Necessary components of psychological treatment in pain management programs: A Delphi study

Interpretation bias and its relationship with pain: a systematic review and meta-analysis

ABSTRACT

The aim of this review was to systematically review and meta-analyse evidence for the presence of interpretation bias in pain and to establish the likely role of interpretation bias in chronic pain. The primary questions were whether people experiencing pain showed a greater interpretation bias than people without pain and whether interpretation bias was associated with pain outcomes. We were also interested in evaluating existing longitudinal and intervention research, which could inform interpretation bias as a causal mechanism and/or treatment target in pain. A total of 33 studies across 31 articles were identified (combined n = 4842). People with chronic pain showed a greater interpretation bias than people without pain, with a moderate effect (g = 0.602). This effect was even more pronounced when interpretation bias was measured with the word association task, reaching a large effect size (g = 0.899). Interpretation bias was associated with degree of pain interference, pain catastrophising, and less reliably with pain severity, but not with experimental pain outcomes. Longitudinal studies (k = 3) were mixed as to whether interpretation bias predicted subsequent pain. Whereas, intervention studies (k = 3) showed that interpretation bias could be modified and, for chronic pain, led to improved pain outcomes. Overall, data show that interpretation biases are robust among those with chronic pain compared with those without and are associated with pain interference. There is emerging evidence that interpretation biases are a treatment target that can be modified for improved pain outcomes.

Development and preliminary validation of the evaluation scale for nurses' core emergency response abilities in sudden major infectious disease outbreaks

BACKGROUND

In recent years, the escalating frequency and intensity of infectious disease outbreaks have underscored the profound severity and global ramifications of public health challenges confronting healthcare systems. As frontline responders during emerging infectious disease crises, nurses' core emergency response competencies critically influence the timeliness and efficacy of outbreak prevention and control measures. Currently, standardized assessment instruments for evaluating nurses' core emergency response capabilities during major infectious disease outbreaks remain underdeveloped.

AIMS

This study aimed to construct and psychometrically validate a Core Emergency Response Competency Evaluation Scale for nurses during major infectious disease outbreaks.

METHODS

A convenience sample of nurses was recruited from eight tertiary hospitals in Henan Province, China. The three-phase study comprised: (1) item generation (Delphi survey and pilot testing), (2) scale development (item analysis and exploratory factor analysis), and (3) scale validation (reliability and validity assessments).

RESULTS

The finalized 45-item scale encompasses eight dimensions: Fundamental Nursing Knowledge, Legal Policy & Ethical Practice, Core Nursing Skills, Disease Assessment & Monitoring, Emergency Response Coordination, Infection Prevention & Control, Nurse Personal Attributes, and Rehabilitation & Recovery. Exploratory factor analysis demonstrated an 83.353% cumulative variance contribution for the eight-factor model. Confirmatory factor analysis indicated excellent model fit (χ²/df = 1.943, RMR = 0.020, RMSEA = 0.050, IFI = 0.951, TLI = 0.947, CFI = 0.951, PNFI = 0.835). The scale exhibited strong reliability (Cronbach's α = 0.987, split-half = 0.956, test-retest = 0.977) and validity (I-CVI = 0.875-1.00; S-CVI = 0.974). Convergent validity was supported by AVE values (0.611-0.778) and CR values (0.903-0.955).

CONCLUSION

The psychometrically robust Core Emergency Response Competency Evaluation Scale for Sudden Major Infectious Diseases demonstrates excellent reliability and validity, providing a scientifically validated tool for assessing nurses' emergency preparedness in infectious disease crises.

Immune-inflammatory effects of the multicomponent intervention FIBROWALK in outdoor and online formats for patients with fibromyalgia

The multicomponent intervention FIBROWALK integrates pain science education (PSE), therapeutic exercise, cognitive behavioral therapy (CBT), and mindfulness training for treating fibromyalgia (FM). This study investigated the effects of the FIBROWALK in online (FIBRO-On) and outdoor (FIBRO-Out) formats compared to treatment-as-usual (TAU) on core clinical variables along with serum immune-inflammatory biomarkers and brain-derived neurotrophic factor (BDNF). Furthermore, the predictive value of these biomarkers on clinical response to FIBROWALK was also evaluated. 120 participants were randomly divided into three groups: TAU, TAU + FIBRO-On or TAU + FIBRO-Out. Clinical and blood assessments were conducted pre-post treatment. Both FIBRO-Out and FIBRO-On showed effectiveness (vs TAU) by improving functional impairment and kinesiophobia. Individuals allocated to FIBRO-Out (vs TAU) additionally showed decreases in pain, fatigue, depressive symptoms, and serum IL-6 and IL-10 levels along with IL-6/IL-4 ratio; patients allocated to FIBRO-On only showed a less stepped increase in IL-6 compared to TAU. An exaggerated pro-inflammatory profile along with higher levels of BDNF at baseline predicted greater clinical improvements in both active treatment arms. Our results suggest that FIBROWALK -in online and outdoor formats- is effective in individuals with FM and has significant immune regulatory effects in FM patients, while immune-inflammatory pathways and BDNF levels may in part predict its clinical effectiveness. Trial registration number NCT05377567 (clinicaltrials.gov).

