The chronic pain skills study: Protocol for a randomized controlled trial comparing hypnosis, mindfulness meditation and pain education in Veterans

Evaluating the benefits of a second pain treatment following a clinical trial

OBJECTIVE

To examine the value of including an open label phase after a clinical trial of pain treatments by examining participant characteristics and potential benefits.

METHOD

Secondary data analysis. Veterans with chronic pain who completed a randomized controlled trial (RCT) comparing hypnosis, mindfulness meditation, and pain education were invited to participate in an open label phase. Average and worst pain intensities, pain interference, and depression were assessed pre- and postopen label phase; global impressions of change and treatment satisfaction were assessed at postopen label phase only.

RESULTS

Of those who were offered the open label phase, 40% (n = 68) enrolled. Enrollees were likely to be older, to have attended more sessions in the RCT, to be satisfied with their first treatment, and to perceive improvement in their ability to manage pain after the RCT. In the open label phase, depression and worst pain decreased across all three treatment conditions. No other improvements were observed. However, most Veterans perceived improvements in pain intensity, ability to manage pain, and pain interference, and were satisfied with the second intervention.

CONCLUSIONS

There appears to be some value to adding an open label phase to the end of a trial of pain treatments. A substantial portion of study participants elected to participate and reported it to be beneficial. Exploring data from an open label phase can illuminate important aspects of patient experience, barriers to and facilitators of care, as well as treatment preferences. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sleep and Pain in Veterans with Chronic Pain: Effects of Psychological Pain Treatment and Temporal Associations

Introduction

Chronic pain is highly prevalent in US military Veterans. Non-opioid and non-pharmacologic treatments are recommended when clinically appropriate, but research on the mechanisms underlying benefits of these treatments is lacking. Here, we examined the role of sleep in the effects of three non-pharmacologic pain treatments in Veterans. Specifically, we investigated whether treatment effects on sleep predicted treatment effects on pain occurring later, or vice versa.

Methods

Veterans enrolled in a randomized controlled trial were invited to participate in this supplementary sleep study. A total of 174 Veterans were randomized to one of three 8-session, in-person, group-based pain treatments: hypnosis, mindfulness meditation, or education control. Measurements included self-reported sleep disturbance, pain intensity, and pain catastrophizing; sleep duration was assessed with actigraphy. Sleep and pain measurements were obtained at baseline, posttreatment, and 3-month posttreatment follow-up.

Results

At baseline, average pain intensity was moderate (mean ± SD: 5.7 ± 1.7 on the 0-10 Numeric Rating Scale), pain catastrophizing was just below the clinically relevant threshold (mean ± SD: 28.6 ± 12.2 on the Pain Catastrophizing Scale), and subjective sleep disturbance exceeded the US population average (mean ± SD: 58.5 ± 8.1 on the Patient Reported Outcomes Measurement Information System Sleep Disturbance - Short Form). By contrast, objective sleep duration was consistent with the recommended daily sleep amount of 7-8 h for adults (mean ± SD: 8.3 ± 1.4 h). Across treatment conditions, pain intensity, pain catastrophizing, and subjective sleep disturbance were significantly less at posttreatment and 3-month follow-up than at baseline (p < 0.001). Actigraphic sleep duration did not differ significantly as a function of time. There was a high degree of covariation among the measures of pain intensity, pain catastrophizing, and sleep disturbance (p < 0.05). However, self-reported sleep disturbance was not significantly correlated with actigraphic sleep duration (|r| <= 0.13, p > 0.05). Sleep and pain variables observed at prior assessments predicted these same variables at subsequent assessments. There was no significant evidence that changes in pain preceded changes in sleep or that changes in sleep preceded changes in pain (all p > 0.05).

Discussion

For this study's Veterans, treatment-related changes in sleep and pain appeared to occur in parallel. The concomitant changes in sleep and pain suggest that therapies improving pain in Veterans may yield attendant benefits for the treatment of sleep, and possibly vice versa.

Effects of hypnosis, mindfulness meditation, and education for chronic pain on substance use in veterans: A supplementary analysis of a randomized clinical trial

PURPOSE/OBJECTIVE

To examine the impact of three behavioral interventions for chronic pain on substance use.

