Utilizing a learning health system to capture real-world patient data: Application of the reliable change index to evaluate and improve the outcome of a pain rehabilitation program

BACKGROUND AND OBJECTIVES

The learning healthcare system (LHS) has been developed to integrate patients' clinical data into clinical decisions and improve treatment outcomes. Having little guidance on this integration process, we aim to explain (a) an applicable analytic tool for clinicians to evaluate the clinical outcomes at a group and an individual level and (b) our quality improvement (QI) project, analyzing the outcomes of a new outpatient pain rehabilitation program ("Back-in-Action": BIA) and applying the analysis results to modify our clinical practice.

METHODS

Through our LHS (CHOIR; https://choir.stanford.edu), we administered the Pain Catastrophizing Scale (PCS), Chronic Pain Acceptance Questionnaire (CPAQ), and Patient-Reported Outcomes Measures (PROMIS)® before and after BIA. After searching for appropriate analytic tools, we decided to use the Reliable Change Index (RCI) to determine if an observed change in the direction of better (improvement) or worse (deterioration) would be beyond or within the measurement error (no change).

RESULTS

Our RCI calculations revealed that at least a 9-point decrease in the PCS scores and 10-point increase in the CPAQ scores would indicate reliable improvement. RCIs for the PROMIS measures ranged from 5 to 8 T-score points (i.e., 0.5-0.8 SD). When evaluating change scores of the PCS, CPAQ, and PROMIS measures, we found that 94% of patients showed improvement in at least one domain after BIA and 6% showed no reliable improvement.

CONCLUSIONS

Our QI project revealed RCI as a useful tool to evaluate treatment outcomes at a group and an individual level, and RCI could be incorporated into the LHS to generate a progress report automatically for clinicians. We further explained how clinicians could use RCI results to modify a clinical practice, to improve the outcomes of a pain program, and to develop individualized care plans. Lastly, we suggested future research areas to improve the LHS application in pain practice.

Does Catastrophizing Predict Response to Treatment in Patients With Vestibular Disorders? A Prospective Cohort Study

OBJECTIVE

Determine levels of catastrophizing in patients with vestibular disorders and prospectively evaluate their relationship with patient-reported outcome measures.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care neurotology vestibular disorders clinic.

PATIENTS

Adult patients with various vestibular disorders.

INTERVENTIONS

Patients were given the Dizziness Handicap Inventory (DHI) and the Dizziness Catastrophizing Scale (DCS) at a baseline visit and follow-up visit after treatment.

MAIN OUTCOME MEASURES

Correlation studies were used to determine the relationships between DHI and DCS. Multivariable linear regression was performed to determine the relationship between DCS and DHI change with treatment, accounting for demographic variables.

RESULTS

Forty-six subjects completed both the DHI and the DCS before and after treatment. Patients with higher baseline DCS scores had higher baseline DHI scores ( p < 0.001). There was a significant improvement in both DHI score ( p < 0.001) and DCS ( p < 0.001) at follow-up. Patients who had reduction in DCS scores during were more likely to show reduction in DHI scores ( p < 0.001). A subset of patients had a mindfulness-based stress reduction program included in their treatment. These patients had a greater reduction in both DCS and DHI scores at follow-up compared with those who received other treatments.

CONCLUSIONS

Catastrophizing is associated with higher pretreatment DHI scores and worse treatment outcomes. Addressing dizziness catastrophizing may help improve vestibular outcomes.

Lessons Learned from an Attempted Pragmatic Randomized Controlled Trial for Improvement of Chronic Pain-Associated Disability in Green Professions: Long-Term Effectiveness of a Guided Online-Based Acceptance and Commitment Therapy &nbsp;(PACT-A)

Musculoskeletal symptoms are increased in farmers, whereas the prevalence of chronified pain is unknown. Online interventions based on acceptance and commitment therapy (ACT) have shown encouraging results in the general population, representing a promising approach for reducing pain interference in green professions (i.e., farmers, foresters, gardeners). We conducted a pragmatic RCT comparing a guided ACT-based online intervention to enhanced treatment-as-usual in entrepreneurs, contributing spouses, family members and pensioners in green professions with chronic pain (CPG: ≥grade II, ≥6 months). Recruitment was terminated prematurely after 2.5 years at N = 89 (of planned N = 286). Assessments were conducted at 9 weeks (T1), 6 months (T2) and 12 months (T3) post-randomization. The primary outcome was pain interference (T1). The secondary outcomes encompassed pain-, health- and intervention-related variables. No treatment effect for reduction of pain interference was found at T1 (β = -0.16, 95%CI: -0.64-0.32, p = 0.256). Improvements in cognitive fusion, pain acceptance, anxiety, perceived stress and quality of life were found only at T3. Intervention satisfaction as well as therapeutic and technological alliances were moderate, and uptake and adherence were low. Results are restricted by low statistical power due to recruitment issues, high study attrition and low intervention adherence, standing in contrast to previous studies. Further research is warranted regarding the use of ACT-based online interventions for chronic pain in this occupational group. Trial registration: German Clinical Trial Registration: DRKS00014619. Registered: 16 April 2018.