Mediators and Moderators of two online interventions for managing pain, fear of progression and functional ability in rheumatoid arthritis

This is a secondary analysis of a trial comparing online mindfulness-based stress reduction with cognitive-behaviour therapy for people with rheumatoid arthritis. Both interventions were administered over eight weeks with five lessons and accompanied by weekly therapist contact. For the purposes of this study, we investigated the pain severity, fear of progression and functional ability as the outcome variables because the treatments had differential effects on these three outcomes but had equivalent effects on other variables. We examined mediators and moderators of relative treatment efficacy of mindfulness based stress reduction (n = 91) versus cognitive-behaviour therapy (n = 103) for these outcomes. For pain severity, no significant mediators or moderators were identified. However, amongst those with low pain severity, mindfulness-based stress reduction was more efficacious than cognitive-behaviour therapy for fears of progression. Furthermore, mindfulness-based stress reduction was more efficacious than cognitive-behaviour therapy for functional ability for those with high trait mindfulness at baseline. Changes in fear of progression during treatment fully mediated the effect of treatment group on functional ability over follow-up. While both online mindfulness-based stress reduction and cognitive-behaviour therapy were efficacious for people with rheumatoid arthritis, mindfulness-based stress reduction was more effective in reducing fears of progression and improving functional ability for those with low levels of pain severity and high levels of mindfulness at baseline, respectively. These results highlight the importance of treating fear of progression for people with rheumatoid arthritis as reductions in fears of progression over treatment led to improvements in functional ability six months later.

A Tale of Two Treatments: A Randomised Controlled Trial of Mindfulness or Cognitive Behaviour Therapy Delivered Online for People with Rheumatoid Arthritis

INTRODUCTION

This study aimed to determine the relative efficacy of mindfulness-based stress reduction (MBSR) or cognitive behaviour therapy (CBT) in comparison to a waitlist control (WLC) for people with rheumatoid arthritis (RA). Participants completed assessments before and after treatment and at 6-month follow-up.

METHODS

Two hundred and sixty-nine participants with RA were recruited and randomised in a 2:2:1 ratio to MBSR:CBT:WLC. Participants completed a semi-structured clinical interview for depression and were stratified for history of recurrent depression. We measured the primary outcome of pain interference, as well as pain severity, depression, anxiety, functional ability, and fear of progression. We predicted that MBSR and CBT would result in improvements compared to WLC. We also predicted that those with a history of recurrent depression would benefit more from MBSR than CBT for depression.

RESULTS

MBSR and CBT were equally efficacious in reducing pain interference compared to WLC. Similar results were found for depression. MBSR demonstrated superior outcomes to CBT for fear of progression at post-treatment and functional ability at 6-month follow-up. CBT only was better than WLC for pain severity at 6-month follow-up. Depressive status did not moderate the efficacy of treatment.

CONCLUSIONS

MBSR and CBT resulted in statistically and clinically significant changes in pain interference compared to WLC. MBSR was more efficacious than CBT for functional ability and fear of progression, while CBT showed superiority for pain severity. The effect sizes were comparable to those achieved with face-to-face interventions, confirming both online treatments are effective for people with RA.

An online pain management program for people with hypermobile Ehlers-Danlos Syndrome or hypermobility spectrum disorder: a three-staged development process

PURPOSE

Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are painful, chronic and multi-systemic conditions. No online pain management programs for hEDS/HSD currently exist. We aimed to develop one by exploring what people with hEDS/HSD want in such programs.

MATERIALS AND METHODS

A Delphi was conducted via online surveys of stakeholders: participants with hEDS/HSD and healthcare professionals (HCP). In survey 1, participants were asked if a hEDS/HSD-specific online pain management program was important, listing up to 20 topics important to know about pain. In survey 2, participants rated the importance of those topics. Consensus was set as ≥75% rating of at least "important". Using topics that reached consensus, the online program was developed. Usability testing was performed using the Systems Usability Scale (SUS).

RESULTS

396 hEDS/HSD and 29 HCP completed survey 1; 151 hEDS/HSD and 12 HCP completed survey 2. 81% of hEDS/HSD and 69% of HCP rated a hEDS/HSD-specific program as at least "important". Thirty-five topics reached consensus to guide content for the HOPE program (Hypermobile Online Pain managemEnt). SUS score was 82.5, corresponding to "high acceptability".

CONCLUSIONS

A hEDS/HSD-specific online pain management program is important to stakeholders. Utilising a Delphi approach to incorporate stakeholder input, an evidence-informed and user appropriate program was developed.

Pain Catastrophizing: Controversies, Misconceptions and Future Directions

Recent reports have pointed to problems with the term "pain catastrophizing." Critiques of the term pain catastrophizing have come from several sources including individuals with chronic pain, advocates for individuals with chronic pain, and pain scholars. Reports indicate that the term has been used to dismiss the medical basis of pain complaints, to question the authenticity of pain complaints, and to blame individuals with pain for their pain condition. In this paper, we advance the position that the problems prompting calls to rename the construct of pain catastrophizing have little to do with the term, and as such, changing the term will do little to solve these problems. We argue that continued calls for changing or deleting the term pain catastrophizing will only divert attention away from some fundamental flaws in how individuals with pain conditions are assessed and treated. Some of these fundamental flaws have their roots in the inadequate training of health and allied health professionals in evidence-based models of pain, in the use of psychological assessment and intervention tools for the clinical management of pain, and in gender equity and antiracism. Critiques that pain scholars have leveled against the defining, operational, and conceptual bases of pain catastrophizing are also addressed. Arguments for reconceptualizing pain catastrophizing as a worry-related construct are discussed. Recommendations are made for remediation of the problems that have contributed to calls to rename the term pain catastrophizing. PERSPECTIVE: The issues prompting calls to rename the construct of pain catastrophizing have their roots in fundamental flaws in how individuals with pain are assessed and treated. Efforts to address these problems will require more than a simple change in terminology.

Pain Catastrophizing Dimensions Mediate the Relationship between Chronic Pain Severity and Depression

BACKGROUND

Although past studies have found significant positive correlations of both pain severity and overall pain catastrophizing (PC) levels with depression in chronic pain samples, less is known about the extent to which specific PC dimensions (i.e., helplessness, magnification, rumination) explain links between pain severity and depression.

