1
|
Krypotos AM, Crombez G, Vlaeyen JWS. The dynamics of pain avoidance: the exploration-exploitation dilemma. Pain 2024; 165:2145-2149. [PMID: 38537054 DOI: 10.1097/j.pain.0000000000003222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/07/2024] [Indexed: 09/18/2024]
Affiliation(s)
- Angelos-Miltiadis Krypotos
- Research Group of Healthy Psychology, KU Leuven, Belgium
- Department of Clinical Psychology, Utrecht University, the Netherlands
| | - Geert Crombez
- Department of Experimental-Clinical and Health Psychology, Ghent University, Belgium
| | - Johan W S Vlaeyen
- Research Group of Healthy Psychology, KU Leuven, Belgium
- Department of Experimental Health Psychology, Maastricht University, the Netherlands
| |
Collapse
|
2
|
Gatzounis R, Gelissen A, Theuerzeit D, Meulders A. Rewarding Approach Behaviour Attenuates the Return of Pain-Related Avoidance After Successful Extinction with Response Prevention. THE JOURNAL OF PAIN 2024; 25:104453. [PMID: 38145858 DOI: 10.1016/j.jpain.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023]
Abstract
After successful exposure treatment for chronic pain, pain-related fear and avoidance may return, i.e., relapse may occur. This return of fear and avoidance may be modulated by various post-treatment factors. In this study, we aimed to investigate two potential factors that may affect return of fear and avoidance, i.e. cognitive load and rewarding approach behaviour. In an operant pain-related avoidance conditioning paradigm, healthy pain-free volunteers first learned to fear and avoid an arm-reaching movement that was often paired with painful electrocutaneous stimulation (T1), by performing alternative movements that were less often (T2) or never (T3) paired with pain. During extinction with response prevention, participants were only allowed to perform T1, and pain was omitted. To model relapse, two unexpected painful stimuli were presented (i.e., reinstatement manipulation), after which participants could freely choose among the three arm-reaching movements again. During test, the Low Load group performed an additional easy digit task, whereas the High Load group performed a more cognitively demanding digit task. The Reward group performed the demanding digit task, whilst being rewarded to perform T1. Results showed that pain-related fear and avoidance returned, irrespective of cognitive load imposed. When participants were rewarded to approach T1, however, the return of avoidance, but not fear, was attenuated. Our findings suggest that engaging in rewarding activities may facilitate the maintenance of treatment outcomes, and provide additional support to the growing body of literature indicating a divergent relationship between fear and avoidance. PERSPECTIVE: Results of this experiment suggest that engaging in rewarding activities may optimize exposure treatment for chronic pain, by dampening the return of pain-related avoidance - though not of pain-related fear - after extinction.
Collapse
Affiliation(s)
- Rena Gatzounis
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands
| | - Anouk Gelissen
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands
| | - Daniëlla Theuerzeit
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands
| | - Ann Meulders
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands; Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium.
| |
Collapse
|
3
|
Hedman-Lagerlöf M, Gasslander N, Ahnlund Hoffmann A, Bragesjö M, Etzell A, Ezra S, Frostell E, Hedman-Lagerlöf E, Ivert C, Liliequist B, Ljótsson B, Hoppe JM, Palmgren J, Spansk E, Sundström F, Särnholm J, Tzavara G, Buhrman M, Axelsson E. Effect of exposure-based vs traditional cognitive behavior therapy for fibromyalgia: a two-site single-blind randomized controlled trial. Pain 2024; 165:1278-1288. [PMID: 38131181 PMCID: PMC11090030 DOI: 10.1097/j.pain.0000000000003128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/13/2023] [Accepted: 10/13/2023] [Indexed: 12/23/2023]
Abstract
ABSTRACT Fibromyalgia is a debilitating pain condition for which treatment effects are typically modest. The most evaluated psychological treatment is traditional cognitive behavior therapy (T-CBT), but promising effects have recently been seen in exposure-based cognitive behavior therapy (Exp-CBT). We investigated whether Exp-CBT was superior to T-CBT in a randomized controlled trial. Self-referred participants with fibromyalgia (N = 274) were randomized (1:1) to 10 weeks of Exp-CBT or T-CBT. Treatments were delivered online and presented as "CBT for fibromyalgia." Participants were assessed at baseline, weekly during treatment, posttreatment, and at 6- and 12-month follow-up. Primary outcome was the difference in reduction in fibromyalgia severity as measured using the Fibromyalgia Impact Questionnaire (FIQ) over 11 assessment points from baseline to posttreatment, modelled within an intention-to-treat framework using linear mixed effects models fitted on multiple imputed data. Approximately 91% of weekly FIQ scores were collected over the main phase. There was no significant difference between Exp-CBT and T-CBT in the mean reduction of fibromyalgia severity from pretreatment to posttreatment (b = 1.3, 95% CI -3.0 to 5.7, P = 0.544, d = -0.10). Minimal clinically important improvement was seen 60% in Exp-CBT vs 59% in T-CBT. Effects were sustained up to 12 months posttreatment. This well-powered randomized trial indicated that Exp-CBT was not superior to T-CBT for fibromyalgia. Both treatments were associated with a marked reduction in fibromyalgia severity, and the online treatment format might be of high clinical utility. T-CBT can still be regarded a reference standard treatment that remains clinically relevant when compared to novel treatment approaches.