The Role of Pain Catastrophizing and Pain Acceptance in Performance-Based and Self-Reported Physical Functioning in Individuals with Fibromyalgia and Obesity

Impaired physical functioning is one of the most critical consequences associated with fibromyalgia, especially when there is comorbid obesity. Psychological factors are known to contribute to perceived (i.e., subjective) physical functioning. However, physical function is a multidimensional concept encompassing both subjective and objective functioning. The contribution of psychological factors to performance-based (i.e., objective) functioning is unclear. This study aims to investigate the contribution of pain catastrophizing and pain acceptance to both self-reported and performance-based physical functioning. In this cross-sectional study, 160 participants completed self-report measures of pain catastrophizing, pain acceptance, and pain severity. A self-report measure and a performance-based test were used to assess physical functioning. Higher pain catastrophizing and lower pain acceptance were associated with poorer physical functioning at both self-reported and performance-based levels. Our results are consistent with previous evidence on the association between pain catastrophizing and pain acceptance with self-reported physical functioning. This study contributes to the current literature by providing novel insights into the role of psychological factors in performance-based physical functioning. Multidisciplinary interventions that address pain catastrophizing and pain acceptance are recommended and might be effective to improve both perceived and performance-based functioning in women with FM and obesity.

Psychological Flexibility Is Key for Reducing the Severity and Impact of Fibromyalgia

Fibromyalgia has a significant impact on the lives of patients; symptoms are influenced by psychological factors, such as psychological flexibility and catastrophizing. The objective of this study was to determine the importance of these variables in moderating the association between the severity and impact of fibromyalgia symptoms. A total of 187 patients from a general hospital population were evaluated using the Combined Index of Severity of Fibromyalgia (ICAF), the Fibromyalgia Impact Questionnaire (FIQ), the Acceptance and Action Questionnaire-II (AAQ-II), and the Pain Catastrophizing Scale (PCS). A series of multiple regression analyses were carried out using the PROCESS macro and decision tree analysis. The results show that psychological flexibility modulates the relation between severity and the impact of fibromyalgia symptoms. Catastrophism has residual importance and depends on the interaction with psychological flexibility. Interaction occurs if the severity of the disease is in transition from a mild to a moderate level and accounts for 40.1% of the variance in the sample. These aspects should be considered for evaluation and early intervention in fibromyalgia patients.

Development and initial validation of a brief questionnaire on the patients’ view of the in-session realization of the six core components of Acceptance and Commitment Therapy

Background

Assessing in-session processes is important in psychotherapy research. The aim of the present study was to create and evaluate a short questionnaire capturing the patients’ view of the in-session realization of the six core components of Acceptance and Commitment Therapy (ACT).

Method

In two studies, psychotherapy patients receiving ACT (Study 1: n = 87) or Cognitive-Behavioral Therapy (CBT) (Study 2, Sample 1: n = 115; Sample 2: n = 156) completed the ACT session questionnaire (ACT-SQ). Therapists were n = 9 ACT therapists (Study 1) and n = 77 CBT trainee therapists (Study 2).

Results

Factor structure: Exploratory factor analyses suggested a one-factor solution for the ACT-SQ. Reliability: Cronbach’s alpha of the ACT-SQ was good (Study 1: α = .81; Study 2, Sample 1: α = .84; Sample 2: α = .88). Convergent validity: The ACT-SQ was positively correlated with validated psychotherapeutic change mechanisms (p < .05). Criterion validity: Higher ACT-SQ scores were associated with better treatment outcomes (p < .05).

Conclusion

The study provides preliminary evidence for the reliability and validity of the ACT-SQ to assess the in-session realization of the six core components of ACT in the patients’ view. Further validation studies and ACT-SQ versions for therapists and observers are necessary.

Further development in the assessment of psychological flexibility: validation of the German committed action questionnaire

Background

Psychological flexibility is considered a fundamental aspect of health. It includes six interrelated facets: 1) cognitive defusion, 2) acceptance, 3) contact with the present moment, 4) self-as-context, 5) values, and 6) committed action. To gain further insight into psychological flexibility and its effects on health, reliable and valid instruments to assess all facets are needed. Committed action is one facet that is understudied. A long and short version of a validated measure (CAQ and CAQ-8) have been developed in English. Currently, there are no German versions of the CAQ. Aim of this study is to validate German-language versions of these in a chronic pain population.

Methods

The CAQ instructions and items were translated and evaluated in a chronic pain population (N = 181). Confirmatory factor analysis and Mokken scale analysis were conducted to evaluate the German questionnaires. Correlations with health outcomes, including quality of life (SF-12), physical and emotional functioning (MPI, BPI, PHQ-9, GAD-7), pain intensity, and with other facets of psychological flexibility (CPAQ, FAH-II) were investigated for convergent validity purposes. Scale reliability was assessed by the alpha, MS, lambda-2, LCRC, and omega coefficient.