AIM

This study assessed the relative importance of PC dimensions as mediators of relations between chronic pain severity and depression.

DESIGN

A cross sectional study design was employed.

METHOD

Mainland Chinese adults with chronic pain (n = 983) completed validated questionnaire measures of PC, depression, and chronic pain severity within a cross-sectional research design.

RESULTS

Analyses indicated helplessness mediated the association between pain severity and depression while magnification partially mediated the association of helplessness with depression. Conversely, rumination did not make a significant contribution in the mediation model.

CONCLUSIONS

The helplessness dimension of PC, in particular, may help to explain why people with more severe chronic pain are prone to co-occurring depression.

Group-Based Integrative Pain Management in Primary Care: A Study Protocol for Multilevel Interventions to Address Health Disparities

Background

Socioeconomically disadvantaged populations have a high prevalence of chronic pain, exacerbated by social isolation, intersectional stigma, and disparities in pain assessment and treatment. Effective interventions using a multilevel, biopsychosocial approach are needed to decrease the unequal burden of pain. Group-based integrative pain management in primary care safety net clinics is a promising model to improve pain care for racially and ethnically diverse low-income people.

Objective

To describe a study protocol to test the impacts of 2 group-based models - group acupuncture and integrative group medical visits - on multilevel pain-related outcomes.

Methods

The study uses a 2x2 factorial randomized clinical trial to test two 12 week group-based models: group acupuncture and integrative group medical visits (IGMV, with psychoeducation, mind-body approaches, and social support). English or Spanish-speaking adults with chronic pain for ≥3 months receiving care in San Francisco Department of Public Health primary care clinics are eligible for the trial. All participants will receive usual care and be randomized to group acupuncture, IGMV, both, or waitlist control. The primary outcomes are changes from baseline to 3 month follow-up in pain impact and in social support for chronic pain. Secondary outcomes include pain interference, pain intensity, depression, anxiety, quality of life, and social isolation. Data will include patient-reported outcomes, electronic health record data, and qualitative interviews, focus groups and observations to assess multilevel individual, interpersonal and organizational outcomes.

Discussion

Multilevel approaches are needed to advance health equity in pain management. Our study contributes to knowledge of group-based integrative pain management in primary care safety net clinics to address multilevel barriers and disparities in pain care.

A synthesis of meta-analyses of mindfulness-based interventions in pain

ABSTRACT

Mindfulness interventions have become popular in recent decades, with many trials, systematic reviews, and meta-analyses of the impact of mindfulness-based interventions (MBIs) on pain. Although many meta-analyses provide support for MBIs, the results are more mixed than they at first appear. The aim of this umbrella review was to determine the strength of evidence for MBIs by synthesizing available meta-analyses in pain. We conducted a systematic search in 5 databases and extracted data from published meta-analyses as the unit of analysis. For each outcome, we reported the range of effect sizes observed across studies and identified the largest meta-analysis as the "representative" study. We separately analysed effect sizes for different pain conditions, different types of MBIs, different control groups, and different outcomes. We identified 21 meta-analyses that included 127 unique studies. According to Assessment of Multiple Systematic Review ratings, the meta-analyses ranged from very strong to weak. Overall, there was an impact of MBIs on pain severity, anxiety, and depression but not pain interference or disability. When conditions were considered in isolation, only fibromyalgia and headache benefited significantly from MBIs. Mindfulness-based interventions were more efficacious for pain severity than passive control conditions but not active control conditions. Only pain severity and anxiety were affected by MBIs at follow-up. Overall, our results suggest that individual meta-analyses of MBIs may have overestimated the efficacy of MBIs in a range of conditions. Mindfulness-based interventions likely have a role in pain management but should not be considered a panacea.

A systematic review of cognitive behavioral therapy-based interventions for comorbid chronic pain and clinically relevant psychological distress

Objective

Chronic pain frequently co-occurs with clinically relevant psychological distress. A systematic review was conducted to identify the efficacy of cognitive behavioral therapy-based interventions for patients with these comorbid conditions.

Methods

The systematic search was carried out in Medline, PsycINFO, Web of Science, and Scopus up to March 18th, 2023. Four reviewers independently conducted screenings, extraction, and quality assessment.

Results

Twelve randomized controlled trials and one non-randomized controlled trial involving 1,661 participants that examined the efficacy of Cognitive Behavioral Therapy (nine studies), Mindfulness-based Interventions (three studies), Acceptance and Commitment Therapy (one study), and Behavioral Activation Therapy for Depression (one study) were included. Compared to treatment as usual, six out of eight studies of traditional Cognitive Behavioral Therapy reported significant differences in the reduction of depressive symptoms at post-treatment (d from 1.31 to 0.18) and four out of six at follow-up (d from 0.75 to 0.26); similarly, five out of six reported significant differences in the reduction of anxiety symptoms at post-treatment (d from 1.08 to 0.19) and three out of four at follow-up (d from 1.07 to 0.27). Overall, no significant differences between traditional Cognitive Behavioral Therapy and treatment as usual were reported at post-treatment and follow-up in the studies exploring pain intensity and pain catastrophizing.

Conclusion

The available evidence suggests that traditional Cognitive Behavioral Therapy may produce significant benefits for the improvement of depression, anxiety, and quality of life, but not for pain intensity and pain catastrophizing. More evidence is needed to determine the effects of MBI, ACT, and BATD.

Systematic review registration

PROSPERO, CRD42021219921.

Development of the Life Gatekeeper suicide prevention training programme in China: a Delphi study

Background

Youth suicide has been a pressing public mental health concern in China, yet there is a lack of gatekeeper intervention programmes developed locally to prevent suicide among Chinese adolescents.

Aims

The current Delphi study was the first step in the systematic development of the Life Gatekeeper programme, the first gatekeeper programme to be developed locally in China that aims to equip teachers and parents with the knowledge, skills and ability to identify and intervene with students at high risk of suicide.

