MBCT for CLBP management. The findings show that MBCT is a feasible, tolerable, acceptable, and potentially efficacious treatment option for CLBP. Further, MBCT, and possibly CT, could have sustained benefits that exceed MM on some important CLBP outcomes. A future definitive randomized controlled trial is needed to evaluate these treatments and their differences.

Mindfulness meditation for workplace wellness: An evidence map

BACKGROUND

Mindfulness interventions aim to foster greater attention and awareness of present moment experiences. Uptake of mindfulness programs in the workplace has grown as organizations look to support employee health, wellbeing, and performance.

OBJECTIVE

In support of evidence-based decision making in workplace contexts, we created an evidence map summarizing physical and mental health, cognitive, affective, and interpersonal outcomes from systematic reviews of randomized controlled trials (RCTs) of mindfulness interventions.

METHODS

We searched nine electronic databases to July 2017, dually-screened all reviews, and consulted topic experts to identify systematic reviews on mindfulness interventions. The distribution of evidence is presented as an evidence map in a bubble plot.

RESULTS

In total, 175 systematic reviews met inclusion criteria. Reviews included a variety of mindfulness-based interventions. The largest review included 109 randomized controlled trials. The majority of these addressed general health, psychological conditions, chronic illness, pain, and substance use. Twenty-six systematic reviews assessed studies conducted in workplace settings and with healthcare professionals, educators, and caregivers. The evidence map shows the prevalence of research by the primary area of focus. An outline of promising applications of mindfulness interventions is included.

CONCLUSIONS

The evidence map provides an overview of existing mindfulness research. It shows the body of available evidence to inform policy and organizational decision-making supporting employee wellbeing in work contexts.

Acceptance and Commitment Therapy (ACT) for HIV-infected Hazardous Drinkers: A Qualitative Study of Acceptability

Alcohol use is a significant problem in HIV care, and clinical trials of alcohol interventions for people living with HIV infection (PLWH) have produced mixed results. The purpose of this qualitative study was to collect preliminary data on the practical feasibility and acceptability of Acceptance and Commitment Therapy (ACT) as a treatment for PLWH who are hazardous drinkers. A total of 25 PLWH participated in individual interviews. Four major themes emerged from the thematic analysis: (I) Perceived Appropriateness for PLWH and People who use Alcohol and/or other Substances, (II) General Satisfaction and Dissatisfaction, (III) Positive and Negative Effects on Participants and (IV) Facilitators and Barriers to Implementing ACT Intervention Strategies.

Protocol for a feasibility and acceptability study using a brief ACT-based intervention for people from Southwest Wales who live with persistent pain

INTRODUCTION

Persistent pain affects a large percentage of the UK population and its burden has wide ramifications that affect physical, psychological, socioeconomic and occupational status. Pain has a significant impact on people's well-being and quality of life. Some of the most common comorbidities found in this population are depression and anxiety and also maladaptive behaviours such as fear avoidance and catastrophising.

METHODS AND ANALYSIS

This is a protocol for a study assessing the feasibility and acceptability of a novel Acceptance and Commitment Therapy (ACT)-based intervention for people from Southwest Wales who live with persistent pain. A group of 12 participants will be recruited through the Health and Wellbeing Academy (Swansea University). After being referred by an Osteopath, and attending a brief meeting with the researcher, the participants will take part in six sessions over six consecutive weeks. 'A Mindful Act' is an ACT-based group programme aiming to teach people how to develop more acceptance and self-compassion, be more mindful and clarify personal values in order to live a more rich and meaningful life. The main outcomes will include the feasibility of the recruitment process and the measurement tools, the acceptability of the intervention for both the participants and the Osteopaths and the adherence to the programme. In order to measure acceptability of the intervention, qualitative interviews will be conducted to provide an insight into peoples' experiences of taking part. Data will be analysed using Thematic Analysis, with the use of NVIVO 10. In addition, quantitative data will be collected at baseline, on completion of the programme and at 1 month and 3 months follow-up to reveal any differences in psychological flexibility, depression, anxiety, fear avoidance and general health status. The findings will help enhance the intervention by making appropriate modifications to the processes and procedures involved, following the recommendations made by the Medical Research Council framework. A larger scale study is envisaged to follow, in order to investigate the full effectiveness and cost-effectiveness of 'A Mindful Act'.

ETHICS AND DISSEMINATION

This study was approved by the College of Human and Health Sciences Research Ethics Committee at Swansea University in December 2017. The findings will be disseminated through various means including: the first author's PhD thesis, peer-reviewed journals as well as well as national and international conferences and public events.

The Relationship Between Heart Rate Variability, Psychological Flexibility, and Pain in Neurofibromatosis Type 1

Individuals with neurofibromatosis type 1 (NF1) and plexiform neurofibromas (PNs) can experience chronic pain. Previous research has examined the relationship between heart rate variability (HRV) and persistent pain. HRV is an index of autonomic nervous system functioning, and reflects the variability in time elapsed between heartbeats. Patients with chronic pain tend to exhibit lower HRV, which has been associated with poor adaptability, or psychological flexibility, to stress. The aim of the current study was to examine relationships between HRV, psychological flexibility, and pain in a sample of adolescents and young adults (AYAs) with NF1 and PNs. AYA participants (n = 40) 16 to 34 years of age with NF1 completed baseline measures of pain and psychological functioning, and underwent a 5-minute electrocardiogram (ECG). A subset of 20 participants completed follow-up questionnaires and a second ECG 8 weeks later. Spectral analyses of ECGs yielded a measure of high-frequency heart rate variability (HF-HRV). Baseline correlations revealed that lower HF-HRV is related to greater inflexibility and more pain interference, but not pain intensity. Moreover, psychological inflexibility significantly mediated the relationship between HF-HRV and pain interference. Finally, regression models indicated that baseline psychological inflexibility is a significant predictor of HF-HRV at follow-up and, separately, that baseline HF-HRV significantly predicted pain intensity at follow-up. These findings suggest complex mind-body processes in the experience of pain in NF1, which have not been studied previously. Implications for pain-related interventions and future research are discussed.

Stress, mindfulness, and the allergic patient

INTRODUCTION

The global incidence and prevalence of allergic diseases are increasing as is the intensity and duration of excessive psychological stress due to multiple factors associated with living in today's world such as personal, social and political unrest, increased fear and anxiety, and/or depression often leading to hopelessness. Both allergy and chronic psychological stress are characterized by immune imbalances that have similar characteristics. Thus, it is reasonable to posit that the two are interactive and stress may induce as well as complicate at least some allergic diseases. Areas covered: Stress management/reduction has been proposed with various physical, pharmacological, and psychological interventions for both preventive and therapeutic reasons. A useful intervention involves mindfulness techniques, which allow the individual to put their life situation in context for better personal management. Expert commentary: Future studies must be developed that will further examine the role of excess psychological stress in specific allergic diseases and evaluate the effectiveness of various stress intervention protocols, particularly those involving mindfulness, to determine which individual would best respond clinically to which intervention. When this is accomplished, assessment and treatment of psychological stress will become a standard component of clinical care for allergy, asthma, and other immune-based diseases.