Results

A bifactor model consisting of one general factor and two methodological factors emerged from the analysis. Criteria for reliability and validity were met. Medium to strong correlations to health outcomes and other facets of psychological flexibility were found. Results were similar to the original English version.

Conclusions

The present study presents a valid and reliable instrument to investigate committed action in German populations. Future studies could expand the present findings by evaluating the German CAQ versions in non-pain populations. The role of committed action and the wider psychological flexibility model in pain and other conditions deserves further investigation.

Predictors and mediators of outcome in cognitive behavioral therapy for chronic pain: the contributions of psychological flexibility

There is now a consensus in the literature that future improvements in outcomes obtained from cognitive behavioral therapy (CBT) for chronic pain will require research to identify patient and treatment variables that help explain outcomes. The first aim of this study was to assess whether pre-treatment scores on measures of psychological (in)flexibility, acceptance, committed action, cognitive (de)fusion, and values-based action predict outcomes in a multidisciplinary, multicomponent, group-based CBT program for adults with chronic pain. The second aim was to assess whether change scores on these same measures mediate outcomes in the treatment program. Participants were 232 people attending treatment for chronic pain. Of the psychological flexibility measures, only pre-treatment scores on the psychological inflexibility scale predicted outcomes; higher scores on this measure were associated with worse outcomes. However, change scores on each of the psychological flexibility measures separately mediated outcomes. The efficacy of CBT for chronic pain may be improved with a greater focus on methods that increase psychological flexibility.

Early Changes in Pain Acceptance Predict Pain Outcomes in Interdisciplinary Treatment for Chronic Pain

Studies have shown that pain acceptance is associated with a better pain outcome. The current study explored whether changes in pain acceptance in the very early treatment phase of an interdisciplinary cognitive-behavioral therapy (CBT)-based treatment program for chronic pain predict pain outcomes. A total of 69 patients with chronic, non-malignant pain (at least 6 months) were treated in a day-clinic for four-weeks. Pain acceptance was measured with the Chronic Pain Acceptance Questionnaire (CPAQ), pain outcomes included pain intensity (Numeric Rating Scale, NRS) as well as affective and sensory pain perception (Pain Perception Scale, SES-A and SES-S). Regression analyses controlling for the pre-treatment values of the pain outcomes, age, and gender were performed. Early changes in pain acceptance predicted pain intensity at post-treatment measured with the NRS (B = −0.04 (SE = 0.02); T = −2.28; p = 0.026), affective pain perception at post-treatment assessed with the SES-A (B = −0.26 (SE = 0.10); T = −2.79; p = 0.007), and sensory pain perception at post-treatment measured with the SES-S (B = −0.19 (SE = 0.08); T = −2.44; p = 0.017). Yet, a binary logistic regression analysis revealed that early changes in pain acceptance did not predict clinically relevant pre-post changes in pain intensity (at least 2 points on the NRS). Early changes in pain acceptance were associated with pain outcomes, however, the impact was beneath the threshold defined as clinically relevant.

Acceptance: a factor to consider in persistent pain after neck trauma

Background and aims

Studies on the interaction between acceptance and pain-related processes after neck trauma are to our knowledge sparse and such treatment strategies are rarely incorporated in management and treatment of posttraumatic neck pain. Thus, the aim of the present study is to investigate how acceptance relates to persistent pain in patients after neck trauma, when controlling for the influence of other psychological factors, trauma characteristics and demographic variables.

Methods

Consecutive patients with persistent pain and disability after neck trauma (n = 565) were assessed by a multi-professional team at a specialized pain rehabilitation clinic. Separate regression analyses were conducted with three outcomes: pain distribution, pain interference, and pain severity. Predictors were age, sex, education, time since trauma, type of trauma, anxiety, depression, and acceptance.

Results

Acceptance was the only factor associated with all outcomes, and patients with lower acceptance displayed more widespread pain and greater interference and severity of pain. The results also showed that higher depression was associated with worse pain interference and severity, whilst anxiety only mattered significantly for pain severity and not for pain interference. Female sex was related to more widespread pain and greater pain interference.

Conclusions

Overall acceptance stood out as the most important factor for the different outcomes and lower acceptance was associated with more widespread pain distribution and greater pain interference and severity.

Implications

The findings of this study add to a growing body of literature confirming that the development of chronicity after neck trauma should be understood as a multidimensional process, best described by a biopsychosocial model. The results also suggest that psychological factors and especially acceptance might be important processes with implications for enhanced recovery after neck trauma.

How does reduction in pain lead to reduction in disability in patients with musculoskeletal pain?

Purpose

Reduction in pain following multidisciplinary treatment is most often associated with a reduction in disability. To further elaborate the relationship between pain intensity and disability, the present study investigated three main questions: first, whether multidisciplinary treatment leads to a significant improvement in pain, disability and psychological variables (depression, pain acceptance and catastrophizing). Second, it was examined whether pain reduction may account for significant changes in the psychological variables (pre- to follow-up change scores). Finally, it was analyzed whether the psychological changes mediate the association between reduction in pain and in disability after controlling for age, sex and pain history.

