Pain catastrophizing, activity engagement and pain willingness as predictors of the benefits of multidisciplinary cognitive behaviorally-based chronic pain treatment

Role of Pain Catastrophizing in the Effects of Cognitive Behavioral Therapy for Chronic Pain in Different Subgroups: An Exploratory Secondary Data Analysis Using Finite Mixture Models

INTRODUCTION

Providing effective treatment for debilitating chronic pain is a challenge among many populations including military service members. Cognitive behavioral therapy for chronic pain (CBT-CP) is a leading psychological pain treatment. Pain catastrophizing is a pivotal mediator of pain-related outcomes. The purpose of this study was (1) to identify patient subgroups who differ in response to CBT-CP and (2) to explore the characteristics that define these patient subgroups. The overall goal was to obtain a better understanding of factors that may influence response to CBT-CP.

MATERIALS AND METHODS

This study was a secondary analysis of data from a clinical trial of 149 U.S. active duty service members with chronic pain. Participants underwent group-based CBT-CP for 6 weeks and completed pre- and posttreatment assessments. Finite mixture models were employed to identify subgroups in treatment response, with pain impact score as the primary outcome measure.

RESULTS

We identified two classes of nearly equal size with distinct pain impact responses. One class reported improved pain impact scores following CBT-CP. This improvement was significantly associated with lower (better) baseline depression scores and greater improvement in posttreatment pain catastrophizing. In contrast, the other class reported slightly worse mean pain impact scores following CBT-CP treatment; this response was not related to baseline depression or change in pain catastrophizing.

CONCLUSIONS

Our findings demonstrate that a sizable proportion of individuals with chronic pain may not respond to group-based CBT-CP and may require a more individualized treatment approach.

Incarcerated Men: Pain Experiences Shaped by Altered Independence and Loss of Autonomy

BACKGROUND

Individuals experiencing pain while incarcerated depend on nurses, security structures, processes, and regulations for relief.

PURPOSE

The intent of this research was to understand men's experience of pain during incarceration to inform correctional nursing practice.

METHOD

Interpretive description, co-positioned with relational ethics, guided this study. Twelve incarcerated men participated in a single 1-hour interview that was audio-recorded and transcribed. The resultant text was analyzed for themes.

FINDINGS

The two main themes were dependence on staff and institutional processes and dependence on oneself and others who were incarcerated. Participants reported a substantial loss in their ability to access pain-relieving medications, products, and services. Unresponsive or delayed pain-relieving interventions from nurses contributed to their sense of indignity, disrespect, and injustice. The participants employed whatever was available, mainly exercise equipment and social support, to manage their pain.

DISCUSSION

Nurses must engage with incarcerated patients meaningfully to understand and respond to contextual factors that influence their pain experiences. Participants identified loss of autonomy and dependence on nurses as barriers to their pain relief.

CONCLUSION

Nurse engagement and responsiveness are crucial to altering incarcerated men's perceptions of injustice or helplessness while improving their pain experiences. Nurses must also foster autonomous pain-management approaches that men can use without limitations within correctional settings.

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.

Co-occurrence of chronic pain and anxiety/depression symptoms in U.S. adults: prevalence, functional impacts, and opportunities

ABSTRACT

Co-occurrence of chronic pain and clinically significant symptoms of anxiety and/or depression is regularly noted in the literature. Yet, little is known empirically about population prevalence of co-occurring symptoms, nor whether people with co-occurring symptoms constitute a distinct subpopulation within US adults living with chronic pain or US adults living with anxiety and/or depression symptoms (A/D). To address this gap, this study analyzes data from the 2019 National Health Interview Survey, a representative annual survey of self-reported health status and treatment use in the United States (n = 31,997). Approximately 12 million US adults, or 4.9% of the adult population, have co-occurring chronic pain and A/D symptoms. Unremitted A/D symptoms co-occurred in 23.9% of US adults with chronic pain, compared with an A/D prevalence of 4.9% among those without chronic pain. Conversely, chronic pain co-occurred in the majority (55.6%) of US adults with unremitted A/D symptoms, compared with a chronic pain prevalence of 17.1% among those without A/D symptoms. The likelihood of experiencing functional limitations in daily life was highest among those experiencing co-occurring symptoms, compared with those experiencing chronic pain alone or A/D symptoms alone. Among those with co-occurring symptoms, 69.4% reported that work was limited due to a health problem, 43.7% reported difficulty doing errands alone, and 55.7% reported difficulty participating in social activities. These data point to the need for targeted investment in improving functional outcomes for the nearly 1 in 20 US adults living with co-occurring chronic pain and clinically significant A/D symptoms.