Current status of acceptance and commitment therapy for chronic pain: a narrative review

It is well known that chronic pain is prevalent, complex to manage, and associated with high costs, in health care and society in general. Thanks to advances in new forms of cognitive behavioral therapy (known as third-wave CBT), currently clinicians and researchers have an empirically validated psychological treatment with increasing research support for the treatment of chronic pain. This treatment is called acceptance and commitment therapy (ACT). The main aim of this paper is to provide a narrative review that summarizes and integrates the current state of knowledge of ACT in the management of chronic pain as well as discuss current challenges and opportunities for progress. Based on the psychological flexibility model, ACT extends previous forms of CBT and integrates many CBT-related variables into six core therapeutic processes. ACT is a process-based therapy that fosters openness, awareness, and engagement through a wide range of methods, including exposure-based and experiential methods, metaphors, and values clarification. To our knowledge, there are three published systematic reviews and meta-analyses that support the effectiveness of ACT for chronic pain and many studies focused on specific processes derived from the psychological flexibility model. There is also promising support for the cost-effectiveness of ACT; however, the current evidence is still insufficient to establish firm conclusions about cost-effectiveness and the most efficient means of delivery. Additional well-designed economic evaluations are needed. Other research aims include delineating the neurobiological underpinnings of ACT, refining available outcome and process measures or develop new ones for ACT trials, and meeting the challenge of wide dissemination and implementation in real-world clinical practice.

Group-based Acceptance and Commitment Therapy (ACT) for Older Veterans: Findings from a Quality Improvement Project

OBJECTIVES

The purpose of this project was to develop, implement, and evaluate a 12-session Acceptance and Commitment Therapy (ACT) for Older Veterans group protocol.

METHODS

The Plan-Do-Study-Act (PDSA) quality improvement model was the foundational process for this project. Veterans age 55 years and older participated in an ACT for Older Veterans group in an outpatient geropsychology clinic at a Veterans Affairs Medical Center. Study methods included analysis of participant feedback gathered in a focus group, process measures (i.e., number of sessions attended and number of early terminations), and outcome measures (i.e., depressive symptoms, anxiety symptoms, and psychological flexibility).

RESULTS

Seventeen participants completed an average of ten sessions. Less than 25% of participants terminated early. Depressive symptoms improved, though there were no statistically significant changes in anxiety symptoms and psychological flexibility. The focus group yielded several recommendations that were implemented in subsequent groups.

CONCLUSIONS

The PDSA model helped in the development of a group therapy intervention that is both relevant and beneficial to older Veterans presenting with a variety of biopsychosocial issues. Results provide support for further research investigation of ACT for Older Veterans Group.

CLINICAL IMPLICATIONS

ACT used in a group format is a feasible and acceptable psychotherapy for older Veterans.

Hardiness, Perseverative Cognition, Anxiety, and Health-Related Outcomes: A Case for and Against Psychological Hardiness

The present study investigates the utility of psychological hardiness as well as the differences between rumination and worry. Undergraduate students completed questionnaires assessing hardiness, worry, rumination, mindfulness, neuroticism, anxiety, somatization, coping, and health. Correlations and partial correlations controlling for neuroticism were examined. Hardiness was negatively correlated with neuroticism, rumination, worry, and anxiety and positively correlated with mindfulness, coping, and health. When neuroticism was statistically controlled, the relationships between hardiness and rumination, health, and coping became nonsignificant, and the relationships between hardiness and worry, mindfulness, and anxiety, although attenuated, remained significant. Rumination and worry were positively correlated, but when neuroticism was statistically controlled, this relationship became nonsignificant. The results suggest that hardiness is better conceptualized as a personality style that contributes to psychological well-being. Furthermore, our findings suggest that rumination and worry are distinct cognitive processes.

The Pivotal Role of Pediatric Psychology in Chronic Pain: Opportunities for Informing and Promoting New Research and Intervention in a Shifting Healthcare Landscape

PURPOSE OF REVIEW

In the context of new efforts to formulate more comprehensive diagnostic and treatment processes for chronic pain conditions, this review aims to provide an overview of some of the most salient developments in the diagnosis and clinical treatment of pediatric chronic pain and to delineate the current and future role of clinical pediatric psychologists in these efforts.

RECENT FINDINGS

The acceptance and promotion of the multidisciplinary approach to pediatric pain management has had an especially significant impact on the field of pediatric psychology. Though chronic pain was historically conceptualized as a biomedical problem, psychology is increasingly viewed as a routine, integral, and component part of treatment. With this evolving biopsychosocial paradigm, pediatric psychology is poised to help shape the development of this field, contributing to emerging conceptual and diagnostic frameworks via consultation, research, clinical care, and education. This review discusses the role of pediatric psychologists as collaborators in emerging diagnostic and assessment frameworks, leaders in pain-related research, drivers of clinical care, and educators for providers, patients, and the lay public. With increased opportunities to enhance the conceptualization and treatment of pediatric pain, pediatric psychologists have an important role to play in reducing the prevalence and persistence of pediatric pain.

Breathlessness catastrophizing relates to poorer quality of life in adults with cystic fibrosis

BACKGROUND

Cystic Fibrosis (CF) is the most common genetic disease affecting children and young adults in Canada. It is a multi-system disease, however lung disease is largely responsible for mortality. Treatment advances have resulted in increased life expectancy and a subsequent need to better understand psychosocial issues associated with quality of life in adults living with CF. Emerging research suggests that anxiety and depression are related to poorer health-related quality of life (HRQoL) in CF patients, but there is little research examining cognitive processes, such as breathlessness catastrophizing. The present study addresses this gap in the literature.

METHODS

Participants in this study are based on a convenience sample of patients recruited during their regular CF clinic appointments at a tertiary care center. Forty-five adults (M_age = 30.73 years) completed measures of lung function, depression, anxiety, pain, breathlessness catastrophizing, and HRQoL at one time point.

RESULTS

Results of a hierarchical multiple regression indicate that increased breathlessness catastrophizing was related to poorer HRQoL, after controlling for lung function, depression, anxiety, and pain (p < .05). Depression, pain, and breathlessness catastrophizing all emerged as significant unique predictors of HRQoL.