Collapse
Affiliation(s)
- Maria Hedman-Lagerlöf
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Nils Gasslander
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Alice Ahnlund Hoffmann
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Maria Bragesjö
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Amanda Etzell
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Simon Ezra
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Elsa Frostell
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erik Hedman-Lagerlöf
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Gustavsberg Primary Health Care Center, Region Stockholm, Stockholm, Sweden
| | - Caroline Ivert
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Björn Liliequist
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Johanna M. Hoppe
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Josefin Palmgren
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Edward Spansk
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Felicia Sundström
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Josefin Särnholm
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Georgia Tzavara
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Monica Buhrman
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Erland Axelsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Liljeholmen Primary Health Care Center, Region Stockholm, Stockholm, Sweden
- Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden
| |
Collapse
|
4
|
Smakowski A, Hüsing P, Völcker S, Löwe B, Rosmalen JGM, Shedden-Mora M, Toussaint A. Psychological risk factors of somatic symptom disorder: A systematic review and meta-analysis of cross-sectional and longitudinal studies. J Psychosom Res 2024; 181:111608. [PMID: 38365462 DOI: 10.1016/j.jpsychores.2024.111608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Current diagnostic concepts of somatic symptom disorder (SSD) in DSM-5 and bodily distress disorder (BDD) in ICD-11 require certain psychological criteria, but researchers have called for further specification. Therefore, in a first step, this systematic review and meta-analysis aimed to summarize the current evidence on psychological factors associated with SSD/BDD and/or disorder-relevant clinical outcomes such as symptom severity and impairment. METHODS Psychological factors were systematically searched using Pubmed, Cochrane Library and Psycinfo via EBSCO. Studies providing original data in English or German, after 2009 were included. Cross-sectional, cohort and case-control studies investigating at least one psychological factor in individuals with SSD/BDD in the context of disorder-relevant outcomes were included. RESULTS Forty-three eligible studies (n = 3760 patients) in SSD (none in BDD) provided data on at least one psychological factor, 37 in case-control format, 10 cross-sectional and 5 longitudinal. Meta-analyses of the case-control studies found patients with SSD to be more impaired by depression (SMD = 1.80), anxiety (SMD = 1.55), health anxiety (SMD = 1.31) and alexithymia (SMD = 1.39), compared to healthy controls. Longitudinal results are scarce, mixed, and require refining, individual studies suggest self-concept of bodily weakness, anxiety and depression to be predictive for persistent SSD and physical functioning. CONCLUSION This review provides a detailed overview of the current evidence of psychological factors in relation to SSD/BDD. Future studies on SSD and BDD should include under-studied psychological factors, such as negative affect, fear avoidance, or emotion regulation. More longitudinal studies are needed to assess the predictive value of these factors.