Multidimensional visualization and analysis of chronic pain variables of patients who attended a chronic pain program

Psychologically-based chronic pain variables measure multiple domains of the pain experience such as anxiety, depression, catastrophizing, acceptance and stages of change. These variables measure specific areas such as emotional and cognitive states towards chronic pain and its management, acceptance towards the chronic pain condition, and an individual's readiness to move towards self-management methods. Conceptually, these variables appear to be interrelated to each other, and also form groupings of similar underlying themes. Groupings that have been previously discussed for these variables include positive and negative affect, and improved and poor adjustment. Psychological experience of chronic pain as a whole is mostly understood through conceptually consolidating individual scores across different measures covering multiple domains. A map of these variables in relation to each other can offer an overview for further understanding and exploration. We hereby visualize highlights of relationships among 11 psychosocial chronic pain variables including measures examining physical and somatic aspects, using three-dimensional biplots. Variables roughly form two groupings, with one grouping consisting of items of negative affect, cognition, and physical state ratings, and the other grouping consisting of items of acceptance and the later three stages of change (contemplation, action, maintenance). Also, we follow up with canonical correlation as a complement to further identify key relationships between bimodal groupings. Key variables linking bimodal relationships consist of catastrophizing, depression and anxiety in one grouping and activity engagement in the other. Results are discussed in the context of existing literature.

Pain Catastrophizing and Clinical Outcomes Among Patients Receiving a Novel Cognitive-Behavioral Therapy for Irritable Bowel Syndrome: An Experimental Therapeutics Approach

Irritable bowel syndrome (IBS) is the most common gastrointestinal (GI) condition treated by GI and primary care physicians. Although IBS symptoms (abdominal pain, bowel problems) are generally refractory to medical therapies, consistent research has shown that they improve following cognitive-behavioral therapy (CBT). Notwithstanding empirical support for CBT, there is less research explicating the reasons for why or how it works. Like other pain disorders, the focus on change mechanisms for behavioral pain treatments has focused on pain-specific cognitive-affective processes that modulate pain experience, few of which are more important than pain catastrophizing (PC). The fact that PC changes are seen across treatments of differing theoretical and technical orientation, including CBT, yoga, and physical therapy, suggests that it may be a nonspecific (vs. theory-based) change mechanism akin to therapeutic alliance and treatment expectancy. Therefore, the current study examined change in PC as a concurrent mediator of IBS symptoms severity, global GI symptom improvement, and quality of life among 436 Rome III-diagnosed IBS patients enrolled in a clinical trial undergoing two dosages of CBT versus a nonspecific comparator emphasizing education and support. Results from structural equation modeling parallel process mediation analyses suggest that reduction in PC during treatment are significantly associated with improvement in IBS clinical outcomes through 3-month follow-up. Results from the current study provide evidence that PC may be an important, albeit nonspecific change mechanism, during CBT for IBS. Overall, reducing the emotional unpleasantness of pain through cognitive processes is associated with improved outcomes for IBS.

Evaluation of the Relationship Between Geographic Proximity and Treatment for People Referred to a Metropolitan Multidisciplinary Pain Clinic

OBJECTIVE

This study examined which patient characteristics are associated with traveling further to attend a metropolitan, publicly funded pain management service, and whether travel distance was associated with differences in treatment profile, duration, and percentage of appointments attended.

DESIGN

Cross-sectional observational cohort study.

METHOD

Patients ≤70 years of age with a single referral between January 2014 and June 2018 who had not died within 12 months of their first appointment and who had a usual place of residence were included (N = 1,684; mean age = 47.2 years; 55.5% female). Travel distance was calculated with the HERE Routing API on the basis of historical travel times for each scheduled appointment.