Patients and methods

Patients suffering from chronic musculoskeletal pain (n=279) attended a German inpatient multidisciplinary program lasting 15 consecutive days on average, with self-report data collected at pretreatment, posttreatment and three-month follow-up.

Results

Repeated measures ANOVAs showed a significant improvement in pain intensity, disability, pain acceptance, catastrophizing and depression at posttreatment and follow-up. Univariate regression analyses revealed that changes in pain intensity accounted for significant changes in depression, pain catastrophizing and pain acceptance (pre- to follow-up change scores). The results of Multiple Mediation Procedure showed that pain reduction did affect reduction in disability through improvement of depression, catastrophizing and acceptance.

Conclusion

Our findings support a cognitive-behavioral model of pain that posits an important role for pain-related cognitive and emotional processes in long-term outcomes following multidisciplinary pain treatment, in particular for the modulation of disability due to pain. The results add evidence to the notion that pain-related cognitions are dynamic features varying over time dependent on the internal situation.

Perspective

The current findings are relevant to the management of patients with musculoskeletal pain. The results support the notion that, in contrast with the view of enduring personality traits, pain-related cognitions and emotions reflect a situational response that varies over time.

Medicate or Meditate? Greater Pain Acceptance is Related to Lower Pain Medication Use in Persons With Chronic Pain and Spinal Cord Injury

OBJECTIVES

There is little information about whether use of pain self-management skills that are common targets of psychosocial interventions for pain are associated with reduced reliance on pain medications. The aim of this study was to test whether higher chronic pain acceptance, which is a readily modified pain self-management approach, is related to lower use of pain medications (eg, opioid medications, and gabapentinoids) in a sample with chronic pain and spinal cord injury (SCI).

MATERIALS AND METHODS

This is a cross-sectional survey study of pain medication use, pain severity and distribution (Brief Pain Inventory [BPI]), depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), and chronic pain acceptance (Chronic Pain Acceptance Questionnaire [CPAQ]) administered to a sample of 120 adults with chronic pain and SCI.

RESULTS

Regression results indicated that, above and beyond the effects of pain intensity, pain distribution, and depressive symptoms, higher pain acceptance was related to lower use of all types of pain medications, and lower odds of using opioid medications or gabapentinoids. Pain intensity was not related to pain medication use, but greater pain distribution was related to using more pain medications in general and to greater odds of using gabapentinoids.

DISCUSSION

Findings from this study indicate that those with chronic pain and SCI who have a more accepting orientation to pain are less reliant on pain medications, and thereby experience lower risks associated with medication consumption. Longitudinal, daily process, and clinical trial studies are needed to better understand the association between pain acceptance and pain medication consumption.

Predicting factors of outcome in multidisciplinary treatment of chronic neuropathic pain

Purpose

Evidence of the effectiveness of multidisciplinary treatment with a focus on neuropathic pain is still rare. The present study investigated whether multidisciplinary treatment leads to improvement of neuropathic pain in outcome (pain intensity and disability) and psychological (depression, pain acceptance, and catastrophizing) variables at posttreatment and 3-month follow-up. We examined whether and to what extent psychological changes can predict long-term outcome at 3-month follow-up, when other variables are controlled for (baseline characteristics and changes in pain parameters).

Patients and methods

Patients suffering from a chronic neuropathic pain condition (n=141) attended an inpatient multidisciplinary program lasting about 15 continuous days with self-report data collected at pretreatment, posttreatment, and 3-month follow-up.

Results

Repeated-measures ANOVAs showed a significant improvement of pain intensity, disability, pain acceptance, catastrophizing, and depression at posttreatment. These improvements remained stable over the 3-month follow-up for all variables except for depression. The inclusion of psychological changes in multiple regression analyses greatly increased the variance in outcome, explained by baseline characteristics and changes in pain parameters.

Conclusion

The results could help clinicians to determine which variables should be emphasized during inpatient treatment and during the follow-up period, in order to maintain the gains after an inpatient multidisciplinary treatment for neuropathic pain.

Perspective

The present study demonstrates the beneficial effects of an inpatient multidisciplinary program for neuropathic pain and further question the resistant nature of neuropathic pain to treatment. The results add evidence to the relevance of cognitive-behavioral models of pain positing an important role for pain-related thoughts and emotions in long-term outcome following multidisciplinary pain treatment.

Pain Catastrophizing, Mindfulness, and Pain Acceptance: What's the Difference?

OBJECTIVES

It is not known whether psychosocial chronic pain treatments produce benefits through the unique mechanisms specified by theory. Fundamental to gaining an accurate understanding of this issue is to first determine whether the most widely used process measures assess unique constructs and predict unique variance in pain outcomes. This study examined the associations between the Pain Catastrophizing Scale (PCS), Five-Facet Mindfulness Questionnaire (FFMQ-SF), and the Chronic Pain Acceptance Questionnaire (CPAQ-8), and determined their unique contributions to the prediction of pain intensity, pain interference, and depression.