CONCLUSIONS

Breathlessness catastrophizing is a potential target for clinical intervention and might impact HRQoL. Further research on breathlessness catastrophizing in CF is warranted including longitudinal studies to examine the mechanisms by which breathlessness catastrophizing relates to HRQoL and treatment outcomes in CF.

Changes in Parent Psychological Flexibility after a One-Time Mindfulness-Based Intervention for Parents of Adolescents with Persistent Pain Conditions

Parenting a child with chronic pain can be stressful and impact parent functioning in a variety of areas. Several studies have examined mindfulness-based interventions (MBIs) for parents of children with different health and mental health conditions. However, no studies to date have examined MBIs for parents of children with pain conditions. This study aimed to: (1) determine the feasibility and acceptability of a one-time MBI workshop for parents (n = 34) of adolescents with painful conditions (chronic pain and inflammatory bowel disease) who were participating in a concurrent mindfulness group for adolescents with pain, and (2) examine changes in parent mindfulness and psychological flexibility following the intervention. A mixed-method design was used. In terms of feasibility and acceptability, high recruitment and retention rates were observed, and parents reported high satisfaction scores with the workshop. Changes pre to post intervention showed that dimensions of parent psychological flexibility, but not parent mindfulness, improved following participation in the workshop. Qualitative analyses based on parent responses on a questionnaire uncovered seven themes of parent "takeaways" following participation in the workshop: Mindfulness Skills, Not Alone, Psychological Flexibility, Parent⁻Child Interactions, Self-Efficacy, Optimism/Positivity/Hope, and Awareness of Values. Taken together, these findings suggest that a one-time MBI workshop offered to parents whose teen was participating in a concurrent mindfulness group for pain is a feasible and promising intervention for parents of children with pain conditions.

A Model of the Intersection of Pain and Opioid Misuse in Children and Adolescents

Despite being a significant public health concern, the role of opioid prescriptions in potentiating risk of opioid misuse in the context of pediatric pain has been under-investigated. To address this gap, the present review identifies theory-based hypotheses about these associations, reviews the extant literature on opioid prescriptions that supports these hypotheses, and provides routes for future empirical studies. A multi-level model of mechanisms through which opioid prescriptions may impact pain and other negative outcomes in youth, including risk for opioid misuse and related problems, is proposed with particular attention paid to the role that psychologists can play in informing policies and developing preventative interventions in healthcare settings.

Personal strengths reported by people with chronic illness: A qualitative study

BACKGROUND

Self-management of chronic illness can be highly demanding and people need to mobilize their personal strengths to live well with their condition. More knowledge is needed about how people with chronic illness perceive and use their personal strengths as a basis for better integrating empowering person-centred approaches into health care.

OBJECTIVE

To explore what people with chronic illness describe as their strengths relevant to their health and well-being.

SETTING AND PARTICIPANTS

Thirty-nine participants (11 men) from 4 outpatient self-management programmes were recruited to individual or group interviews. Participants included patients with chronic respiratory disease (n = 7), chronic pain (n = 18) and morbid obesity (n = 14). Interviews were analysed using content analysis.

RESULTS

A number of personal strengths were reported and categorized into 3 domains: (i) Internal strengths, (ii) External strengths and (iii) Self-management strategies. Internal strengths included being persistent, having a positive outlook, being kind and caring, experiencing positive emotions, being kind towards oneself, reconciling oneself with the situation, having courage and having knowledge and insight. External strengths included support from family, friends, peers and health-care providers. Self-management strategies included being active, planning and prioritizing, reducing stress, goal setting and seeking knowledge and help.

DISCUSSION AND CONCLUSION

The study provides insights into personal strengths as reported by people with chronic illness. The results complement prior findings on strengths in people with health challenges and can aid in incorporating person-centred approaches into health care.

Risk Factors and Pooled Rate of Prolonged Opioid Use Following Trauma or Surgery: A Systematic Review and Meta-(Regression) Analysis

BACKGROUND

Prolonged use of opioids initiated for surgical or trauma-related pain management has become a global problem. While several factors have been reported to increase the risk of prolonged opioid use, there is considerable inconsistency regarding their significance or effect size. Therefore, we aimed to pool the effects of risk factors for prolonged opioid use following trauma or surgery and to assess the rate and temporal trend of prolonged opioid use in different settings.

METHODS

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched Embase, PubMed, Web of Science, EBM (Evidence-Based Medicine) Reviews - Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from inception to August 28, 2017, without language restriction. Observational studies reporting risk factors for, or the rate of, prolonged opioid use among adult patients following surgery or trauma with a minimum of 1 month of follow-up were included. Study and patient characteristics, risk factors, and the rate of prolonged opioid use were synthesized.

RESULTS

Thirty-seven studies with 1,969,953 patients were included; 4.3% (95% confidence interval [CI] = 2.3% to 8.2%) of patients continued opioid use after trauma or surgery. Prior opioid use (number needed to harm [NNH] = 3, odds ratio [OR] = 11.04 [95% CI = 9.39 to 12.97]), history of back pain (NNH = 23, OR = 2.10 [95% CI = 2.00 to 2.20]), longer hospital stay (NNH = 25, OR = 2.03 [95% CI = 1.03 to 4.02]), and depression (NNH = 40, OR = 1.62 [95% CI = 1.49 to 1.77]) showed some of the largest effects on prolonged opioid use (p < 0.001 for all but hospital stay [p = 0.042]). The rate of prolonged opioid use was higher in trauma (16.3% [95% CI = 13.6% to 22.5%]; p < 0.001) and in the Workers' Compensation setting (24.6% [95% CI = 2.0% to 84.5%]; p = 0.003) than in other subject enrollment settings. The temporal trend was not significant for studies performed in the U.S. (p = 0.07) while a significant temporal trend was observed for studies performed outside of the U.S. (p = 0.014).

CONCLUSIONS

To our knowledge, this is the first meta-analysis reporting the pooled effect of risk factors that place patients at an increased chance for prolonged opioid use. Understanding the pooled effect of risk factors and their respective NNH values can aid patients and physicians in developing effective and individualized pain-management strategies with a lower risk of prolonged opioid use.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Chiari 1000 Registry Project: assessment of surgical outcome on self-focused attention, pain, and delayed recall

BACKGROUND

Prior research has typically found a negative relationship between chronic pain and memory, and we examined whether cognitive control processes (e.g. reflection and rumination) moderated this relationship in individuals with Chiari malformation Type I (CM). CM is a neurological condition in which the cerebellar tonsils descend into the medullary and upper cervical spine regions potentially resulting in severe headaches and neck pain.