RESULTS

Median travel time was 27.5 minutes (Q1, Q3: 12.5, 46.2). Ordinal regression showed that women had 20% lower odds of traveling further, but people who were overweight or obese (odds ratio [OR] = 1.4-2.3), unemployed (OR = 1.27), or taking higher opioid dosages (OR = 1.79-2.82) had higher odds of traveling further. People traveling >60 minutes had fewer treatment minutes (median = 143 minutes) than people living within 15 minutes of the pain clinic (median = 440 minutes), and a smaller proportion of those traveling >60 minutes attended group programs vs. medical appointments only (n = 35, 17.0%) relative to those living within 15 minutes of their destination (n = 184, 32.6%). People living 16-30 minutes from the clinic missed the highest proportion of appointments.

CONCLUSIONS

Although people traveling further for treatment may be seeking predominantly medical treatment, particularly opioid medications, the present findings highlight the need to further explore patient triage and program models of care to ensure that people living with persistent disabling pain can access the same level of care, regardless of where they live.

Does Pain Acceptance Buffer the Negative Effects of Catastrophizing on Function in Individuals With Chronic Pain?

OBJECTIVES

Pain catastrophizing and pain acceptance are psychological factors that have been shown to be associated with pain-related outcomes and predict multidisciplinary pain treatment outcomes. However, they are rarely examined in the same study. This study aimed to: (1) assess the independent roles of pain catastrophizingand pain acceptance as predictors of pain intensity, pain interference, and depression; and (2) evaluate the potential moderating role of pain acceptance on the association between pain catastrophizing and both pain and function.

MATERIALS AND METHODS

A sample of 467 adults with chronic pain completed an online survey including measures of pain intensity, pain interference, depression, pain catastrophizing, and pain acceptance.

RESULTS

Pain catastrophizing and pain acceptance were independent predictors of pain interference. Only pain catastrophizing and the activity engagement domain of pain acceptance were independent predictors of pain intensity and depression. Activity engagement moderated the association between pain catastrophizing and depression, indicating a buffering effect on the negative effects of catastrophizing on depression. Pain willingness moderated the association between pain catastrophizing and pain interference, such that endorsing low pain willingness may override any negative effects of pain catastrophizing.

DISCUSSION

The findings suggest that pain catastrophizing and pain acceptance are independently important to adjustment to chronic pain. Research is needed to determine if treatments that target both for change are more effective than treatments that target only one.

Behavioral Activation and Inhibition Systems: Further Evaluation of a BIS-BAS Model of Chronic Pain

OBJECTIVES

The role of the behavioral inhibition system (BIS) and behavioral activation system (BAS) in function has been evaluated in a wide range of populations. However, research on the role of the BIS and BAS in pain is in its early stages. This study sought to evaluate the utility of a BIS-BAS model of chronic pain.

METHODS

Participants were 164 individuals with chronic pain who responded to an online survey. Participants provided information about pain location, intensity, and frequency and completed questionnaires assessing behavioral inhibition and activation sensitivity, pain catastrophizing, pain interference, activity engagement, pain willingness, hope, and pain self-efficacy. Seven hierarchical regression analyses were conducted to test hypothesized associations between BIS and BAS sensitivity and measures of participant function.

RESULTS

BIS scores were significantly and positively associated with pain catastrophizing, anxiety, depression, and pain interference and were negatively associated with activity engagement, hope, and pain self-efficacy (P<0.01). BAS scores showed significant and positive associations with activity engagement and hope and showed significant negative associations with pain catastrophizing and anxiety (P<0.05). Furthermore, BIS sensitivity evidenced stronger associations with all the other study measures than did BAS sensitivity.

CONCLUSIONS

The findings provide important new information regarding the utility of the BIS-BAS model of chronic pain. Our results support the idea that BIS activation is more important than BAS activation in explaining a variety of pain-related outcomes, including positive and negative responses to pain, and suggest that modification of the model may be indicated. These results have several theoretical and clinical implications.