Collapse
Affiliation(s)
- Abigail Smakowski
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
| | - Paul Hüsing
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany
| | - Sophia Völcker
- Medical School Hamburg, Department of Psychology, Hamburg, Germany
| | - Bernd Löwe
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany
| | - Judith G M Rosmalen
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation (ICPE), Netherlands
| | - Meike Shedden-Mora
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany; Medical School Hamburg, Department of Psychology, Hamburg, Germany
| | - Anne Toussaint
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
| |
Collapse
|
5
|
Huth D, Bräscher AK, Tholl S, Fiess J, Birke G, Herrmann C, Jöbges M, Mier D, Witthöft M. Cognitive-behavioral therapy for patients with post-COVID-19 condition (CBT-PCC): a feasibility trial. Psychol Med 2024; 54:1122-1132. [PMID: 37842765 DOI: 10.1017/s0033291723002921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND The post-COVID-19 condition describes the persistence or onset of somatic symptoms (e.g. fatigue) after acute COVID-19. Based on an existing cognitive-behavioral treatment protocol, we developed a specialized group intervention for individuals with post-COVID-19 condition. The present study examines the feasibility, acceptance, and effectiveness of the program for inpatients in a neurological rehabilitation setting. METHODS The treatment program comprises eight sessions and includes psychoeducational and experience-based interventions on common psychophysiological mechanisms of persistent somatic symptoms. A feasibility trial was conducted using a one-group design in a naturalistic setting. N = 64 inpatients with a history of mild COVID-19 that fulfilled WHO criteria for post-COVID-19 condition were enrolled. After each session, evaluation forms were completed and psychometric questionnaires on somatic and psychopathological symptom burden were collected pre- and post-intervention. RESULTS The treatment program was well received by participants and therapists. Each session was rated as comprehensible and overall satisfaction with the sessions was high. Pre-post effect sizes (of standard rehabilitation incl. new treatment program; intention-to-treat) showed significantly reduced subjective fatigue (p < 0.05, dav = 0.33) and improved disease coping (ps < 0.05, dav = 0.33-0.49). CONCLUSIONS Our results support the feasibility and acceptance of the newly developed cognitive-behavioral group intervention for individuals with post-COVID-19 condition. Yet, findings have to be interpreted cautiously due to the lack of a control group and follow-up measurement, the small sample size, and a relatively high drop-out rate.
Collapse
Affiliation(s)
- Daniel Huth
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Anne-Kathrin Bräscher
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sarah Tholl
- Department of Clinical Psychology and Psychotherapy, University of Konstanz, Konstanz, Germany
| | - Johanna Fiess
- Department of Clinical Psychology and Psychotherapy, University of Konstanz, Konstanz, Germany
| | - Gunnar Birke
- Kliniken Schmieder Gailingen, Gailingen, Germany
| | | | | | - Daniela Mier
- Department of Clinical Psychology and Psychotherapy, University of Konstanz, Konstanz, Germany
| | - Michael Witthöft
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg University Mainz, Mainz, Germany
| |
Collapse
|
6
|
Vogt R, Haas J, Baumann L, Sander A, Klose C, Riecke J, Rief W, Bingel U, Maser D, Witthöft M, Keßler J, Zugaj MR, Ditzen B, Glombiewski JA. EFFects of Exposure and Cognitive behavioral Therapy for chronic BACK pain ("EFFECT-BACK"): study protocol for a randomized controlled trial. Trials 2024; 25:176. [PMID: 38468293 PMCID: PMC10926644 DOI: 10.1186/s13063-024-08017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/26/2024] [Indexed: 03/13/2024] Open
Abstract
INTRODUCTION Chronic back pain is a widespread medical condition associated with high socioeconomic costs and increasing prevalence. Despite the advanced implementation of multidisciplinary approaches, providing a satisfactory treatment offer for those affected is often not possible. Exposure therapy (EXP) promises to be an effective and economical form of treatment and in a previous pilot study showed to be superior to cognitive behavioral therapy (CBT) in reducing perceived limitations of movement. The current study aims to further compare the efficacy of both treatment methods and identify those patient groups that particularly benefit from EXP. METHODS The general objective of this randomized multicenter clinical trial (targeted N = 380) is to improve and expand the range of treatments available to patients with chronic back pain. As the primary objective of the study, two different psychological treatments (EXP and CBT) will be compared. The primary outcome measure is a clinically significant improvement in pain-related impairment, measured by the QPBDS, from baseline to 6-month follow-up. Secondary outcome measures are absolute changes and clinically significant improvements in variables coping, psychological flexibility, depressiveness, catastrophizing, exercise avoidance and fear of exercise, and intensity of pain. Participants are recruited in five psychological and medical centers in Germany and receive ten sessions of manualized therapy by trained licensed CBT therapists or clinical psychologists, who are currently in their post-gradual CBT training. Potential predictors of each treatment's efficacy will be explored with a focus on avoidance and coping behavior. CONCLUSION This study will be the first RCT to compare CBT and EXP in chronic back pain in a large sample, including patients from different care structures due to psychological and medical recruitment centers. By identifying and exploring potential predictors of symptom improvement in each treatment group, this study will contribute to enable a more individualized assignment to treatment modalities and thus improves the care situation for chronic back pain and helps to create a customized treatment program for subgroups of pain patients. If our findings confirm EXP to be an efficacious and efficient treatment concept, it should gain more attention and be further disseminated. TRIAL REGISTRATION ClinicalTrials.gov NCT05294081. Registered on 02 March 2022.