METHODS

CM patients who had (n = 341) and had not (n = 297) undergone decompression surgery completed the McGill Pain Questionnaire-Short Form-Revised (SF-MPQ-2), the Rey Auditory Verbal Learning Test (RAVLT), and the Rumination-Reflection Questionnaire (RRQ). Immediate recall scores were compared to those of 102 healthy controls, and delayed recall performance was compared across other variables within the CM group.

RESULTS

CM patients performed more poorly on immediate recall than did controls. Within CM patients, we observed main effects for reflection and age, and a pain x reflection x surgical status (surgery v. no surgery) interaction in which non-decompressed individuals with low levels of pain and high levels of reflection showed superior delayed recall relative to non-decompressed individuals with higher pain and all decompressed individuals.

CONCLUSIONS

CM patients show an immediate recall deficit relative to controls, regardless of surgical status. High levels of reflection were associated with better delayed recall performance in non-decompressed CM patients with lower pain levels. High levels of chronic pain may overwhelm increased focused attention abilities, but higher levels of reflection partially overcome the distracting effects of pain and this may represent a type of resilience.

Persistent Post-Mastectomy Pain: Risk Factors and Current Approaches to Treatment

Persistent Post-Mastectomy Pain (PPMP) is a common condition that can follow surgeries for breast cancer, the most common cancer in women. Because of the frequency of PPMP and its potential severity, it has received increasing research attention. This manuscript reviews the recent research literature, beginning with a brief history and then relevant medical, surgical, demographic, and psychosocial risk factors. Subsequently, social, psychological, and functional sequelae that have been linked to PPMPS are considered, as is research on current pharmacological, psychological, and rehabilitative approaches to treatment. The review concludes with a discussion of directions for future research and treatment that might reduce the incidence and impact of PPMP on breast cancer survivors. PERSPECTIVE: This article describes current research literature involving mechanisms, risks, and treatments related to persistent post-mastectomy pain. Implications of research findings also are discussed for pre- and post-surgical approaches to pain management, current treatments, and promising research directions.

Meditation or exercise for preventing acute respiratory infection (MEPARI-2): A randomized controlled trial

Background

Practice of meditation or exercise may enhance health to protect against acute infectious illness.

Objective

To assess preventive effects of meditation and exercise on acute respiratory infection (ARI) illness.

Design

Randomized controlled prevention trial with three parallel groups.

Setting

Madison, Wisconsin, USA.

Participants

Community-recruited adults who did not regularly exercise or meditate.

Methods

1) 8-week behavioral training in mindfulness-based stress reduction (MBSR); 2) matched 8-week training in moderate intensity sustained exercise (EX); or 3) observational waitlist control. Training classes occurred in September and October, with weekly ARI surveillance through May. Incidence, duration, and area-under-curve ARI global severity were measured using daily reports on the WURSS-24 during ARI illness. Viruses were identified multiplex PCR. Absenteeism, health care utilization, and psychosocial health self-report assessments were also employed.

Results

Of 413 participants randomized, 390 completed the trial. In the MBSR group, 74 experienced 112 ARI episodes with 1045 days of ARI illness. Among exercisers, 84 had 120 episodes totaling 1010 illness days. Eighty-two of the controls had 134 episodes with 1210 days of ARI illness. Mean global severity was 315 for MBSR (95% confidence interval 244, 386), 256 (193, 318) for EX, and 336 (268, 403) for controls. A prespecified multivariate zero-inflated regression model suggested reduced incidence for MBSR (p = 0.036) and lower global severity for EX (p = 0.042), compared to control, not quite attaining the p<0.025 prespecified cut-off for null hypothesis rejection. There were 73 ARI-related missed-work days and 22 ARI-related health care visits in the MBSR group, 82 days and 21 visits for exercisers, and 105 days and 24 visits among controls. Viruses were identified in 63 ARI episodes in the MBSR group, compared to 64 for EX and 72 for control. Statistically significant (p<0.05) improvements in general mental health, self-efficacy, mindful attention, sleep quality, perceived stress, and depressive symptoms were observed in the MBSR and/or EX groups, compared to control.

Conclusions

Training in mindfulness meditation or exercise may help protect against ARI illness.

Limitations

This trial was likely underpowered.

Trial registration

Clinicaltrials.gov NCT01654289

Effects of a community-based multicomponent rehabilitation programme for patients with fibromyalgia: protocol for a randomised controlled trial

INTRODUCTION

People with fibromyalgia (FM) suffer from symptoms such as widespread pain, non-refreshing sleep, fatigue and reduced quality of life. Effects of pharmacological treatment are questionable and non-pharmacological treatments are recommended as first-line therapy. To date the majority of patients with FM in Norway are not offered any targeted treatment. The aim of this randomised controlled trial is to investigate the effects of a community-based multicomponent rehabilitation programme comprising an acceptance-based and mindfulness-based group intervention, the Vitality Training Programme (VTP), followed by tailored physical activity counselling.

MATERIALS AND METHODS

General practitioners refer potential participants to a rheumatologist in specialist healthcare for diagnostic clarification and assessment of comorbidities. Inclusion criteria are widespread pain/FM ≥3 months, age 20-50 and work participation (minimum part-time) within the last 2 years. The intervention group attends the VTP comprising 10 weekly 4 hour group sessions plus a booster session after 6 months. Thereafter, they receive 12 weeks of individually tailored physical exercise counselled by physiotherapists at community-based Healthy Life Centers. The control group follows treatment as usual. The primary outcome is Patient Global Impression of Change. Secondary outcomes include self-reported pain, fatigue and sleep quality, psychological distress, mindfulness, health-related quality of life, physical activity, work ability and exercise beliefs and habits. To achieve a power of 80% and allow for 10% dropout, 70 participants are needed in each arm. All analyses will be conducted on intention-to-treat bases and measured as differences between groups at 12 months follow-up.

ETHICS AND DISSEMINATION

The study is approved and granted by the Norwegian South-Eastern Regional Health Authority (reference 2016015). Ethics approval was obtained from Regional Committee for Medical and Health Research Ethics (reference 2015/2447/REK sør-øst A). Results will be submitted to appropriate journals and presented in relevant conferences and social media.

TRIAL REGISTRATION

ISRCTN 96836577.