METHODS

A cross-sectional study was conducted with undergraduate students (N=260) reporting chronic or intermittent pain. Correlations, regression models, and multiple mediation models were performed. Relevant covariates were included.

RESULTS

The PCS, FFMQ-SF scales, and CPAQ-8 were correlated in mostly expected directions, but not so highly as to indicate redundancy. The PCS significantly predicted pain intensity, interference, and depression. The FFMQ-SF Observing and Describing scales predicted pain intensity; Nonreactivity and Nonjudging significantly predicted interference and depression, respectively. The CPAQ-8 was not a significant predictor in any of the regression models. The PCS was a comparatively stronger mediator than the FFMQ-SF scales in the intensity to interference, and intensity to depression mediation models.

DISCUSSION

The findings indicate that pain catastrophizing, mindfulness, and pain acceptance are related, but unique constructs. The PCS and select FFMQ-SF scales were uniquely associated with the criterion measures. However, the PCS emerged as the most robust process, highlighting the importance of targeting this cognitive domain in streamlining pain treatments to optimize outcome.

The Mediating Roles of Acceptance and Cognitive Reappraisal in the Relation Between Hope and Posttraumatic Growth Among Adolescents After the Ya'an Earthquake

Previous theoretical research has indicated that hope, cognitive reappraisal, and acceptance may contribute to posttraumatic growth (PTG). However, the combined effects of these factors on PTG have not yet been evaluated. Therefore, the current study examined the mediating roles of cognitive reappraisal and acceptance in the relationship between hope and PTG among Chinese adolescents following the Ya'an earthquake. The sample included 397 adolescent survivors, who completed self-report measures 2.5 years after the earthquake. The mediating effects were assessed by constructing a multiple indirect effects model. The findings indicated that traumatic exposure only have predictive value for PTG, but not other variables. Moreover, when we controlled for gender, age, and traumatic exposure, hope had a direct and positive effect on PTG. We found an indirect and positive effect of hope on PTG via cognitive reappraisal and acceptance, as well as via an indirect path from cognitive reappraisal to acceptance. These findings suggest that utilising the mediating roles of cognitive reappraisal and acceptance in the relationship between hope and PTG is crucial in developing methods for fostering PTG.

Mindfulness-based stress reduction and cognitive behavioral therapy for chronic low back pain: similar effects on mindfulness, catastrophizing, self-efficacy, and acceptance in a randomized controlled trial

Cognitive behavioral therapy (CBT) is believed to improve chronic pain problems by decreasing patient catastrophizing and increasing patient self-efficacy for managing pain. Mindfulness-based stress reduction (MBSR) is believed to benefit patients with chronic pain by increasing mindfulness and pain acceptance. However, little is known about how these therapeutic mechanism variables relate to each other or whether they are differentially impacted by MBSR vs CBT. In a randomized controlled trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with chronic low back pain (N = 342), we examined (1) baseline relationships among measures of catastrophizing, self-efficacy, acceptance, and mindfulness and (2) changes on these measures in the 3 treatment groups. At baseline, catastrophizing was associated negatively with self-efficacy, acceptance, and 3 aspects of mindfulness (nonreactivity, nonjudging, and acting with awareness; all P values <0.01). Acceptance was associated positively with self-efficacy (P < 0.01) and mindfulness (P values <0.05) measures. Catastrophizing decreased slightly more posttreatment with MBSR than with CBT or UC (omnibus P = 0.002). Both treatments were effective compared with UC in decreasing catastrophizing at 52 weeks (omnibus P = 0.001). In both the entire randomized sample and the subsample of participants who attended ≥6 of the 8 MBSR or CBT sessions, differences between MBSR and CBT at up to 52 weeks were few, small in size, and of questionable clinical meaningfulness. The results indicate overlap across measures of catastrophizing, self-efficacy, acceptance, and mindfulness and similar effects of MBSR and CBT on these measures among individuals with chronic low back pain.

A Validation and Generality Study of the Committed Action Questionnaire in a Swedish Sample with Chronic Pain

PURPOSE

Psychological flexibility is the theoretical model that underpins Acceptance Commitment Therapy (ACT). There is a growing body of evidence indicating that ACT is an effective treatment for chronic pain but one component of the model, committed action, has not been sufficiently researched. The purpose of this study is to validate Swedish-language versions of the full length Committed Action Questionnaire (CAQ; CAQ-18) and the shortened CAQ (CAQ-8), to examine the generality of previous results related to committed action and to further demonstrate the relevance of this construct to the functioning of patients with chronic pain.

METHOD

The study includes preliminary analyses of the reliability and validity of the CAQ. Participants were 462 consecutive referrals to the Pain Rehabilitation Unit at Skåne University Hospital.

RESULTS

The Swedish-language versions of the CAQ (CAQ-18 and CAQ-8) demonstrated high levels of internal consistency and satisfactory relationships with various indices of patient functioning and theoretically related concepts. Confirmatory factor analyses showed that the Swedish versions of the CAQ yielded similar two-factor models as found in the original validation studies. Hierarchical regression analyses identified the measures as significant contributors to explained variance in patient functioning.