Collapse
Affiliation(s)
- Rabea Vogt
- Department of Psychology, University of Kaiserslautern-Landau (RPTU), Kaiserslautern, Germany.
| | - Julia Haas
- Department of Psychology, University of Kaiserslautern-Landau (RPTU), Kaiserslautern, Germany
| | - Lukas Baumann
- Institute of Medical Biometry (IMBI), University of Heidelberg, Heidelberg, Germany
| | - Anja Sander
- Institute of Medical Biometry (IMBI), University of Heidelberg, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry (IMBI), University of Heidelberg, Heidelberg, Germany
| | - Jenny Riecke
- Department of Clinical Psychology and Psychotherapy, Philipps - University of Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps - University of Marburg, Marburg, Germany
| | - Ulrike Bingel
- Department of Neurology, Center for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University Duisburg Essen, Essen, Germany
| | - Dustin Maser
- Department of Neurology, Center for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University Duisburg Essen, Essen, Germany
| | - Michael Witthöft
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jens Keßler
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Marco Richard Zugaj
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Beate Ditzen
- Institute of Medical Psychology, Center for Psychosocial Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Julia Anna Glombiewski
- Department of Psychology, University of Kaiserslautern-Landau (RPTU), Kaiserslautern, Germany
| |
Collapse
|
7
|
Zhou LP, Zhang RJ, Shang J, Kang L, Zhang ZG, Zhang B, Wang JQ, Jia CY, Zhao CH, Zhang HQ, Zhang XL, Shen CL. Comparative effectiveness of nonpharmacological interventions in reducing psychological symptoms among patients with chronic low back pain. Int J Surg 2024; 110:478-489. [PMID: 37755380 PMCID: PMC10793751 DOI: 10.1097/js9.0000000000000798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVES Chronic low back pain (CLBP) can seriously impair the quality of life of patients and has a remarkable comorbidity with psychological symptoms, which, in turn, can further exacerbate the symptoms of CLBP. Psychological treatments are critical and nonnegligent for the management of CLBP, and thus, should attract sufficient attention. However, current evidence does not suggest the superiority and effectiveness of nonpharmacological interventions in reducing psychological symptoms among patients with CLBP.Thus, this study was designed to compare the effectiveness of nonpharmacological interventions for depression, anxiety, and mental health among patients with CLBP and to recommend preferred strategies for attenuating psychological symptoms in clinical practice. METHODS In this systematic review and network meta-analysis (NMA), PubMed, Embase Database, Web of Science, and Cochrane Library were searched from database inception until March 2022. Randomized clinical trials (RCTs) that compare different nonpharmacological interventions for depression, anxiety, and mental health among patients with CLBP were eligible. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was used. Four reviewers in pairs and divided into two groups independently performed literature selection, data extraction, and risk of bias, and certainty of evidence assessments. This NMA was conducted with a random effects model under a frequentist framework. The major outcomes were depression, anxiety, and mental health presented as the standardized mean difference (SMD) with the corresponding 95% CI. RESULTS A total of 66 RCTs that randomized 4806 patients with CLBP met the inclusion criteria. The quality of evidence was typically low or some risks of bias (47 out of 66 trials, 71.3%), and the precision of summary estimates for effectiveness varied substantially. In addition, 7 categories of interventions with 26 specific treatments were evaluated. For depression, mind body therapy (pooled SMD = -1.20, 95% CI: -1.63 to -0.78), biopsychosocial approach (pooled SMD = -0.41, 95% CI: -0.70 to -0.12), and physical therapy (pooled SMD = -0.26, 95% CI: -0.50 to -0.02) exhibited remarkable effectiveness in reducing depression compared with the control group. For managing anxiety, mind body therapy (pooled SMD = -1.35, 95% CI: -1.90 to -0.80), multicomponent intervention (pooled SMD = -0.47, 95% CI: -0.88 to -0.06), and a