RESEARCH METHOD/DESIGN

Participants were 328 Veterans with chronic pain receiving care at one of two Veterans Affairs Medical Centers in the northwest United States. Participants were randomly assigned to one of three 8-week manualized in-person group treatments: (a) hypnosis (HYP), (b) mindfulness meditation (MM), or (c) active education control (ED). Substance use frequency was assessed using 10 individual items from the WHO-ASSIST, administered at baseline prior to randomization and at 3- and 6-month posttreatment.

RESULTS

Baseline substance use (i.e., any use) in the past 3 months was reported by 22% (tobacco), 27% (cannabis), and 61% (alcohol) of participants. Use of all other substances assessed was reported by < 7% of participants. Results showed that MM, as compared to ED, significantly reduced risk of daily cannabis use by 85% and 81% at the 3- and 6-month posttreatment follow-ups, respectively, after adjusting for baseline use. HYP, as compared to ED, significantly reduced risk of daily cannabis use by 82% at the 6-month posttreatment follow-up after adjusting for baseline use. There was no intervention effect on tobacco or alcohol use at either posttreatment follow-up.

CONCLUSIONS/IMPLICATIONS

HYP and MM for chronic pain may facilitate reductions in cannabis use, even when reducing such use is not a focus of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effects of osteopathic manipulative treatment associated with pain education and clinical hypnosis in individuals with chronic low back pain: study protocol for a randomized sham-controlled clinical trial

BACKGROUND

Patients with chronic low back pain (CLBP) suffer with functional, social, and psychological aspects. There is a growing number of studies with multimodal approaches in the management of these patients, combining physical and behavioral therapies such as osteopathic manipulative treatment, associating pain education and clinical hypnosis. The aim of the present study will be to evaluate the effects of osteopathic manipulative treatment (OMT) associated with pain neuroscience education (PNE) and clinical hypnosis (CH) on pain and disability in participants with CLBP compared to PNE, CH, and sham therapy.

METHODS

A randomized controlled clinical trial will be conducted in participants aged 20-60 years with CLBP who will be divided into two groups. Group 1 will receive PNE and CH associated with OMT, and G2 will receive PNE, CH, and sham therapy. In both groups, 4 interventions of a maximum of 50 min and with an interval of 7 days will be performed. As primary outcomes, pain (numerical pain scale), pressure pain threshold (pressure algometer), and disability (Oswestry Disability Questionnaire) will be evaluated and, as a secondary outcome, global impression of improvement (Percent of Improvement Scale), central sensitization (Central Sensitization Questionnaire), biopsychosocial aspects (Start Beck Toll Questionnaire), and behavior of the autonomic nervous system (heart rate variability) will be assessed. Participants will be evaluated in the pre-intervention moments, immediately after the end of the protocol and 4 weeks after the procedures. Randomization will be created through a simple randomized sequence and the evaluator will be blinded to the allocation of intervention groups.

DISCUSSION

The guidelines have been encouraging multimodal, biopsychosocial approaches for patients with CLBP; in this sense, the results of this study can help clinicians and researchers in the implementation of a model of treatment strategy for these patients. In addition, patients may benefit from approaches with minimal risk of deleterious effects and low cost. In addition, it will enable the addition of relevant elements to the literature, with approaches that interact and do not segment the body and brain of patients with CLBP, allowing new studies in this scenario.

TRIALS REGISTRATION

Date: September 4, 2021/Number: NCT05042115 .

Immediate Effects of Hypnosis, Mindfulness Meditation, and Prayer on Cold Pressor Outcomes: A Four-Arm Parallel Experimental Study

Purpose

Previous research supports the usefulness of hypnosis (HYP), mindfulness meditation (MM), and prayer as pain self-management strategies in adults with chronic pain. However, their effects on acute pain have been less researched, and no previous head-to-head study compared the immediate effects of these three approaches on pain-related outcomes. This study compared the immediate effects of HYP, MM, and Christian prayer (CP) on pain intensity, pain tolerance, and stress as assessed by heart rate variability (HRV).