CONCLUSION

The development, translation and further validation of the CAQ is an important step forward in evaluating the utility of the psychological flexibility model to the treatment of chronic pain. The CAQ can both assist researchers interested in mediators of chronic pain treatment and further enable research on change processes within the psychological flexibility model.

A content review of cognitive process measures used in pain research within adult populations

BACKGROUND AND OBJECTIVE

Previous research suggests that measures of cognitive process may be confounded by the inclusion of items that also assess cognitive content. The primary aims of this content review were to: (1) identify the domains of cognitive processes assessed by measures used in pain research; and (2) determine if pain-specific cognitive process measures with adequate psychometric properties exist.

DATABASES AND DATA TREATMENT

PsychInfo, CINAHL, PsycArticles, MEDLINE, and Academic Search Complete databases were searched to identify the measures of cognitive process used in pain research. Identified measures were double coded and the measure's items were rated as: (1) cognitive content; (2) cognitive process; (3) behavioural/social; and/or (4) emotional coping/responses to pain.

RESULTS

A total of 319 scales were identified; of these, 29 were coded as providing an un-confounded assessment of cognitive process, and 12 were pain-specific. The cognitive process domains assessed in these measures are Absorption, Dissociation, Reappraisal, Distraction/Suppression, Acceptance, Rumination, Non-Judgment, and Enhancement. Pain-specific, un-confounded measures were identified for: Dissociation, Reappraisal, Distraction/Suppression, and Acceptance. Psychometric properties of all 319 scales are reported in supplementary material.

CONCLUSIONS

To understand the importance of cognitive processes in influencing pain outcomes as well as explaining the efficacy of pain treatments, valid and pain-specific cognitive process measures that are not confounded with non-process domains (e.g., cognitive content) are needed. The findings of this content review suggest that future research focused on developing cognitive process measures is critical in order to advance our understanding of the mechanisms that underlie effective pain treatment.

SIGNIFICANCE

Many cognitive process measures used in pain research contain a 'mix' of items that assess cognitive process, cognitive content, and behavioural/emotional responses. Databases searched: PsychInfo, CINAHL, PsycArticles, MEDLINE and Academic Search Complete. This review describes the domains assessed by measures assessing cognitive processes in pain research, as well as the strengths and limitations of these measures.

Self-Management Interventions to Prevent Depression in People with Mobility Limitations

Introduction

This focused review reports on the impact of self-management interventions on depression in people with a mobility disability.

Method

There were two phases to the search including a comprehensive scoping review of the literature examining multiple secondary conditions impacted by self-management programs (Phase 1) and a focused review of the literature detailing the impact of self-management interventions on depression (Phase 2). CINAHL, PubMed, and PsyclNFO were searched for articles published between January 1988 through August 2014 and studies were screened by the first author based on specific inclusion and exclusion criteria.

Results

Twenty-five studies met criteria with results, demonstrating a mixed effect of self-management programs on depression. Sixteen studies included an intervention and control/comparison group, of which eight (50%) had a significant effect on depression. A further nine studies did not include a control/comparison group and five found significant changes in depression and four found no change. Eighteen out of 25 studies (72%) were rated as having moderate-to-high bias and nine different outcome measures were used across studies.

Discussion

Based on the mixed findings and varied approaches adopted for intervention and outcome assessment, future research should adopt a more rigorous methodological approach to examine self-management interventions on depression.

Development and Preliminary Testing of a Screening Measure of Acceptance and Willingness in Relation to Pain, Fatigue, and Sadness in Chronic Pain

BACKGROUND

The manner in which one responds to the experience of chronic pain is a primary determinant of pain-related distress and disruptions in functioning. In particular, responses to pain that reflect substantial unwillingness, or a lack of acceptance, in relation to pain are reliably associated with greater difficulties in comparison with responses that reflect willingness and acceptance. To date, several multi-item self-report assessments have been developed to evaluate pain-related willingness and acceptance. The purpose of the present research was to develop and evaluate a single item measure, the Acceptance and Willingness screener (AWS).

METHODS

Participants included 172 individuals with chronic pain. The AWS consisted of 4 statements, reflecting various degrees of acceptance and willingness to experience pain, and participants were asked to endorse the statement that was most reflective of their views.

RESULTS

Overall, responses were fairly evenly distributed across the statements (range, 20% to 29%). Correlation and regression results indicated significant associations between AWS responses and measures of pain intensity, depression, pain interference, and engagement in activity. Furthermore, when individuals were grouped according to the statement endorsed, significant between-group differences were indicated across these same measures. Differences were particularly pronounced for groups endorsing the lowest levels of acceptance and willingness and those endorsing the highest.

CONCLUSIONS

These results correspond with previous work and provide initial support for the validity of a single item screening measure of acceptance and willingness in chronic pain.