Methods

The Delphi method was used to elicit a consensus of experts who were invited to evaluate the importance of training content, the feasibility of the training delivery method, the possibility of achieving the training goals and, finally, the appropriateness of the training materials. Two Delphi rounds were conducted among local experts with diversified professional backgrounds in suicide research and practice. Statements were accepted for inclusion in the adjusted training programme if they were endorsed by at least 80% of the panel.

Results

Consensus was achieved on 201 out of 207 statements for inclusion into the adapted guidelines for the gatekeeper programme, with 151 from the original questionnaire and 50 generated from comments of the panel members. These endorsed statements were synthesised to develop the content of the Life Gatekeeper training programme.

Conclusions

This Delphi study provided an evidence base for developing the first gatekeeper training programme systematically and locally in China. We hope that the current study can pave the way for more evidence-based suicide prevention programmes in China. Further study is warranted to evaluate the effectiveness of the Life Gatekeeper training programme.

Acceptability of a Pain History Assessment and Education Chatbot (Dolores) Across Age Groups in Populations With Chronic Pain: Development and Pilot Testing

BACKGROUND

The delivery of education on pain neuroscience and the evidence for different treatment approaches has become a key component of contemporary persistent pain management. Chatbots, or more formally conversation agents, are increasingly being used in health care settings due to their versatility in providing interactive and individualized approaches to both capture and deliver information. Research focused on the acceptability of diverse chatbot formats can assist in developing a better understanding of the educational needs of target populations.

OBJECTIVE

This study aims to detail the development and initial pilot testing of a multimodality pain education chatbot (Dolores) that can be used across different age groups and investigate whether acceptability and feedback were comparable across age groups following pilot testing.

METHODS

Following an initial design phase involving software engineers (n=2) and expert clinicians (n=6), a total of 60 individuals with chronic pain who attended an outpatient clinic at 1 of 2 pain centers in Australia were recruited for pilot testing. The 60 individuals consisted of 20 (33%) adolescents (aged 10-18 years), 20 (33%) young adults (aged 19-35 years), and 20 (33%) adults (aged >35 years) with persistent pain. Participants spent 20 to 30 minutes completing interactive chatbot activities that enabled the Dolores app to gather a pain history and provide education about pain and pain treatments. After the chatbot activities, participants completed a custom-made feedback questionnaire measuring the acceptability constructs pertaining to health education chatbots. To determine the effect of age group on the acceptability ratings and feedback provided, a series of binomial logistic regression models and cumulative odds ordinal logistic regression models with proportional odds were generated.

RESULTS

Overall, acceptability was high for the following constructs: engagement, perceived value, usability, accuracy, responsiveness, adoption intention, esthetics, and overall quality. The effect of age group on all acceptability ratings was small and not statistically significant. An analysis of open-ended question responses revealed that major frustrations with the app were related to Dolores' speech, which was explored further through a comparative analysis. With respect to providing negative feedback about Dolores' speech, a logistic regression model showed that the effect of age group was statistically significant (χ22=11.7; P=.003) and explained 27.1% of the variance (Nagelkerke R2). Adults and young adults were less likely to comment on Dolores' speech compared with adolescent participants (odds ratio 0.20, 95% CI 0.05-0.84 and odds ratio 0.05, 95% CI 0.01-0.43, respectively). Comments were related to both speech rate (too slow) and quality (unpleasant and robotic).

CONCLUSIONS

This study provides support for the acceptability of pain history and education chatbots across different age groups. Chatbot acceptability for adolescent cohorts may be improved by enabling the self-selection of speech characteristics such as rate and personable tone.

Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain

Seriously ill patients often experience persistent pain. As a part of a comprehensive repertoire of pain interventions, palliative care clinicians can help by using behavioral pain management. Behavioral pain management refers to evidence-based psychosocial interventions to reduce pain intensity and enhance functional outcomes and quality of life. Conceptualized using the biopsychosocial model, techniques involve promoting helpful behaviors (e.g., activity pacing, stretching, and relaxation exercises) and modifying underlying patterns of thinking, feeling, and communicating that can exacerbate pain. The authors have expertise in pain management, clinical health psychology, geropsychology, behavioral science, and palliative medicine. The article reviews the current evidence for behavioral interventions for persistent pain and provides 10 recommendations for behavioral pain management.

Core components of an effective pain management education programme for surgical nurses: A Delphi study*

The critical reason for this study is the inadequate training received by surgical nurses in acute and chronic pain management nursing services for patients.

Strategic Priorities for Implementation of Father-Inclusive Practice in Mental Health Services for Children and Families: A Delphi Expert Consensus Study

The aim of this study was to investigate expert consensus on barriers and facilitators to the organizational implementation of Father-Inclusive Practice (FIP) in child and family services to establish strategic priorities for implementation. An international panel of 56 experts in child and family service provision and father inclusion were surveyed using the Delphi technique. Three online questionnaires were used to gather opinions and measure experts’ levels of agreement in regard to factors that enable or hinder the organizational implementation of FIP. Survey design, analysis and interpretation was guided by the Consolidated Framework for Implementation Research (CFIR). Consensus was achieved for 46.4% (n = 13) statements. Eight barriers and five facilitators were identified as strategic priorities to organizational implementation of FIP. The key factors were related to the following CFIR themes: leadership engagement, access to information and knowledge, implementation climate, structural characteristics, networks and communication, client needs and resources, external policies and incentives, and reflecting and evaluating. The study findings suggest that issues related to central prioritization, top-down organizational processes and external policy context should represent priority areas for implementation. Our results prioritise methods for improving FIP by highlighting the key areas of organizational practice to be addressed by tailored implementation strategies.