Participants and Methods

A total of 232 healthy adults were randomly assigned to, and completed, a single 20-minute session of MM, SH, CP, or an attention control (CN), and underwent two cycles (one pre- and one post-intervention) of Cold Pressor Arm Wrap (CPAW). Sessions were audio-delivered. Participants responded to pre- and post-intervention pain intensity measurements. Pain tolerance (sec) was assessed during the CPAW cycles. HRV was assessed at baseline, and at pre- and post-intervention CPAW cycles. The study protocol was pre-registered at the ClinicalTrials.gov registry (NCT04491630).

Results

Small within-group decreases in pain intensity and small increases in pain tolerance were found for HYP and MM from the pre- to the post-intervention. Small within-group improvements in the LH/HF ratio were also found for HYP. The exploratory between-group pairwise comparisons revealed a medium effect size effects of HYP on pain tolerance relative to the control condition. The effects of CP were positive, but small and not statistically significant. Only small to medium, though non-significant, Time × Group interaction effects were found.

Conclusion

Study results suggest that single short-term HYP and MM sessions, but not biblical-based CP, may be useful for acute pain self-management, with HYP being the slightly superior option. Future research should compare the effects of different types of prayer and examine the predictors and moderators of these pain approaches' effects on pain-related outcomes.

Effects of hypnosis vs mindfulness meditation vs education on chronic pain intensity and secondary outcomes in veterans: a randomized clinical trial

ABSTRACT

Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) with an active education control (ED). Veterans (N = 328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity [API]) and secondary outcomes were assessed at pretreatment, posttreatment, and 3 and 6 months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pretreatment to posttreatment change in API; however, pretreatment to posttreatment improvements in API and several secondary variables were seen for participants in all 3 conditions. Participation in MM resulted in greater decreases in API and pain interference at 6 months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3 and 6 months posttreatment compared with ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all 3 interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.

Delivery of a Group Hypnosis Protocol for Managing Chronic Pain in Outpatient Integrative Medicine

Although strong evidence exists for using individual hypnosis to treat pain, evidence regarding group applications is limited. This project evaluated changes in multiple outcome measures in persons with chronic pain treated with 8 weeks of group hypnosis. Eighty-five adults with diverse chronic pain etiologies completed an 8-session, structured group hypnosis treatment. Pain intensity, pain interference, and global health were evaluated at baseline, posttreatment, and 3- and 6-months posttreatment. Linear mixed effects models assessed changes in outcomes over time. In a model testing, all three outcome measures simultaneously, participants improved substantially from pre- to posttreatment and maintained improvement across follow-up. Analyses of individual outcomes showed significant pre- to posttreatment reductions in pain intensity and interference, which were maintained for pain intensity and continued to improve for pain interference across follow-up. The findings provide compelling preliminary evidence that a group format is an effective delivery system for teaching individual skills in using hypnosis for chronic pain management. Larger randomized controlled trials are warranted to demonstrate equivalence of outcomes between treatment modes.

Pain Catastrophizing Mediates the Relationship Between Pain Intensity and Sleep Disturbances in U.S. Veterans With Chronic Pain

INTRODUCTION

Veterans with chronic pain frequently report comorbid disruptions in sleep and psychological dysfunction. The purpose of this study was to investigate whether psychological function variables mediate the sleep-pain relationship. Knowledge regarding such contributing factors can inform the development and optimization of treatments for sleep disturbances and pain.

MATERIALS AND METHODS

In an IRB-approved, registered clinical trial, we collected objective sleep data from U.S. military Veterans with chronic pain (N = 184, ages 23-81) using wrist actigraphy for 7 days and self-reported survey data assessing sleep quality, pain intensity, and psychological function (depression, anxiety, post-traumatic stress disorder, and pain catastrophizing). We investigated the associations between objectively measured and self-reported sleep quality and self-reported pain intensity. In addition, using parallel mediation analyses, we examined whether psychological function variables mediated these associations.