A Network Analysis of Potential Antecedents and Consequences of Pain-Related Activity Avoidance and Activity Engagement in Adolescents

OBJECTIVE

This study sets out to identify potential daily antecedents and consequences of pain-related activity avoidance and engagement behavior in adolescents with chronic pain.

METHODS

Adolescents (N = 65, Mage = 14.41) completed baseline self-reports and a diary for 14 days. Afternoon and evening reports were used to infer a network structure of within-day associations between pain intensity, pain-related fear, pain catastrophizing, affect, and pain-related activity avoidance and engagement behavior. Baseline psychological flexibility was examined as a potential resilience factor.

RESULTS

Activity avoidance in the evening was predicted by pain-related fear and avoidance earlier that afternoon. Activity engagement was predicted by positive affect and activity engagement in the afternoon. Pain-related behavior in the afternoon was not related to subsequent changes in pain intensity, pain-related fear, pain catastrophizing, or affect. Pain-related fear in the afternoon was predictive of increased levels of pain and pain catastrophizing in the evening. Both pain-related fear and pain catastrophizing in the evening were predicted by negative affect in the afternoon. Psychological flexibility was associated with lower levels of daily activity avoidance and buffered the negative association between pain intensity and subsequent activity engagement.

CONCLUSIONS

This study provides insight into unique factors that trigger and maintain activity avoidance and engagement and into the role of psychological flexibility in pediatric pain. Future work should focus on both risk and resilience factors and examine the role of psychological flexibility in chronic pediatric pain in greater detail.

Effects of a pain management programme on occupational performance are influenced by gains in self-efficacy

Introduction

The perceived capacity to perform particular activities or skills (i.e. self-efficacy) is paramount in occupational therapy and is thought to be reinforced by actual functional capacity. This study examined whether changes in self-efficacy or confidence to lift weighted items influences changes in occupational performance and disability levels in patients attending a cognitive behavioural therapy pain management programme.

Method

Clients attending an 8-week cognitive behavioural therapy pain management programme ( N = 125) completed questionnaires before treatment, at discharge, and at 3-month and 6-month reviews, including measures of pain self-efficacy, disability and self-perceived performance and satisfaction using the Canadian occupational performance measure. Analyses examined disability and occupational performance over time, adjusting for baseline characteristics (age, sex, education), and sought to determine whether self-efficacy or lifting confidence influenced the outcomes.

Results

The level of disability, lifting confidence, self-efficacy and occupational performance all improved over time; however, only occupational performance and lifting confidence maintained improvements up to the 6-month review. Self-efficacy had a greater impact on occupational performance than lifting confidence.

Publications on the Association Between Cognitive Function and Pain from 2000 to 2018: A Bibliometric Analysis Using CiteSpace

BACKGROUND This study aimed to use CiteSpace software to conduct a bibliometric analysis of published studies on the association between pain and cognitive function from 2000 to 2018. The study also aimed to determine publication patterns and authorship and to identify recent trends for research in this field. MATERIAL AND METHODS Publications on the association between cognitive function and pain between 2000 and 2018 were identified from the Web of Science database. Bibliographic information, including authorship, country, citation frequency, changes in citation, and interactive visualization were generated using CiteSpace software. Co-citation, or frequency of two publications cited together by another publication, was also studied. RESULTS On 8th January 2019, 4,889 publications were identified. The United States (1132 publications) and the University of Washington (87 publications) were the most productive country and institution, respectively. The journal, Pain (182 publications) had the largest number of publications and was the most frequently cited journal (citation counts, 1569) with the highest centrality (0.62). Author A had the largest number of publications (21). Author B had the greatest co-citation count (223). Author C tied with Author D as the first co-cited author in terms of centrality (0.18). Author E in 2011 (co-citation count, 96) and Author F in 2008 (centrality: 0.11) had the highest co-citation counts and centrality, respectively. The keyword 'empathy' ranked first for research developments with the highest citation burst (10.045). CONCLUSIONS Bibliometric analysis of the association between pain and cognitive function might identify new directions for future research.

Support for the Spanish version of the CPAQ-8 as a measure of chronic pain acceptance

AIM AND OBJECTIVE

To provide evidence regarding the psychometric properties of the Spanish eight-item version of the Chronic Pain Acceptance Questionnaire (CPAQ-8).