"FastSchool": A single session of an interprofessional pain management program for chronic pain patients inspired by cognitive behavioral therapy

OBJECTIVES

Multidisciplinary approaches to treating chronic pain have been proven effective. Currently, chronic pain patients face lengthy waitlists in pain medicine departments. To overcome this problem, we developed the "FastSchool" program to educate patients about pain management and treatment. In this study, we evaluated the benefit of a "FastSchool" session on pain and catastrophizing in chronic pain patients.

METHODS

Included patients had chronic non-cancer pain, no more than 2 visits to a pain medicine department. Patients attended a single 3-hour session, conducted by an interprofessional team. Four topics were addressed: chronic pain mechanisms, pharmacological therapies, physical activity, and the management of analgesics. Patients completed questionnaires at baseline and at 3 months post-session to assess pain interference, pain intensity, and catastrophizing.

RESULTS

The study population included 88 patients; 71 completed the follow-up questionnaires. Pain interference (p = 0.002), average pain intensity (p = 0.013), and catastrophizing (p < 0.001) decreased 3 months after FastSchool. At M3, 35 % of patients felt their pain had improved based on the Patient Global Impression of Change.

CONCLUSION

FastSchool, an innovative short-term educational program inspired by cognitive behavioral therapy, showed positive results in reducing pain impact.

PRACTICE IMPLICATIONS

Implementation of FastSchool in pain medicine departments would reduce waitlist times for non-pharmacological treatment.

Effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent therapy in online and outdoor format in individuals with fibromyalgia: Study protocol of a randomized, controlled trial (On&Out study)

Introduction: The On&Out study is aimed at assessing the effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent intervention conducted in two different settings: online (FIBRO-On) or outdoors (FIBRO-Out). Both interventions have proved to be efficacious in the short-term but there is no study assessing their comparative effectiveness nor their long-term effects. For the first time, this study will also evaluate the cost-utility (6-month time-horizon) and the effects on immune-inflammatory biomarkers and Brain-Derived Neurotrophic Factor (BDNF) levels of both interventions. The objectives of this 6-month, randomized, controlled trial (RCT) are 1) to examine the effectiveness and cost-utility of adding FIBRO-On or FIBRO-Out to Treatment-As-Usual (TAU) for individuals with fibromyalgia (FM); 2) to identify pre-post differences in blood biomarker levels in the three study arms and 3) to analyze the role of process variables as mediators of 6-month follow-up clinical outcomes. Methods and analysis: Participants will be 225 individuals with FM recruited at Vall d'Hebron University Hospital (Barcelona, Spain), randomly allocated to one of the three study arms: TAU vs. TAU + FIBRO-On vs. TAU + FIBRO-Out. A comprehensive assessment to collect functional impairment, pain, fatigue, depressive and anxiety symptoms, perceived stress, central sensitization, physical function, sleep quality, perceived cognitive dysfunction, kinesiophobia, pain catastrophizing, psychological inflexibility in pain and pain knowledge will be conducted pre-intervention, at 6 weeks, post-intervention (12 weeks), and at 6-month follow-up. Changes in immune-inflammatory biomarkers [i.e., IL-6, CXCL8, IL-17A, IL-4, IL-10, and high-sensitivity C-reactive protein (hs-CRP)] and Brain-Derived Neurotrophic Factor will be evaluated in 40 participants in each treatment arm (total n = 120) at pre- and post-treatment. Quality of life and direct and indirect costs will be evaluated at baseline and at 6-month follow-up. Linear mixed-effects regression models using restricted maximum likelihood, mediational models and a full economic evaluation applying bootstrapping techniques, acceptability curves and sensitivity analyses will be computed. Ethics and dissemination: This study has been approved by the Ethics Committee of the Vall d'Hebron Institute of Research. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media and various community engagement activities. Trial registration number NCT05377567 (clinicaltrials.gov).

A Digital Video and Text Messaging Intervention to Support People With Chronic Pain During Opioid Tapering: Content Development Using Co-design

BACKGROUND

People living with chronic pain report that tapering prescribed opioids is challenging and more support is needed. In our formative research, consumers indicated that mobile health (mHealth) technology could be an acceptable form of support for opioid tapering and may improve tapering self-efficacy.

OBJECTIVE

We aimed to evaluate and improve the content of an mHealth intervention before pilot-testing, based on consumer and clinician feedback.

METHODS

Participants were 12 consumers and 12 clinicians who evaluated an initial draft of a video script and 90 SMS text messages. Consumers and clinicians rated the appropriateness and likely usefulness (consumers) or likely effectiveness (clinicians) of a video script and a random selection of 15 SMS text messages using a 5-point Likert-type scale (1=totally disagree; 5=totally agree). Each draft SMS text message was reviewed by 2 consumers and 2 clinicians. Texts were deemed acceptable for inclusion in the pilot intervention only if the summed participant ratings of text appropriateness and usefulness or effectiveness were ≥8. Participants were also invited to provide open-text feedback on the draft script and SMS text messages.

RESULTS

Consumers generally agreed that the draft video script and text content were likely to be appropriate (video: mean 4.4, SD 0.52; text: mean 4.3, SD 0.79) and useful (video: mean 4.3, SD 0.65; text: mean 4.2, SD 0.84). Similarly, clinicians generally agreed that the draft video script and text content were likely to be appropriate (video: mean 4.5, SD 0.67; text: mean 4.4, SD 0.81) and effective (video: mean 4.0, SD 0.43; text: mean 4.3, SD 0.76). Overall, 77% (69/90) of the draft texts met the threshold rating for acceptability for inclusion in the pilot test of mHealth intervention by consumers, and 82% (74/90) met the threshold for acceptability by clinicians. Consumers' and clinicians' ratings were used to rank order the texts. The top 56 draft texts (all meeting the threshold levels of acceptability) were selected for inclusion in the pilot intervention. When consumer or clinician feedback was provided, the texts meeting the criteria for inclusion in the pilot were further revised and improved. Feedback on the video script was also used to further improve the acceptability of the video script before pilot-testing the intervention.