RESULTS

Actigraphy showed suboptimal sleep duration (less than 7 hours) and sleep fragmentation for most participants. Self-reported poor sleep quality and pain intensity were significantly correlated. Pain catastrophizing was found to mediate the association between self-reported sleep quality and pain intensity.

CONCLUSIONS

Sleep disturbances in this sample of Veterans with chronic pain included insufficient sleep, fragmented sleep, and perceived poor sleep quality. Analyses suggest that poor perceived sleep quality and pain intensity are mediated via pain catastrophizing. The finding highlights the potential importance of pain catastrophizing in Veterans with chronic pain. Future longitudinal research is needed to determine the extent to which treatments that reduce pain catastrophizing might also improve both sleep and pain outcomes.

Functional Changes in Brain Activity Using Hypnosis: A Systematic Review

Hypnosis has proven a powerful method in indications such as pain control and anxiety reduction. As recently discussed, it has been yielding increased attention from medical/dental perspectives. This systematic review (PROSPERO-registration-ID-CRD42021259187) aimed to critically evaluate and discuss functional changes in brain activity using hypnosis by means of different imaging techniques. Randomized controlled trials, cohort, comparative, cross-sectional, evaluation and validation studies from three databases—Cochrane, Embase and Medline via PubMed from January 1979 to August 2021—were reviewed using an ad hoc prepared search string and following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. A total of 10,404 articles were identified, 1194 duplicates were removed and 9190 papers were discarded after consulting article titles/abstracts. Ultimately, 20 papers were assessed for eligibility, and 20 papers were included after a hand search (n^total = 40). Despite a broad heterogenicity of included studies, evidence of functional changes in brain activity using hypnosis was identified. Electromyography (EMG) startle amplitudes result in greater activity in the frontal brain area; amplitudes using Somatosensory Event-Related Potentials (SERPs) showed similar results. Electroencephalography (EEG) oscillations of θ activity are positively associated with response to hypnosis. EEG results showed greater amplitudes for highly hypnotizable subjects over the left hemisphere. Less activity during hypnosis was observed in the insula and anterior cingulate cortex (ACC).

A Systematic Review of a Polyvagal Perspective on Embodied Contemplative Practices as Promoters of Cardiorespiratory Coupling and Traumatic Stress Recovery for PTSD and OCD: Research Methodologies and State of the Art

Baseline respiratory sinus arrhythmia (RSA) has been proposed as a transdiagnostic biomarker of stress vulnerability across psychopathologies, and a reliable association between PTSD, OCD and lower resting RSA was found. Contemplative practices have been linked to the activation of the vagus as well as to an increased RSA that, according to the polyvagal theory, reflects the activation of the ventral vagal complex (VVC) and may promote PTSD and OCD recovery. PubMed and Scopus databases were selected to conduct a search following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines, and A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) was used to appraise the methodological quality for this systematic review. Six articles met the inclusion criteria (one cross-sectional study, one study with pre-post measurements, two cohort studies and two RCT studies). Mindfulness-related interventions promoted parasympathetic activity, an increased vagal tone and improvements in PTSD and OCD symptoms. According to the polyvagal theory, mindfulness-related and compassion-related meditations would be conceptualized as neural exercises expanding the capacity of the ventral vagal complex to regulate the present state and to promote resilience. Clinical and methodological issues are discussed.

Transdiagnostic Cognitive Processes in Chronic Pain and Comorbid PTSD and Depression in Veterans

BACKGROUND

Chronic pain in Veterans is a major problem compounded by comorbid posttraumatic stress disorder (PTSD) and depression. Adopting a transdiagnostic framework to understanding "shared territory" among these diagnoses has the potential to inform our understanding of the underlying cognitive processes and mechanisms that transverse diagnostic boundaries.

PURPOSE

To examine the associations between pain-related cognitive processes (diversion, distancing, absorption, and openness), pain intensity, PTSD and depressive symptoms, and the extent to which Veterans with chronic pain with and without comorbid PTSD and depression engage in different/similar pain-related cognitive processes.

METHODS

Secondary analysis of pretreatment data with a subsample (n = 147) of Veterans with chronic pain from a larger clinical trial. Pretreatment PCL-5 and PROMIS Depression scales were used to categorize participants into three groups: (a) Pain-only; (b) Pain-PTSD; and (c) Pain-PTSD-DEP.