METHOD

Three hundred adults with chronic pain completed measures of pain acceptance, committed action, fear of movement, anxiety, depression, and health-related quality of life. A confirmatory factor analysis (CFA) of the CPAQ-8 was performed. Reliability and validity were also evaluated.

RESULTS

The CFA confirmed a two-factor structure. The CPAQ-8 Total and subscale scores showed acceptable-to-good internal consistency. Furthermore, the Total and the Activity Engagement scale scores showed moderate associations with Committed Action scores, supporting construct validity. Both the Total and the two subscale scores showed good criterion validity.

CONCLUSION

The findings provide further support for the reliability and validity of the Spanish version of the CPAQ-8 Total and subscale scores.

Pain and posttraumatic stress disorder in refugees who survived torture: The role of pain catastrophizing and trauma-related beliefs

BACKGROUND

Traumatized refugees with comorbid pain report more severe posttraumatic stress disorder (PTSD), respond less well to PTSD-focused treatments and exhibit greater disability. A mutually maintaining relationship may exist between pain and PTSD, that may be partly accounted for by depression, but no prior studies have tested this assumption in traumatized refugees.

METHOD

Self-report measures of pain, PTSD, depression, disability, pain catastrophizing (PC) and trauma-related beliefs (TRBs) were administered to 197 refugees referred to the Danish Institute Against Torture (DIGNITY) prior to treatment. The contribution of pain, depression, PC, and TRBs to the overall variance in PTSD severity was examined. We also examined whether the relationship between pain and PTSD was mediated by PC and TRBs, after controlling for depression.

RESULTS

Depression, pain severity, PC and TRBs together accounted for 66% of the overall variance in PTSD, with depression being the primary contributor (57%). In univariate tests, both PC and TRBs significantly mediated the relationship between pain interference/severity and PTSD. However, after controlling for depression only PC mediated this relationship.

CONCLUSIONS

Negative beliefs about pain and the trauma made small, but additive contributions to the relationship between pain and PTSD severity, after controlling for depression. Longitudinal studies with refugees, involving tests of more complex mutual maintenance models, are warranted.

SIGNIFICANCE

After controlling for symptoms of depression, pain catastrophizing and negative trauma-related beliefs partly mediated the relationship between pain and PTSD in tortured refugees. The results suggest that all three variables are important in a mutual mediation model of pain and PTSD, and as targets for treatment, in traumatized refugees.

The Role of Sleep Quality and Fatigue on the Benefits of an Interdisciplinary Treatment for Adults With Chronic Pain

BACKGROUND

Interdisciplinary chronic pain treatment is effective for reducing pain intensity and pain-related disability, and for improving psychological function. However, the mechanisms that underlie these treatment-related benefits are not yet well understood. Sleep problems and fatigue are modifiable factors often comorbid with chronic pain. The goal of this study was to evaluate the role that changes in sleep quality and fatigue might have on the benefits of an interdisciplinary chronic pain treatment.

METHODS

A total of 125 adults with chronic pain participated in a 4-week interdisciplinary pain management program. Measures of depression, sleep disturbance, fatigue, pain intensity, and physical function were administered at pre- and post-treatment. Three regression analyses were conducted to evaluate the contribution of pre- to post-treatment improvements in fatigue and sleep disturbance to the pre- to post-treatment improvements in pain intensity, disability, and depression, while controlling for demographic characteristics (age and sex) and pain intensity.

RESULTS

Changes in fatigue and sleep disturbance made independent and significant contributions to the prediction of treatment-related benefits in pain intensity; improvements in depressive symptoms were predicted by improvements in fatigue, and improvements in disability were only predicted by pre-treatment and pre- to post-treatment decreases in pain intensity (one of the control variables).

CONCLUSIONS

In addition to sleep, fatigue emerged as a key potential mechanism of multidisciplinary chronic pain treatment-related improvements, suggesting that interventions including elements that effectively target sleep and fatigue may enhance the efficacy of interdisciplinary chronic pain programs. This possibility should be evaluated in future research.