biopsychosocial approach (pooled SMD = -0.46, 95% CI: -0.79 to -0.14) were substantially superior to the control group. For improving mental health, multicomponent intervention (pooled SMD = 0.77, 95% CI: 0.14 to 1.39), exercise (pooled SMD = 0.60, 95% CI: 0.08 to 1.11), and physical therapy (pooled SMD = 0.47, 95% CI: 0.02-0.92) demonstrated statistically substantial effectiveness compared with the control group. The rank probability indicated that mind body therapy achieved the highest effectiveness in reducing depression and anxiety among patients with CLBP. Besides, the combined results should be interpreted cautiously based on the results of analyses evaluating the inconsistency and certainty of the evidence. CONCLUSION This systemic review and NMA suggested that nonpharmacological interventions show promise for reducing psychological symptoms among patients with CLBP. In particular, mind body therapy and a biopsychosocial approach show considerable promise, and mind body therapy can be considered a priority choice in reducing depression and anxiety. These findings can aid clinicians in assessing the potential risks and benefits of available treatments for CLBP comorbidity with psychological symptoms and provide evidence for selecting interventions in clinical practice. More RCTs involving different interventions with rigorous methodology and an adequate sample size should be conducted in future research.
Collapse
Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Ren-Jie Zhang
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Jin Shang
- Department of Radiology, the First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Liang Kang
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Zhi-Gang Zhang
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Bo Zhang
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Jia-Qi Wang
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Chong-Yu Jia
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Chen-Hao Zhao
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Huang-Qing Zhang
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Xian-Liang Zhang
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| | - Cai-Liang Shen
- Department of Orthopedics and Spine Surgery
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University
| |
Collapse
|
8
|
Linton SJ, O'Sullivan PB, Zetterberg HE, Vlaeyen JWS. The "future" pain clinician: Competencies needed to provide psychologically informed care. Scand J Pain 2024; 24:sjpain-2024-0017. [PMID: 39119640 DOI: 10.1515/sjpain-2024-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 07/09/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND & OBJECTIVE Psychologically informed care has been proposed to improve treatment outcomes for chronic pain and aligns with a person-centered approach. Yet implementation lags behind, and studies suggest that a lack of competency leads to poor results. It is unclear what training clinicians require to deliver this care. We examine how we might improve psychologically informed care guided by the needs of the patient and in congruence with the scientific literature with a particular focus on how competencies might be upgraded and implementation enhanced. METHODS We selectively review the literature for psychologically informed care for pain. The patient's view on what is needed is contrasted with the competencies necessary to meet these needs and how treatment should be evaluated. RESULTS Patient needs and corresponding competencies are delineated. A number of multi-professional skills and competencies are required to provide psychologically informed care. Single-subject methodologies can determine whether the care has the desired effect for the individual patient and facilitate effectiveness. We argue that becoming a competent "pain clinician" requires a new approach to education that transcends current professional boundaries. CONCLUSIONS Providing person-centered care guided by the needs of the patient and in line with the scientific literature shows great potential but requires multiple competencies. We propose that training the pain clinician of the future should focus on psychologically informed care and the competencies required to meet the individual's needs. Single-subject methodology allows for continual evaluation of this care.