CONCLUSIONS

This study describes the process by which a 28-day mHealth intervention to support patients with chronic pain to taper opioid medications was evaluated and improved before pilot-testing. The mHealth intervention consisted of a 10-minute psychoeducational video about pain and opioid tapering and 56 unique SMS text messages providing information and reassurance (texts delivered twice per day for 28 days). Having established that the content of the mHealth intervention is acceptable to both consumer and clinician groups, the mHealth intervention will be piloted in future research.

Healthcare professionals' experiences and perspectives of team-based interdisciplinary pain rehabilitation with immigrants requiring an interpreter. A qualitative study

PURPOSE

There is a lack of knowledge about interprofessional rehabilitation for culturally diverse patients with chronic pain. This study explores experiences of healthcare professionals developing and working with rehabilitation with patients in need of an interpreter and their experience of working with interpreters.

METHODS

Twelve healthcare professionals at two Swedish specialist rehabilitation centres were interviewed. Grounded theory principles were used for the data collection and analysis.

RESULTS

The main category "Demanding and Meaningful Work" represents three concurrently interacting categories: "Frustration" includes the informants' doubts regarding the benefits of the rehabilitation, lack of care for patients and cultural dissonance between professionals and patients. "Challenges" describes problems in the rehabilitation work due to the need for interpreted mediated communication, the complexity in health status and social aspects among the patients. "Solutions" represents practical working methods and personal approaches developed by the informants for managing frustrations and challenges.

CONCLUSIONS

The informants' frustration and challenges when working with a new group of patients, vulnerable and different in their preconceptions, led to new solutions in working methods and approaches. When starting a pain rehabilitation programme for culturally diverse patients, it is important to consider the rehabilitation team's need for additional time and support.IMPLICATIONS FOR REHABILITATIONHealthcare professionals who encounter immigrants with chronic pain need resources to develop their own skills in order to handle complex ethical questions as the patients represent a vulnerable patient group with many low status identitiesIn order to adapt rehabilitation programmes to patient groups with different languages and pre-understandings of chronic pain, there is a need for a team with specific qualities, i.e., close cooperation, an innovative atmosphere, time and also support from expertsFor appropriate language interpretation it is important to have a professional interpreter and a healthcare professional who are aware of and adopt the rules, possibilities and restrictions of interpretationThe rehabilitation of patients in need of language interpretation needs more time and organisation compared to the rehabilitation of patients who speak the national language.

"So, you must understand that that group changed everything": perspectives on a telehealth group intervention for individuals with chronic pain

BACKGROUND

The Patient Education Empowerment Programme (PEEP) is an interdisciplinary group intervention for people living with chronic pain. As a result of the COVID-19 pandemic, lockdown and restrictions on in-person group-based health care delivery in South Africa, PEEP was modified to a telehealth electronic format (ePEEP) and offered to patients on a waiting list at two interdisciplinary chronic pain clinics in Cape Town, South Africa. The purpose of this study was to explore the feasibility and acceptability of ePEEP through the perspectives of individuals with chronic pain who participated in ePEEP.  METHODS: A qualitative, exploratory descriptive study was conducted. One month after completion of the 6-week ePEEP programme, individuals who participated, were recruited for the study. Data were collected through semi-structured interviews. Data analysis followed an iterative process of inductive content analysis.  RESULTS: Six individuals, all women, consented and participated in the study. Three main themes emerged from the data. Theme one focussed on how ePEEP initiated a journey of personal development and discovery within the participants. In theme two, participants reflected on the importance and value of building peer and therapeutic relationships as part of ePEEP. In theme 3, participants shared that the online learning environment had features which influenced learning about pain in different ways.

CONCLUSION

ePEEP was found to be acceptable, feasible and valuable for the participants. ePEEP facilitated self-discovery, empowerment, relationship building and transformation in the participants, through experiential learning. Although barriers and facilitators to learning were present, both enhanced the learning experience. The positive reception of this telehealth initiative indicates potential for enhanced access to chronic pain management services in the South African setting.

Randomised controlled trial of cognitive behaviour therapy versus mindfulness for people with rheumatoid arthritis with and without a history of recurrent depression: study protocol and design

INTRODUCTION

Psychosocial treatments have been shown to benefit people with rheumatoid arthritis (RA) on various outcomes. Two evidence-based interventions are cognitive behavioural therapy (CBT) and mindfulness-based stress reduction (MBSR). However, these interventions have been compared only once. Results showed that CBT outperformed MBSR on some outcomes, but MBSR was more effective for people with RA with a history of recurrent depression, with efficacy being moderated by history of depressive episodes. However, this was a post-hoc finding based on a small subsample. We aim to examine whether a history of recurrent depression will moderate the relative efficacy of these treatments when delivered online.

METHODS AND ANALYSIS

This study is a randomised controlled trial comparing CBT and MBSR delivered online with a waitlist control condition. History of recurrent depressive episodes will be assessed at baseline. The primary outcome will be pain interference. Secondary outcomes will include pain intensity, RA symptoms, depressive symptoms and anxiety symptoms. Outcome measures will be administered at baseline, post-treatment and at 6 months follow-up. We aim to recruit 300 participants, and an intention-to-treat analysis will be used. Linear mixed models will be used, with baseline levels of treatment outcomes as the covariate, and group and depressive status as fixed factors. The results will demonstrate whether online CBT and MBSR effectively improve outcomes among people with RA. Importantly, this trial will determine whether one intervention is more efficacious, and whether prior history of depression moderates this effect.