Cognitive-behavioral therapy for patients with chronic pain: Implications of gender differences in empathy

Chronic pain is defined as persistent or recurrent pain lasting longer than 3 months; the severity of pain can be rated in terms of intensity, pain-related distress, and functional impairment. Researches have shown an association between psychosocial factors, such as empathic ability, and the severity of pain. Cognitive-behavioral therapy (CBT) is the most common psychologic intervention for individuals with chronic pain. The aim of this study was to investigate the effect of CBT on empathy in chronic pain patients, examining especially gender differences. In total, 89 patients with severe chronic pain (46 men and 43 women) underwent 8 sessions of CBT over the course of 4 weeks. Self-reported clinical symptoms were measured at the beginning and end of the CBT. Empathy was measured using the interpersonal reactivity index, and pain severity was assessed using the short-form McGill pain questionnaire. A comparison of male and female patients before CBT indicated that females showed higher levels of empathy in response to affective issues and reported greater affective pain than males. A mixed analysis of variance revealed that female patients showed higher levels of empathy than did male patients, both before and after CBT. We also found significant relationships between affective pain and empathy for others' personal distress in all patients. These results suggest that the effectiveness of CBT may be affected by chronic pain patients' level of empathy. Although the evident result was not shown in this study, the present findings imply that female patients may formulate excellent therapeutic alliance in CBT intervention that can lead to a clinical benefit.

Psychological Treatment Needs for Chronic Pain in Singapore and the Relevance of the Psychological Flexibility Model

Objective

The goals of the present study were (a) to assess the psychological treatment needs and treatment delivery preferences in people attending services or contacting a hospital website for chronic pain in Singapore, and (b) to explore potential relevance of the psychological flexibility (PF) model for this group by investigating associations between PF and pain-related outcomes.

Design and Setting

This was a cross-sectional questionnaire study of people with chronic pain in Singapore.

Subjects

Current users of treatment services at a tertiary pain management clinic (PMC), users of pain treatment services elsewhere, and non-treatment users.

Methods

Participants were either recruited face-to-face at a pain clinic or via an online portal. All participants completed a questionnaire, including a survey of treatment barriers and needs, treatment delivery preferences for chronic pain, and standardized measures of PF, pain interference, emotional functioning, and health care use.

Results

A total of 200 participants completed the study. Cost of treatment was identified as a main deterrent, while proof of treatment success was identified as a main facilitator for treatment uptake. A majority of participants (88.5%) indicated a preference for face-to-face treatment. In multiple regression analyses, after controlling for relevant demographic variables and pain intensity, PF explained 14% of the variance for pain interference and impact of depressive symptoms and 22% of the variance for depressive symptoms.

Conclusion

A focus on meeting patients' needs at low cost, and providing proof of treatment success may increase psychological treatment uptake. Increasing PF for pain in people from Singapore may also contribute to better patient functioning.

Happy Despite Pain: A Randomized Controlled Trial of an 8-Week Internet-delivered Positive Psychology Intervention for Enhancing Well-being in Patients With Chronic Pain

Supplemental Digital Content is available in the text.

Objectives:

There is preliminary evidence for the efficacy of positive psychology interventions for pain management. The current study examined the effects of an internet-based positive psychology self-help program for patients with chronic musculoskeletal pain and compared it with an internet-based cognitive-behavioral program.

Materials and Methods:

A randomized controlled trial was carried out with 3 conditions: an internet-delivered positive psychology program, an internet-delivered cognitive-behavioral program and waitlist control. A total of 276 patients were randomized to 1 of the 3 conditions and posttreatment data were obtained from 206 patients. Primary outcomes were happiness, depression, and physical impairments at posttreatment and at 6-month follow-up. Intention-to-treat analyses were carried out using mixed regression analyses.

Results:

Both treatments led to significant increases in happiness and decreases in depression. Physical impairments did not significantly decrease compared with waitlist. Improvements in happiness and depression were maintained until 6-month follow-up. There were no overall differences in the efficacy of the 2 active interventions but effects seemed to be moderated by education. Patients with a higher level of education profited slightly more from the positive psychology intervention than from the cognitive-behavioral program.

Discussion:

The results suggest that an internet-based positive psychology and cognitive-behavioral self-help interventions for the management of chronic pain are clinically useful. Because the self-help exercises as used in the current program do not require therapist involvement, dissemination potential is large. Further studies should examine whether it can best be used as stand-alone or add-on treatment combined with established pain treatment programs.

A Mindfulness Program Adapted for Adolescents With Chronic Pain: Feasibility, Acceptability, and Initial Outcomes

OBJECTIVES

Pediatric chronic pain is a major health issue that can lead to significant interference in daily functioning. Mindfulness-based interventions (MBI's), which emphasize acceptance rather than control of pain, have gained increasing attention as a viable treatment option among adults with chronic pain. The effectiveness of MBIs for chronic pain in pediatric populations remains largely unknown. This prospective pre-post interventional study was conducted to examine the feasibility, acceptability, and initial effectiveness of an 8-week group MBI adapted for adolescents (MBI-A) with chronic pain.

MATERIALS AND METHODS

Self-report measures assessing pain characteristics, anxiety, depression, disability, pain catastrophizing, perceived social support, mindfulness, and pain acceptance were administered at baseline, postintervention, and at a 3-month follow-up. In addition, session data were collected to assess each session's impact on patients' coping with pain and stress, body awareness, and sense of feeling less alone.

RESULTS

In total, 42 consecutive patients in a tertiary care chronic pain clinic met eligibility criteria to participate in the MBI-A group. Of these, 21 participated. A treatment completion rate of 90.5% was observed. Between session mindfulness practice was reported by 77% of participants. Participants were highly satisfied with the MBI-A and all participants reported they would recommend the group to a friend. Improvements in pain acceptance were observed between baseline and the 3-month follow-up, in domains of Pain Willingness and Activity Engagement. Session data revealed improved body awareness and improved ability to cope with stress across sessions.

DISCUSSION

The MBI-A is a feasible, well-received intervention for adolescents with chronic pain conditions. Findings support the need for further investigation of the efficacy of MBI-A through randomized-controlled trials.

Advancing Psychologically Informed Practice for Patients With Persistent Musculoskeletal Pain: Promise, Pitfalls, and Solutions

There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples' responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined.

What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis

Background

Self-management interventions fostering self-efficacy improve the well-being of people with chronic pain.

Purpose

The purpose of this study was to synthesize the enablers (what works) and barriers (what does not) of incorporating self-management strategies for people in everyday life after completion of a pain self-management intervention.

Data Sources

Major electronic databases (MEDLINE, AMED, PsycINFO, Cochrane Library, PubMed, CINAHL, Scopus, and Google Scholar) were searched from inception to July 2016.

Study Selection

Study selection included qualitative and mixed-method studies that explored the perceptions of individuals with chronic pain after completion of a self-management intervention.

Data Extraction

A thematic analysis approach was used to synthesize the review findings, and a Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence.