Collapse
Affiliation(s)
- Steven J Linton
- Center for Health and Medical Psychology, School of Behavioral, Social and Legal Sciences, Örebro University, Örebro, Sweden
| | - Peter B O'Sullivan
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Hedvig E Zetterberg
- Center for Health and Medical Psychology, School of Behavioral, Social and Legal Sciences, Örebro University, Örebro, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Johan W S Vlaeyen
- Experimental Health Psychology, Maastricht University, Maastricht, Netherlands and Health Psychology Research Group, KU Leuven, Leuven, Belgium
| |
Collapse
|
9
|
Riecke J, Rief W, Lemmer G, Glombiewski JA. Sustainability of cognitive behavioural interventions for chronic back pain: A long-term follow-up. Eur J Pain 2024; 28:83-94. [PMID: 37470301 DOI: 10.1002/ejp.2160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 02/17/2023] [Accepted: 07/05/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND There is a significant research gap with respect to the long-term sustainability of psychological treatment effects in chronic pain patients. This study aimed to investigate long-term treatment effects of two psychological treatments: cognitive behavioural therapy (CBT) as a broad-spectrum approach and exposure as a specific intervention for fear-avoidant pain patients. METHODS Patients with chronic low back pain were randomized to CBT or exposure in vivo. Long-term follow-up (LTFU) data were available for 64 patients up to 8 years after treatment, with a response rate of 73%. The primary outcomes were pain-related disability and pain intensity and secondary outcomes were emotional distress, psychological flexibility, catastrophizing and pain-related fear. The data analysis was performed with longitudinal multilevel modelling. RESULTS Multilevel analyses showed improvements in all primary outcomes as well as all secondary outcomes from pre-treatment to LTFU for both treatments. The mean proportion of cases meeting reliable and clinical improved criteria in all primary outcome was 36% (range: 22%-46%) in the exposure group and 50% (range: 33%-60%) in the CBT group. Dropout analyses revealed significantly higher deterioration rates over time. Pre-treatment to LTFU effect sizes of the primary outcomes ranged from 0.54 to 1.59. CONCLUSIONS Our results indicate that the effects of psychological treatments might be stable over several years. Treatment gains for exposure as a stand-alone treatment seem to be of shorter duration than a general CBT intervention. Thus, psychological treatments might offer a promising and sustainable long-term perspective for patients with chronic back pain. SIGNIFICANCE The long-term stability of treatment effects is a highly neglected issue despite its inherent importance in the context of chronic pain. This study is the first to investigate treatment effects of cognitive behavioural therapy and in vivo exposure in chronic back pain sufferers up to 8 years after treatment. The findings contribute to an understanding of the sustainability of psychological cognitive behavioural therapy-based intervention effects.
Collapse
Affiliation(s)
- Jenny Riecke
- Department of Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | - Gunnar Lemmer
- Department of Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | | |
Collapse
|
10
|
Ryum T, Stiles TC. Changes in pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy mediate changes in pain intensity on disability in the treatment of chronic low back pain. Pain Rep 2023; 8:e1092. [PMID: 37719924 PMCID: PMC10501475 DOI: 10.1097/pr9.0000000000001092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 05/19/2023] [Accepted: 06/10/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Treatment of chronic low back pain (CLBP) based on the fear-avoidance model (FAM) has received support in randomized controlled trials, but few studies have examined treatment processes associated with treatment outcome. This study examined changes in pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy as mediators of the relation between changes in pain intensity and disability in exposure-based treatment of CLBP. Methods Data from a randomized controlled trial with 2 treatment arms (exposure treatment based on the FAM with/without in-session exposure) was pooled, including only participants with complete data (N = 69). Change scores (pre to booster session) were computed for all variables, and the indirect effect of change in pain intensity on change in 3 measures of disability, through change in the proposed mediators, was tested in parallel mediation analyses. Results Decreases in pain catastrophizing and fear-avoidance beliefs, as well as increases in pain self-efficacy, mediated a unique proportion of the relation between changes in pain intensity and disability, depending on the outcome measure. The direct relation between changes in pain intensity and disability was absent when indirect effects were controlled. Conclusions The results suggest that the way pain is interpreted (pain catastrophizing, fear-avoidance beliefs), as well as pain self-efficacy, are all more critical for reducing disability in exposure-based treatment of CLBP than symptom relief per se.