ETHICS AND DISSEMINATION

The trial has been approved by the Human Research Ethics Committee of the University of Sydney (2021/516). The findings will be subject to publication irrespective of the final results of the study, and based on the outcomes presented in this protocol.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12621000997853p).

New generation psychological treatments in chronic pain

Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called "third wave" CBT. In this review, we examine the evidence for application of acceptance and commitment therapy (ACT), a principal example of this new wave or latest generation of treatment approaches, in people with chronic pain. We identified 25 randomized controlled trials of ACT for adults with chronic pain. Across the included trials, small to large effect sizes favoring ACT were reported for key outcomes including pain interference, disability, depression, and quality of life. Evidence from three studies provided some support for the cost effectiveness of ACT for chronic pain. Evidence also supported the mediating role of theoretically consistent processes of change (psychological flexibility) in relation to treatment outcomes. Investigation of moderators and predictors of outcomes was limited and inconsistent. In future, a greater focus on process based treatments is recommended. This should include continued identification of evidence based processes of change, and research methods more suited to understanding the experience and needs of individual people.

Trends in the Prescription of Strong Opioids for Chronic Non-Cancer Pain in Primary Care in Catalonia: Opicat-Padris-Project

In chronic non-cancer pain (CNCP), evidence of the effectiveness of strong opioids (SO) is very limited. Despite this, their use is increasingly common. To examine SO prescriptions, we designed a descriptive, longitudinal, retrospective population-based study, including patients aged ≥15 years prescribed SO for ≥3 months continuously in 2013–2017 for CNCP in primary care in Catalonia. Of the 22,691 patients included, 17,509 (77.2%) were women, 10,585 (46.6%) were aged >80 years, and most had incomes of <€18,000 per year. The most common diagnoses were musculoskeletal diseases and psychiatric disorders. There was a predominance of transdermal fentanyl in the defined daily dose (DDD) per thousand inhabitants/day, with the greatest increase for tapentadol (312% increase). There was an increase of 66.89% in total DDD per thousand inhabitants/day for SO between 2013 (0.737) and 2017 (1.230). The mean daily oral morphine equivalent dose/day dispensed for all drugs was 83.09 mg. Transdermal fentanyl and immediate transmucosal release were the largest cost components. In conclusion, there was a sustained increase in the prescription of SO for CNCP, at high doses, and in mainly elderly patients, predominantly low-income women. The new SO are displacing other drugs.

Establishing consensus on key elements and implementation enablers of community-based pain programs to support primary health network decision making: an eDelphi study

To address the growing burden of chronic pain, there is a need for national scale-up of community-based pain programs. Primary health networks (PHNs) are best placed to support this scale-up as commissioning bodies of health services. The aim of this eDelphi study was to establish expert consensus on best practice key elements of community-based pain programs and enablers important for program implementation and sustainability to support PHN decision making. A panel of experts was invited to complete three online survey rounds as part of a reactive eDelphi approach to provide feedback on the relevance and importance of proposed key elements and implementation enablers of community-based pain programs. Consensus of 70% agreement by experts was required for each survey round for items to remain, with comments from experts considered by the research team to agree on wording changes and the addition of new items. Ten experts (62.5%) completed all three survey rounds. Expert feedback resulted in a list of 18 best practice key elements of community-based pain program design and 14 program implementation enablers. Changes suggested by experts included the moving of items between lists, rephrasing of items and the addition of new items. The eDelphi results will serve as a resource for PHNs considering the commissioning of community-based pain programs and inform future research to assess the suitability and scalability of existing programs.

Establishing consensus for labeling and defining the later stage of anorexia nervosa: A Delphi study

OBJECTIVE

Varied perspectives on the later stage of anorexia nervosa (AN) have left the field of eating disorders without a consistent label or definition for this subpopulation. As a result, diverse criteria when recruiting participants have led to incomparable results across research studies and a lack of guidance when assessing and treating patients in the clinical context. The aim of the current study was to develop consensus-based guidelines on the labeling and defining of the later stage of AN.

METHOD

Utilizing the Delphi methodology, a professional panel of experts (N = 21) participated in three rounds of questionnaires. Five open-ended questions (Round 1) were analyzed using content analysis to form statements relating to a classification system for labeling and defining the later stage of AN. A total of 80 statements were rated in terms of panelists' level of agreement (Rounds 2 and 3).

RESULTS

Consensus was achieved for 28.8% of statements and a further 16.3% of statements reached near consensus in the second and third round of questionnaires. Two labels were identified with five defining features achieving consensus.

DISCUSSION

Findings from the study suggest an alternative approach to labeling be adopted with consensus-based guidelines established for defining the later stage of AN. Implications that may occur from a unified classification system are explored with longitudinal research required to assess the impact on patients experiencing the later stage of AN.

Sufficient conditions for effective psychological treatment of chronic pain: a qualitative comparative analysis

ABSTRACT

Chronic pain (CP) is the leading cause of years lived with disability globally. Treatment within Western medicine is often multicomponent; the psychological element of treatment varies, yet the optimal conditions for effective reduction of pain-related outcomes remain unclear. This study used qualitative comparative analysis, a relatively new form of evidence synthesis in the field based on set theory to ascertain configurations of intervention components and processes of psychological treatment of chronic pain in adults that lead to more effective interventions. Data were extracted from 38 studies identified in a concurrent Cochrane review and were then subjected to qualitative comparative analysis. Two analyses were conducted: one to examine what is most effective for reducing disability and one to examine what is most effective for reducing distress. Analysis and comparison of the 10 treatments with best outcomes with the 10 treatments with poorest outcomes showed that interventions using graded exposure, graded exercise or behavioural rehearsal (exposure/activity), and interventions aiming to modify reinforcement contingencies (social/operant) reduced disability levels when either approach was applied but not both. Exposure/activity can improve distress levels when combined with cognitive restructuring, as long as social/operant methods are not included in treatment. Clinical implications of this study suggest that treatment components should not be assumed to be synergistic and provided in a single package.