RESULTS

Compared to the Pain-only group, the Pain-PTSD and Pain-PTSD-DEP groups reported significantly greater pain intensity, PTSD and depressive symptoms, and ruminative pain absorption. The Pain-PTSD-DEP group had significantly lower pain diversion and pain openness scores. When diversion and openness were used within the Pain-PTSD-DEP group, however, they were both associated with lower pain intensity and openness was additionally associated with lower PTSD scores. However, in the Pain-PTSD group, pain openness was associated with higher depression scores.

CONCLUSIONS

Across increasing complexity of comorbidity profiles (i.e., one vs. two comorbid conditions), ruminative absorption with pain emerged as a cognitive process that transverses diagnoses and contributes to worse outcomes. Nonjudgmental acceptance may not be universally beneficial, potentially depending upon the nature of comorbidity profiles.

Analgesic Opioid Misuse and Opioid Use Disorder among Patients with Chronic Non-Cancer Pain and Prescribed Opioids in a Pain Centre in France

(1) Background: Chronic non-cancer pain (CNCP) remains a public health challenge around the world. Opioids (PO) have been increasingly used in the treatment of CNCP in the last 20 years. This study aimed to assess the prevalence of opioid misuse and prescribed-opioid use disorder (p-OUD) among patients with CNCP in a pain centre in France, and to analyse risk factors for moderate or severe p-OUD. (2) Method: A cross-sectional study was conducted, including patients consulting for pain management in the pain centre of Brest University Hospital. A self-questionnaire was administered (sociodemographic data, medical data, PO misuse, and p-OUD according the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) criteria). Descriptive, univariate, and multivariate analyses were conducted, together with a principal component analysis, in order to identify factors associated with p-OUD. (3) Results: In total, 115 patients were included, the majority of whom were women, with a mean age of 52 years old [18–82]; 64.3% (n = 74) had a current prescription for opioid analgesics (weak or strong). In this group, 56.7% (n = 42) had no or only mild p-OUD and 43.3% (n = 32) had current moderate or severe p-OUD. Patients with moderate or severe p-OUD were more likely to have a current antidepressant prescription, to have had psychotherapy, to currently use strong opioids and oxycodone, and to report taking more frequent doses than prescribed and feeling dependent. (4) Conclusions: We showed that the prevalence of current moderate/severe p-OUD concerned 43.3% of the patients with a CNCP seeking treatment in a pain centre. According to these results, several measures are relevant in managing p-OUD among patients with CNCP.

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

BACKGROUND

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

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

Behavioral activation and behavioral inhibition: An examination of function in chronic pain

PURPOSE/OBJECTIVE

The objective of the study was to examine the BIS-BAS model of chronic pain. This model posits that 2 neurophysiological systems-the behavioral inhibition system (BIS) sensitized to and activated by punishment cues and the behavioral activation system (BAS) sensitized to and activated by reward cues-make independent and concurrent contributions to 2 domains of pain-related function: pain interference and positive function despite pain. The study additionally hypothesized that BIS and BAS sensitivity would have different associations with these 2 different aspects of pain-related function. BIS activation would be more strongly correlated with pain interference and BAS would be more strongly correlated with positive function despite pain. Research Method/Design: This was a cohort study consisting of the baseline assessments of 328 veterans enrolled in a large clinical trial examining 3 psychosocial interventions for chronic pain.

RESULTS

In multivariable regression adjusting for demographic factors and pain intensity, BIS was associated with greater pain interference and less positive function despite pain. BAS was associated with greater positive function despite pain but to a lesser degree than BIS.

CONCLUSIONS

As hypothesized, BIS and BAS both contributed to pain-related function; however, BIS displayed stronger associations with both pain interference and positive function despite pain. Thus, the hypothesis that BIS-BAS relationships would differ based on the nature of the functional outcome (BIS resulting in poorer function because of pain and BAS better function despite pain) was only partially supported. Findings of the current study suggest the role of BIS in chronic pain may be more pervasive across functional outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).