Collapse
Affiliation(s)
- Truls Ryum
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tore C. Stiles
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
11
|
De Baets L, Meulders A, Van Damme S, Caneiro JP, Matheve T. Understanding Discrepancies in a Person's Fear of Movement and Avoidance Behavior: A Guide for Musculoskeletal Rehabilitation Clinicians Who Support People With Chronic Musculoskeletal Pain. J Orthop Sports Phys Ther 2023; 53:307–316. [PMID: 36884314 DOI: 10.2519/jospt.2023.11420] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND: Generic self-report measures do not reflect the complexity of a person's pain-related behavior. Since variations in a person's fear of movement and avoidance behavior may arise from contextual and motivational factors, a person-centered evaluation is required-addressing the cognitions, emotions, motivation, and actual behavior of the person. CLINICAL QUESTION: Most musculoskeletal rehabilitation clinicians will recognize that different people with chronic pain have very different patterns of fear and avoidance behavior. However, an important remaining question for clinicians is "How can I identify and reconcile discrepancies in fear of movement and avoidance behavior observed in the same person, and adapt my management accordingly?" KEY RESULTS: We frame a clinical case of a patient with persistent low back pain to illustrate the key pieces of information that clinicians may consider in a person-centered evaluation (ie, patient interview, self-report measures, and behavioral assessment) when working with patients to manage fear of movement and avoidance behavior. CLINICAL APPLICATION: Understanding the discrepancies in a person's fear of movement and avoidance behavior is essential for musculoskeletal rehabilitation clinicians, as they work in partnership with patients to guide tailored approaches to changing behaviors. J Orthop Sports Phys Ther 2023;53(5):1-10. Epub: 9 March 2023. doi:10.2519/jospt.2023.11420.
Collapse
|
12
|
Schemer L, Hess CW, Van Orden AR, Birnie KA, Harrison LE, Glombiewski JA, Simons LE. Enhancing Exposure Treatment for Youths With Chronic Pain: Co-design and Qualitative Approach. J Particip Med 2023; 15:e41292. [PMID: 36892929 PMCID: PMC10037174 DOI: 10.2196/41292] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/19/2022] [Accepted: 01/23/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Increasing the access to and improving the impact of pain treatments is of utmost importance, especially among youths with chronic pain. The engagement of patients as research partners (in contrast to research participants) provides valuable expertise to collaboratively improve treatment delivery. OBJECTIVE This study looked at a multidisciplinary exposure treatment for youths with chronic pain through the lens of patients and caregivers with the aim to explore and validate treatment change processes, prioritize and develop ideas for improvement, and identify particularly helpful treatment elements. METHODS Qualitative exit interviews were conducted with patients and caregivers at their discharge from 2 clinical trials (ClinicalTrials.gov NCT01974791 and NCT03699007). Six independent co-design meetings were held with patients and caregivers as research partners to establish a consensus within and between groups. The results were validated in a wrap-up meeting. RESULTS Patients and caregivers described that exposure treatment helped them better process pain-related emotions, feel empowered, and improve their relationship with each other. The research partners developed and agreed upon 12 ideas for improvement. Major recommendations include that pain exposure treatment should be disseminated more not only among patients and caregivers but also among primary care providers and the general public to facilitate an early referral for treatment. Exposure treatment should allow flexibility in terms of duration, frequency, and delivery mode. The research partners prioritized 13 helpful treatment elements. Most of the research partners agreed that future exposure treatments should continue to empower patients to choose meaningful exposure activities, break long-term goals into smaller steps, and discuss realistic expectations at discharge. CONCLUSIONS The results of this study have the potential to contribute to the refinement of pain treatments more broadly. At their core, they suggest that pain treatments should be disseminated more, flexible, and transparent.