Self-Management Interventions to Prevent the Secondary Condition of Pain in People with Disability Due to Mobility Limitations

Introduction

This focused review examines the use and effectiveness of self-management strategies in preventing or managing pain, which is among the most common secondary conditions faced by individuals with a mobility disability.

Methods

This focused review was part of a two-phase comprehensive scoping review. Phase I was a comprehensive scoping review of the literature targeting multiple outcomes of self-management interventions for those with mobility impairment, and Phase II was a focused review of the literature on self-management interventions that target pain as a primary or secondary outcome. Two authors searched CINAHL, PubMed, and PsyclNFO for papers published from January 1988 through August 2014 using specified search terms. Following the scoping review, the authors independently screened and selected the studies and reviewed the eligible studies, and the first author extracted data from the included studies.

Results

The scoping review yielded 40 studies that addressed pain self-management interventions for those living with mobility impairment. These 40 accumulated papers revealed a heterogeneous evidence base in terms of setting (clinic, community, and online), target populations, intervention duration (3 weeks to 24 months), and mode (health-care providers and lay leaders). Most of the reviewed studies reported that the self-management intervention led to significant reduction of pain over time, suggesting that self-management may be a promising approach for addressing pain experienced by people who live with mobility limitations.

Discussion

This review also reveals moderate-to-high bias across studies, and findings indicate that future research should enhance the methodological quality to provide stronger evidence about the effectiveness of self-management strategies for reducing pain among those with mobility impairments.

Does Change Occur for the Reasons We Think It Does? A Test of Specific Therapeutic Operations During Cognitive-Behavioral Treatment of Chronic Pain

OBJECTIVE

To examine the relative validity of 2 conceptual models-Specific, General-by which therapeutic mechanisms in cognitive-behavioral therapy (CBT) for chronic pain achieve favorable outcomes.

METHODS

As part of a clinical trial of enhanced versus standard CBT, people with chronic pain received treatment consisting of 3 pain coping skill modules. In secondary analyses of a subsample (n=56), we examined pretreatment to session 4 (of 10 sessions) changes in Chronic Pain Coping Inventory subscales that corresponded to receipt of one of 3 modules; namely Relaxation, Exercise, and Cognitive Coping modules.

RESULTS

Findings indicated that: (1) participants receiving the Relaxation module improved more than other groups in relaxation skills, and improved substantially on other coping skills, as well; (2) participants receiving Exercise and Cognitive Coping modules showed mixed improvements and did not improve more than other groups on exercise use or cognitive coping, respectively; and (3) measures of patient-therapist working alliance and patient expectations of treatment benefit at session three correlated significantly with some coping skills changes.

DISCUSSION

Change with CBT may occur both by theory-specified mechanisms and general mechanisms. However, the results provide the most support for a General Mechanism model in which changes on coping skills have spreading effects on the use of other coping skills. Significant relationships between some skill changes and indexes of patient-therapist working alliance and outcome expectations suggest that nonspecific factors also play a role in treatment-related changes in the use of pain coping strategies.

The influence of tinnitus acceptance on the quality of life and psychological distress in patients with chronic tinnitus

Recent findings show the importance of acceptance in the treatment of chronic tinnitus. So far, very limited research investigating the different levels of tinnitus acceptance has been conducted. The aim of this study was to investigate the quality of life (QoL) and psychological distress in patients with chronic tinnitus who reported different levels of tinnitus acceptance. The sample consisted of outpatients taking part in a tinnitus coping group (n = 97). Correlations between tinnitus acceptance, psychological distress, and QoL were calculated. Receiver operating characteristic (ROC) curves were used to calculate a cutoff score for the German “Tinnitus Acceptance Questionnaire” (CTAQ-G) and to evaluate the screening abilities of the CTAQ-G. Independent sample t-tests were conducted to compare QoL and psychological distress in patients with low tinnitus acceptance and high tinnitus acceptance. A cutoff point for CTAQ-G of 62.5 was defined, differentiating between patients with “low-to-mild tinnitus acceptance” and “moderate-to-high tinnitus acceptance.” Patients with higher levels of tinnitus acceptance reported a significantly higher QoL and lower psychological distress. Tinnitus acceptance plays an important role for patients with chronic tinnitus. Increased levels of acceptance are related to better QoL and less psychological distress.

Psychological flexibility and catastrophizing as associated change mechanisms during online Acceptance & Commitment Therapy for chronic pain

The underlying mechanisms of the effectiveness of cognitive behavioural interventions for chronic pain need further clarification. The role of, and associations between, pain-related psychological flexibility (PF) and pain catastrophizing (PC) were examined during a randomized controlled trial on internet-based Acceptance & Commitment Therapy (ACT) for chronic pain. We assessed (1) the unique and combined indirect effects of PF and PC on outcomes, and (2) the causality of relations between PF, PC and the primary outcome pain interference in daily life (MPI) during ACT. A total of 238 pain sufferers were allocated to either ACT, a control condition on Expressive Writing, or a waiting list condition. Non-parametric cross-product of coefficients mediational analyses and cross-lagged panel designs were applied. Compared to control conditions, both baseline to post-intervention changes in PF and PC seemed to uniquely mediate baseline to three-month follow-up changes in pain interference and psychological distress. Only PF mediated changes in pain intensity. Indirect effects were twice as large for PF (κ2 = .09-.19) than for PC (κ² PCS = .05-.10). Further assessment of changes during ACT showed, however, that only PF, and not PC, predicted subsequent changes in MPI, while early and late changes in both PF and PC predicted later changes in each other. In conclusion, only PF functioned as a direct, causal working mechanism during ACT, with larger indirect effects that occurred earlier than changes in PC. Additionally, PC may function as an indirect mechanism of change during ACT for chronic pain via its direct influence on PF.