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

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

Electronic Delivery of Pain Education for Chronic Overlapping Pain Conditions: A Prospective Cohort Study

OBJECTIVE

To examine the impact of educational materials for chronic overlapping pain conditions (COPCs), the feasibility of delivering materials online, and to explore its impact on self-reported self-management applications at 3-month follow-up.

DESIGN

Prospective cohort study.

SETTING

Online.

SUBJECTS

Individuals from a university-wide active research repository with ≥1 coded diagnostic COPC by ICD-9/10 in the medical record.

METHODS

We determined the number of COPCs per participant as indicated by diagnostic codes in the medical record. Consenting participants completed self-report questionnaires and read educational materials. We assessed content awareness and knowledge pre- and post-exposure to education. Comprehension was assessed via embedded questions in reading materials in real time. Participants then completed assessments regarding concept retention, self-management engagement, and pain-related symptoms at 3-months.

RESULTS

N = 216 individuals enrolled, with 181 (84%) completing both timepoints. Results indicated that participants understood materials. Knowledge and understanding of COPCs increased significantly after education and was retained at 3-months. Patient characteristics suggested the number of diagnosed COPCs was inversely related to age. Symptoms or self-management application did not change significantly over the 3-month period.

CONCLUSIONS

The educational materials facilitated teaching of key pain concepts in self-management programs, which translated easily into an electronic format. Education alone may not elicit self-management engagement or symptom reduction in this population; however, conclusions are limited by the study's uncontrolled design. Education is likely an important and meaningful first step in comprehensive COPC self-management.

Effectiveness of a Multicomponent Treatment for Fibromyalgia Based on Pain Neuroscience Education, Exercise Therapy, Psychological Support, and Nature Exposure (NAT-FM): A Pragmatic Randomized Controlled Trial

A recent study (FIBROWALK has supported the effectiveness of a multicomponent treatment based on pain neuroscience education (PNE), exercise therapy (TE), cognitive behavioral therapy (CBT), and mindfulness in patients with fibromyalgia. The aim of the present RCT was: (a) to analyze the effectiveness of a 12-week multicomponent treatment (nature activity therapy for fibromyalgia, NAT-FM) based on the same therapeutic components described above plus nature exposure to maximize improvements in functional impairment (primary outcome), as well as pain, fatigue, anxiety-depression, physical functioning, positive and negative affect, self-esteem, and perceived stress (secondary outcomes), and kinesiophobia, pain catastrophizing thoughts, personal perceived competence, and cognitive emotion regulation (process variables) compared with treatment as usual (TAU); (b) to preliminarily assess the effects of the nature-based activities included (yoga, Nordic walking, nature photography, and Shinrin Yoku); and (c) to examine whether the positive effects of TAU + NAT-FM on primary and secondary outcomes at post-treatment were mediated through baseline to six-week changes in process variables. A total of 169 FM patients were randomized into two study arms: TAU + NAT-FM vs. TAU alone. Data were collected at baseline, at six-week of treatment, at post-treatment, and throughout treatment by ecological momentary assessment (EMA). Using an intention to treat (ITT) approach, linear mixed-effects models and mediational models through path analyses were computed. Overall, TAU + NAT-FM was significantly more effective than TAU at posttreatment for the primary and secondary outcomes evaluated, as well as for the process variables. Moderate-to-large effect sizes were achieved at six-weeks for functional impairment, anxiety, kinesiophobia, perceived competence, and positive reappraisal. The number needed to treat (NNT) was 3 (95%CI = 1.6-3.2). The nature activities yielded an improvement in affective valence, arousal, dominance, fatigue, pain, stress, and self-efficacy. Kinesiophobia and perceived competence were the mediators that could explain a significant part of the improvements obtained with TAU + NAT-FM treatment. TAU + NAT-FM is an effective co-adjuvant multicomponent treatment for improving FM-related symptoms.

Mindfulness-Based Program Plus Amygdala and Insula Retraining (MAIR) for the Treatment of Women with Fibromyalgia: A Pilot Randomized Controlled Trial

The lack of highly effective treatments for fibromyalgia (FM) represents a great challenge for public health. The objective of this parallel, pilot randomized controlled trial (RCT) was two-fold: (1) to analyze the clinical effects of mindfulness plus amygdala and insula retraining (MAIR) compared to a structurally equivalent active control group of relaxation therapy (RT) in the treatment of FM; and (2) to evaluate its impact on immune-inflammatory markers and brain-derived neurotrophic factor (BDNF) in serum. A total of 41 FM patients were randomized into two study arms: MAIR (intervention group) and RT (active control group), both as add-ons of treatment as usual. MAIR demonstrated significantly greater reductions in functional impairment, anxiety, and depression, as well as higher improvements in mindfulness, and self-compassion at post-treatment and follow-up, with moderate to large effect sizes. Significant decreases in pain catastrophizing and psychological inflexibility and improvements in clinical severity and health-related quality of life were found at follow-up, but not at post-treatment, showing large effect sizes. The number needed to treat was three based on the criteria of ≥50% Fibromyalgia Impact Questionnaire (FIQ) reduction post-treatment. Compared to RT, the MAIR showed significant decreases in BDNF. No effect of MAIR was observed in immune-inflammatory biomarkers (i.e., TNF-α, IL-6, IL-10, and hs-CRP). In conclusion, these results suggest that MAIR, as an adjuvant of treatment-as-usual (TAU), appears to be effective for the management of FM symptoms and for reducing BDNF levels in serum.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

ClinicalTrials.gov NCT03412916.