Data Synthesis

Thirty-three studies with 512 participants were included. Enablers to self-management included self-discovery-the ability to distinguish self (ie, body, thoughts, and feelings) from pain; feeling empowered by incorporating self-management strategies into practice; and supportive ambience via collaborative relationships with clinicians and support from family and friends. Barriers to self-management included difficulty with sustaining motivation for pain self-management; distress experienced from ongoing pain, anxiety, and depression; and unsupportive relationships with clinicians, family, and friends.

Limitations

This review only included interventions that involved at least 4 self-management skills; thus, informative studies may have been missed. The follow-up period varied from immediately after the intervention to 72 months following the intervention; therefore, it is uncertain which of the key enablers and barriers were most influential long term. Only articles published in the English language were included; studies conducted in low- and middle-income countries could not be located.

Conclusions

The sustained effort to self-manage chronic pain could be exhausting, and motivation could wane over time following intervention. Providing intermittent support in the form of booster sessions and peer support groups may be important. Person-centered care via shared decision making and guided problem solving is essential to facilitating ongoing self-management.

Anhedonia is associated with suicidal ideation independently of depression: A meta-analysis

BACKGROUND

Anhedonia is considered a suicide risk factor in patients with major affective disorders. Here, we wanted to quantify the association between anhedonia and current suicidal ideation according to the absence/presence of between-group differences for depressive scores and psychiatric disorders.

METHODS

We performed a meta-analysis of data on studies retrieved from Medline, Web of Science, and PsycINFO from 1965 to 2016 using, among others, the terms (suicid* or depression) and anhedonia.

RESULTS

We identified 15 observational case-control studies that investigated the anhedonia differences in individuals with and without current (i.e., within the past week, independently of the lifetime suicidality status) suicidal ideation (defined as thoughts of killing oneself). Overall, 657 subjects with and 6,690 subjects without current suicidal ideation could be compared. Anhedonia level was higher in the group with current suicidal ideation than in the group without, with a medium effect size (standardized mean difference = 0.57, z = 5.43, P < 0.001, 95% confidence interval, CI = 0.37-0.79). The association between anhedonia and current suicidal ideation remained significant when controlling for depression and psychiatric disorders. The anhedonia scales used in the selected studies did not allow investigating consummatory and motivational anhedonia separately.

CONCLUSION

Our major finding is the robust association between anhedonia and current suicidal ideation, independently of depression. This is highly relevant for the clinicians' daily practice and might help improving suicidal risk detection and the development of new therapeutic strategies for suicide prevention.

Feasibility randomized-controlled trial of online Acceptance and Commitment Therapy for patients with complex chronic pain in the United Kingdom

BACKGROUND

Acceptance and Commitment Therapy (ACT) has growing support for chronic pain. However, more accessible treatment delivery is needed. This study evaluated the feasibility of online ACT for patients with complex chronic pain in the United Kingdom to determine whether a larger trial is justified.

METHODS

Participants with chronic pain and clinically meaningful disability and distress were randomly assigned to ACT online plus specialty medical pain management, or specialty medical management alone. Participants completed questionnaires at baseline, and 3- and 9-month post-randomization. Primary feasibility outcomes included recruitment, retention and treatment completion rates. Secondary outcomes were between-groups effects on treatment outcomes and psychological flexibility.

RESULTS

Of 139 potential participants, 63 were eligible and randomized (45% recruitment rate). Retention rates were 76-78% for follow-up assessments. Sixty-one per cent of ACT online participants completed treatment. ACT online was less often completed by employed (44%) compared to unemployed (80%) participants. Fifty-six per cent of ACT online participants rated themselves as 'much improved' or better on a global impression of change rating, compared to only 20 per cent of control participants. Three-month effects favouring ACT online were small for functioning, medication and healthcare use, committed action and decentring, medium for mood, and large for acceptance. Small-to-medium effects were maintained for functioning, healthcare use and committed action at 9 months.

CONCLUSIONS

Online ACT for patients with chronic pain in the United Kingdom appears feasible to study in a larger efficacy trial. Some adjustments to treatment and trial procedures are warranted, particularly to enhance engagement among employed participants.

SIGNIFICANCE

This study supports the feasibility of online Acceptance and Commitment Therapy for chronic pain in the United Kingdom and a larger efficacy trial. Refinements to treatment delivery, particularly to better engage employed patients, may improve treatment completion and outcomes.

Perceived Mindfulness and Depressive Symptoms Among People with Chronic Pain

The study purpose was to evaluate pain catastrophizing and psychological distress as mediators for the relationship between perceived mindfulness and depressive symptoms in people with chronic pain. We conducted an online cross-sectional survey with 211 adults with chronic musculoskeletal pain recruited from U.S. clinics and community networks. A serial multiple mediation analysis was performed using ordinary least-squares regressions and a bootstrap testing approach. Pain catastrophizing and psychological distress, independently and jointly, mediated the relationship between mindfulness and depressive symptoms. Rehabilitation counseling professionals should consider targeting mindfulness, pain catastrophizing, and psychological distress in psychosocial treatment for people with chronic pain.

Does a Brief Mindfulness Exercise Improve Outcomes in Upper Extremity Patients? A Randomized Controlled Trial

BACKGROUND

Mindfulness-based interventions are useful in reducing psychologic distress and pain intensity in patients with chronic pain. However, most mindfulness-based interventions are resource-intensive, lengthy, and not feasible for busy orthopaedic surgical practices.

QUESTIONS/PURPOSES

The purpose of this study was to determine if a 60-second personalized mindfulness-based video exercise is (1) associated with improved pain intensity, emotional distress, and state anxiety compared with an attention placebo control (a time-matched educational pamphlet about pain and stress); and (2) feasible and acceptable for patients with upper extremity injury in an orthopaedic practice.

METHODS

This was a single-center, single-blind randomized controlled trial of the mindfulness-based video exercise (60 seconds duration, free online) versus an attention placebo control (an educational pamphlet about pain and stress presented to patients to read over 60 seconds). One hundred forty-nine patients presenting for a new or followup appointment at the office of one of two orthopaedic hand and upper extremity outpatient surgical practices at an urban academic hospital were invited to participate between September 2016 and December 2016. Of 149 patients screened, 125 patients were randomized and completed a demographic questionnaire, the Numeric Rating Scale to assess pain intensity, the State Anxiety subscale of the State Trait Anxiety Inventory to assess state anxiety, and Emotion Thermometers to assess anxiety, anger, and depression before and after the interventions. Postintervention, patients also completed the Client Satisfaction Questionnaire Scale-3 to assess the acceptability. A mean score of 21 or higher is considered acceptable. Feasibility was determined based on number of patients approached who refused participation. The intervention was defined as feasible if refusal rate was lower than 25%. Analysis of covariance was used to test comparative improved pain intensity on the NRS, psychologic distress on the Emotion Thermometers, and state anxiety on the State Anxiety Subscale of the State Trait Anxiety Index after controlling for respective baseline scores. A 1-point minimal clinically important difference (MCID) was used on the NRS for pain intensity.