Effectiveness of mindfulness meditation on pain and quality of life of patients with chronic low back pain

BACKGROUND AND AIM

Recovery of patients with chronic low back pain (LBP) is depended on several physical and psychological factors. Therefore, the authors aimed to examine the efficacy of mindfulness based stress reduction (MBSR) as a mind-body intervention on quality of life and pain severity of female patients with nonspecific chronic LBP (NSCLBP).

METHODS

Eighty-eight patients diagnosed as NSCLBP by physician and randomly assigned to experimental (MBSR+ usual medical care) and the control group (usual medical care only). The subjects assessed in 3 times frames; before, after and 4 weeks after intervention by Mac Gil pain and standard brief quality of life scales. Data obtained from the final sample analyzed by ANCOVA using SPSS software.

RESULTS

The findings showed MBSR was effective in reduction of pain severity and the patients who practiced 8 sessions meditation reported significantly lower pain than patients who only received usual medical care. There was a significant effect of the between subject factor group (F [1, 45] = 16.45, P < 0.001) and (F [1, 45] = 21.51, P < 0.001) for physical quality of life and (F [1, 45] = 13.80, P < 0.001) and (F [1, 45] = 25.07, P < 0.001) mental quality of life respectively.

CONCLUSION

MBSR as a mind-body therapy including body scan, sitting and walking meditation was effective intervention on reduction of pain severity and improvement of physical and mental quality of life of female patients with NSCLBP.

Revising the negative meaning of chronic pain - A phenomenological study

OBJECTIVES

Chronic pain may disable the body, depress the mind and ruin the quality of life. The aim of this study was to use the participants' personal experiences to explore the meaning of the experience of chronic pain and to find successful ways to manage chronic pain.

METHODS

Thirty-four participants with chronic pain were interviewed. The transcribed interviews were analysed using Giorgi's phenomenological method consisting of four phases: (1) reading the transcriptions several times, (2) discriminating meaning units, (3) collecting meaning units into groups and (4) the synthesis.

RESULTS

The participants stated that the key to managing chronic pain was to reconsider the individual meaning of the experience of pain. As a result of the interviews, seven subthemes were found based on the 'Negativity of chronic pain', namely, 'State of reflection', 'Reconsidering values', 'Acceptance of pain', 'Support network', 'Altered self', 'Joys in life' and 'Pain dissociation'.

CONCLUSIONS

Pain is an aversive sensation, which leads to the conclusion that the meaning of the experience is also negative, but it can be reversed. In clinical practice, the focus should be on revising the subjective meaning of pain in order to manage pain and to restore positivity in personal life.

The Mediating Role of Acceptance in Multidisciplinary Cognitive-Behavioral Therapy for Chronic Pain

Cognitive-behavioral therapy (CBT) is the most frequently delivered psychological intervention for adults with chronic pain. The treatment yields modest effect sizes, and the mechanisms of action remain understudied and unclear. Efforts are needed to identify treatment mediators that could be used to refine CBT and improve outcomes. The primary aim of this study was to investigate whether pain-related acceptance, from the psychological flexibility model, mediates changes in outcome over time in a CBT-based treatment program. This includes comparing how this variable relates to 3 other variables posited as potential mediators in standard CBT: life control, affective distress, and social support. Participants attended a 5-week outpatient multidisciplinary program with self-report data collected at assessment, posttreatment, and 12-month follow-up. Multilevel structural equation modeling was used to test for mediation in relation to 3 outcomes: pain interference, pain intensity, and depression. Results indicate that effect sizes for the treatment were within the ranges reported in the CBT for pain literature. Pain-related acceptance was not related to pain intensity, which is in line with past empirical evidence and the treatment objectives in acceptance and commitment therapy. Otherwise, pain-related acceptance was the strongest mediator across the different indices of outcome. Accumulated results like these suggest that acceptance of pain may be a general mechanism by which CBT-based treatments achieve improvements in functioning. More specific targeting of pain-related acceptance in treatment may lead to further improvements in outcome.

PERSPECTIVE

Potential mediators of outcome in a CBT-based treatment for adult chronic pain were investigated using multilevel structural equation modeling. The results highlight the role of pain-related acceptance as an important treatment process even when not explicitly targeted during treatment. These data may help clinicians and researchers better understand processes of change and improve the choice and development of treatment methods.