RESULTS

Adjusted for the baseline means, compared with patients who received the attention placebo control, patients who participated in the mindfulness-based video exercise demonstrated improved pain intensity (mindfulness-based video exercise: 3.03 ± 0.12; control: 3.49 ± 0.12; mean difference: 0.46 [0.12-0.80]; p = 0.008); state anxiety (mindfulness-based video exercise: 32.35 ± 0.59; control: 35.29 ± 0.59; mean difference: 2.94 [1.29-4.59]; p = 0.001); anxiety symptoms (mindfulness-based video exercise: 1.49 ± 0.19; control: 2.10 ± 0.19; mean difference: 0.61 [0.08-1.14]; p = 0.024); depression (mindfulness-based video exercise: 1.03 ± 0.10; control: 1.47 ± 0.11; mean difference: 0.44 [0.15-0.73]; p = 0.004); and anger (mindfulness-based video exercise: 0.76 ± 0.12; control: 1.36 ± 0.12; mean difference: 0.60 [0.26-0.94]; p = 0.001). However, the observed differences in pain intensity were below 1 point on the NRS, which is the MCID established in patients with chronic pain. No MCID is available for the other measures. The mindfulness-based video exercise was feasible based on a dropout rate of 0%, and acceptability reached the medium range with similar scores in both groups (mindfulness-based video exercise: 20.70 ± 5.48; control: 20.52 ± 6.42).

CONCLUSIONS

A 60-second mindfulness-based video exercise is feasible to implement and acceptable to patients in busy orthopaedic practices. This video exercise is also effective in improving momentary pain, anxiety, depression, and anger in this population, but it is unclear whether these improved pain and distress levels are meaningful to patients who present with low levels of pain and psychologic distress. Future studies should seek to discern whether the improved pain and distress levels we observed are clinically important or whether the intervention delivers larger effects in subgroups of patients experiencing greater pain intensity and if the improved pain and distress levels are durable. Such studies might also assess cost-effectiveness, because this mindfulness-based tool takes little time and few resources to use, and the effects and durability of multiple sessions of a mindfulness-based video exercise.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Randomized Controlled Trial of Online Acceptance and Commitment Therapy for Fibromyalgia

In this study, 67 participants (95% female) with fibromyalgia (FM) were randomly assigned to an online acceptance and commitment therapy (online ACT) and treatment as usual (TAU; ACT + TAU) protocol or a TAU control condition. Online ACT + TAU participants were asked to complete 7 modules over an 8-week period. Assessments were completed at pre-treatment, post-treatment, and 3-month follow-up periods and included measures of FM impact (primary outcome), depression, pain, sleep, 6-minute walk, sit to stand, pain acceptance (primary process variable), mindfulness, cognitive fusion, valued living, kinesiophobia, and pain catastrophizing. The results indicated that online ACT + TAU participants significantly improved in FM impact, relative to TAU (P <.001), with large between condition effect sizes at post-treatment (1.26) and follow-up (1.59). Increases in pain acceptance significantly mediated these improvements (P = .005). Significant improvements in favor of online ACT + TAU were also found on measures of depression (P = .02), pain (P = .01), and kinesiophobia (P = .001). Although preliminary, this study highlights the potential for online ACT to be an efficacious, accessible, and cost-effective treatment for people with FM and other chronic pain conditions.

PERSPECTIVE

Online ACT reduced FM impact relative to a TAU control condition in this randomized controlled trial. Reductions in FM impact were mediated by improvements in pain acceptance. Online ACT appears to be a promising intervention for FM.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.

Improved cardiorespiratory fitness after occupational rehabilitation in merged diagnostic groups

BACKGROUND

Various occupational inpatient rehabilitation programs are established in Norway. This study aimed to assess change in cardiorespiratory fitness, pain, anxiety, depression, and quality of life in persons on long-term sick leave due to musculoskeletal-, mental or unspecific disorders after participation in multicomponent inpatient occupational rehabilitation.

METHODS

Twenty-five women and five men (mean age 45.2 years, SD 6.7, range 30-57) volunteered to participate in the study. The participants attended either 8 or 17 full days of occupational multicomponent rehabilitation including physical exercise, cognitive behavioral therapy in the form of acceptance and commitment therapy (ACT), and development of a tailored plan for return to work. Cardiorespiratory fitness was assessed by the Åstrand/Ryhming cycle test at the start and end of rehabilitation program, and at one-year follow-up. Changes in somatic and mental health were measured by questionnaires up to 4 months after start of the program.

RESULTS

Linear mixed models showed that the maximal oxygen uptake increased by 1.1 mL°kg-1°min- 1 during the rehabilitation program and by 3.7 mL°kg-1°min- 1 at one-year follow-up. There were minor improvements in somatic and mental health, and quality of life.

CONCLUSIONS

This study indicates that occupational inpatient multicomponent rehabilitation including physical exercise and ACT may promote a long-term increase in physical exercise that is sufficient to induce a significant increase in cardiorespiratory fitness.

TRIAL REGISTRATION

The current study is not registered, but is part of a larger trial registered at clinicaltrials.gov (No.: NCT01926574, registered 21. Aug 2013).

Acceptance and Commitment Therapy (ACT) for Chronic Pain: A Systematic Review and Meta-Analyses

OBJECTIVES

Chronic pain places a burden on individuals and the economy. Although there is evidence for the effectiveness of cognitive-behavior therapy, it is recognized that the effects are limited. Acceptance and Commitment Therapy (ACT), which aims to increase valued action in the presence of pain, has been suggested as an alternative approach. The objective of this review was to determine the clinical effectiveness of ACT for chronic pain in adults when compared with control conditions and other active treatments.

METHODS

The searches of this systematic review were conducted in the Cochrane library, MEDLINE, EMBASE, CINAHL Plus (EBSCO), and PsycINFO. Grey literature, reference list, and reverse citation searches were also completed.

RESULTS

Eleven trials were included. ACT was favored over controls (no alternative intervention or treatment as usual). Significant, medium to large effect sizes were found for measures of pain acceptance and psychological flexibility, which are typically considered processes of ACT. Significant small to medium effect sizes were found for measures of functioning, anxiety, and depression. Measures of pain intensity and quality of life were not significantly different than zero. Generally effect sizes were smaller at follow-up.

DISCUSSION

ACT was more clinically effective than controls on a number of outcomes. It is possible that methodological limitations, some of which are common to psychological trials, may have led to overestimated effects. Only a few studies compared ACT to active treatments and while the evidence is promising for ACT in the treatment of chronic pain, further methodologically robust trials are required.

Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome - A systematic review and meta-analysis of randomized controlled trials

This updated systematic review aimed at evaluating the efficacy, acceptability and safety of cognitive behavioural therapies (CBTs) in fibromyalgia syndrome (FMS). Clinicaltrials.gov, Cochrane Library, MEDLINE, PsycINFO and SCOPUS were searched from September 2013 to May 2017. Randomized controlled trials (RCTs) comparing CBTs with controls were analysed. Primary outcomes were ≥50% pain relief, ≥20% improvement of health-related quality of life (HRQoL), negative mood, fatigue, disability, acceptability and safety at end of therapy and at 6 months follow-up. Effects were summarized by a random effects model using risk differences (RD) or standardized mean differences (SMD) with 95% confidence intervals (CI). 29 RCTs with 2509 subjects were included. CBTs were superior to controls (waiting list, attention control, treatment as usual, other active non-pharmacological therapies) in pain relief of 50% or greater (RD 0.05 [95% CI 0.02-0.07] (high-quality evidence), improvement of HRQoL of 20% or greater (RD 0.13 [95% CI 0.00-0.26], (moderate quality evidence), and in reducing negative mood (SMD -0.43 [95% CI -0.62 to -0.24]) (high-quality evidence), disability (SMD -0.30 [95% CI -0.52 to -0.08]) (high-quality evidence) and fatigue (SMD - 0-27 [95% CI -0.50 to -0.03]) (high-quality evidence). There were no statistically significant differences between CBTs and controls in acceptability and safety (high-quality evidence). The update did not change the major findings of the previous review. CBTs provided a clinically relevant benefit over control interventions in reducing some key symptoms of FMS and disability at the end of treatment.

SIGNIFICANCE

This updated systematic review with meta-analysis on cognitive behavioural therapies (CBTs) including acceptance-based CBTs endorse the efficacy and tolerability of CBTs in reducing key symptoms and disability in FMS in the short- and long-term if compared to waiting list, treatment as usual, attention controls and active non-pharmacological therapies. CBTs did not differ in efficacy except superiority for coping with pain and tolerability from recommended drug therapy (pregabalin and/or duloxetine).

Identifying the features of partner acceptance of arthritis: A qualitative analysis

Background

Patients who are more accepting of their chronic arthritis pain report better physical, mental, and occupational functioning, but acceptance of arthritis from the partner perspective has received little attention in the literature. In fact, no attempts have been made to define partner acceptance of arthritis and no psychometrically validated measure currently exists.

Aims

The aim of this study was to use qualitative research methods to identify the features of partner acceptance of arthritis and examine the similarities and differences between patient and partner acceptance in an arthritis context.

Methods

Twenty-one romantic partners of individuals with arthritis participated in a semistructured interview focusing on their experiences adjusting to their spouse’s arthritis and their general perceptions of the meaning of acceptance. Interview transcripts were coded using thematic analysis.

Results

Partners’ descriptions of acceptance differed slightly across accounts, but the majority of participants agreed that acceptance is part of a positive process of adjusting to arthritis. Six themes that characterize the acceptance process were identified: (1) understanding the nature of arthritis; (2) believing in the patient’s pain experience; (3) living with negative feelings; (4) establishing a new normal; (5) engaging in valued activities; and (6) relationship willingness.

Conclusions

The identified themes share some commonalities with experiential acceptance and patient chronic pain acceptance, although partner acceptance of arthritis also has several unique features. These findings suggest that more research on this distinct construct is merited. Directions for future research on partner acceptance of arthritis are discussed.

Randomized Trial of the Effect of Mindfulness-Based Stress Reduction on Pain-Related Disability, Pain Intensity, Health-Related Quality of Life, and A1C in Patients With Painful Diabetic Peripheral Neuropathy

IN BRIEF Painful diabetic peripheral neuropathy (PDPN) has a large negative impact on patients' physical and mental functioning, and pharmacological therapies rarely provide more than partial relief. Mindfulness-based stress reduction (MBSR) is a group psychosocial intervention that was developed for patients with chronic illness who were not responding to existing medical treatments. This study tested the effects of community-based MBSR courses for patients with PDPN. Among patients whose PDPN pharmacotherapy had been optimized in a chronic pain clinic, those randomly assigned to treatment with MBSR experienced improved function, better health-related quality of life, and reduced pain intensity, pain catastrophizing, and depression compared to those receiving usual care.

The Effectiveness of a Body-Affective Mindfulness Intervention for Multiple Sclerosis Patients with Depressive Symptoms: A Randomized Controlled Clinical Trial

Purpose: Mindfulness interventions have been shown to treat depressive symptoms and improve quality of life in patients with several chronic diseases, including multiple sclerosis, but to date most evaluation of the effectiveness of mindfulness interventions in multiple sclerosis have used patients receiving standard care as the control group. Hence we decided to evaluate the effectiveness of a group-based body-affective mindfulness intervention by comparing it with a psycho-educational intervention, by means of a randomized controlled clinical trial. The outcome variables (i.e., depression, anxiety, perceived stress, illness perception, fatigue and quality of life) were evaluated at the end of the interventions (T1) and after a further 6 months (T2).

Methods: Of 90 multiple sclerosis patients with depressive symptoms (Beck Depression Inventory-II score greater than 13) who were randomized, 71 completed the intervention (mindfulness group n = 36; psycho-educational group n = 35). The data were analyzed with GLM repeated-measures ANOVA followed by pairwise comparisons.

Results: Per-protocol analysis revealed a time by group interaction on Beck Depression Inventory-II score, with the mindfulness intervention producing a greater reduction in score than the psycho-educational intervention, both at T1 and at T2. Furthermore, the mindfulness intervention improved patients’ quality of life and illness perception at T1 relative to the baseline and these improvements were maintained at the follow-up assessment (T2). Lastly, both interventions were similarly effective in reducing anxiety and perceived stress; these reductions were maintained at T2. A whole-sample intention-to-treat (ITT) analysis broadly confirmed the effectiveness of the mindfulness intervention.

Conclusion: In conclusion, these results provide methodologically robust evidence that in multiple sclerosis patients with depressive symptoms mindfulness interventions improve symptoms of depression and anxiety and perceived stress, modulate illness representation and enhance quality of life and that the benefits are maintained for at least 6 months.

Trial registration: the study was registered in the ClinicalTrials.gov registry (NCT02611401).