Collapse
Affiliation(s)
- Lea Schemer
- Department of Clinical Psychology and Psychotherapy, University of Kaiserslautern-Landau, Landau, Germany
| | - Courtney W Hess
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Amanda R Van Orden
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Kathryn A Birnie
- Department of Anesthesiology, Perioperative, and Pain Medicine, Department of Community Health Sciences, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Lauren E Harrison
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Julia A Glombiewski
- Department of Clinical Psychology and Psychotherapy, University of Kaiserslautern-Landau, Landau, Germany
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| |
Collapse
|
13
|
Kavka T. Harmful or safe? Exposure and pain provocation during physiotherapy of complex regional pain syndrome I: a narrative review. J Back Musculoskelet Rehabil 2022; 36:565-576. [PMID: 36530077 DOI: 10.3233/bmr-220081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a clinical diagnosis and an umbrella term for a heterogeneous group of states associated with pain disproportionate to any inciting event, together with a number of signs and symptoms that are manifested mainly in the limbs. There are often concerns among clinicians and patients about the potential harms caused by pain provocation during physiotherapy of CRPS, even though clinical guidelines de-emphasize pain-contingency. OBJECTIVE The objective of this narrative review is to summarize current evidence regarding potential harms due to pain provocation during so-called exposure-based therapies in individuals with CRPS. METHODS Six studies evaluating exposure-based approach were included (n= 6). RESULTS Although only one included study focused primarily on safety and in the rest of the included studies the reporting of harms was insufficient and therefore our certainty in evidence is very low, taken together with outcome measures, available data does not point to any long-term deterioration in symptoms or function, or any major harms associated with pain provocation during physiotherapy of CRPS. CONCLUSION There is a great need for higher-quality studies to determine which therapeutic approach is the most appropriate for whom and to evaluate the risks and benefits of different approaches in more detail.
Collapse
|
14
|
Eckert AL, Pabst K, Endres DM. A Bayesian model for chronic pain. FRONTIERS IN PAIN RESEARCH 2022; 3:966034. [PMID: 36303889 PMCID: PMC9595216 DOI: 10.3389/fpain.2022.966034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
The perceiving mind constructs our coherent and embodied experience of the world from noisy, ambiguous and multi-modal sensory information. In this paper, we adopt the perspective that the experience of pain may similarly be the result of a probabilistic, inferential process. Prior beliefs about pain, learned from past experiences, are combined with incoming sensory information in a Bayesian manner to give rise to pain perception. Chronic pain emerges when prior beliefs and likelihoods are biased towards inferring pain from a wide range of sensory data that would otherwise be perceived as harmless. We present a computational model of interoceptive inference and pain experience. It is based on a Bayesian graphical network which comprises a hidden layer, representing the inferred pain state; and an observable layer, representing current sensory information. Within the hidden layer, pain states are inferred from a combination of priors p(pain), transition probabilities between hidden states p(paint+1∣paint) and likelihoods of certain observations p(sensation∣pain). Using variational inference and free-energy minimization, the model is able to learn from observations over time. By systematically manipulating parameter settings, we demonstrate that the model is capable of reproducing key features of both healthy- and chronic pain experience. Drawing on mathematical concepts, we finally simulate treatment resistant chronic pain and discuss mathematically informed treatment options.
Collapse
|
15
|
Eccleston C, Fisher E, Liikkanen S, Sarapohja T, Stenfors C, Jääskeläinen SK, Rice AS, Mattila L, Blom T, Bratty JR. A prospective, double-blind, pilot, randomized, controlled trial of an "embodied" virtual reality intervention for adults with low back pain. Pain 2022; 163:1700-1715. [PMID: 35324507 PMCID: PMC9393796 DOI: 10.1097/j.pain.0000000000002617] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/28/2022] [Accepted: 02/13/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Adults with chronic low back pain, disability, moderate-to-severe pain, and high fear of movement and reinjury were recruited into a trial of a novel, automated, digital therapeutics, virtual reality, psychological intervention for pain (DTxP). We conducted a 3-arm, prospective, double-blind, pilot, randomized, controlled trial comparing DTxP with a sham placebo comparator and an open-label standard care. Participants were enrolled for 6 to 8 weeks, after which, the standard care control arm were rerandomized to receive either the DTxP or sham placebo. Forty-two participants completed assessments at baseline, immediately posttreatment (6-8 weeks), 9-week, and 5-month follow-up. We found that participants in the DTxP group reported greater reductions in fear of movement and better global impression of change when compared with sham placebo and standard care post treatment. No other group differences were noted at posttreatment or follow-up. When compared with baseline, participants in the DTxP group reported lower disability at 5-month follow-up, lower pain interference and fear of movement post treatment and follow-up, and lower pain intensity at posttreatment. The sham placebo group also reported lower disability and fear of movement at 5-month follow-up compared with baseline. Standard care did not report any significant changes. There were a number of adverse events, with one participant reporting a serious adverse event in the sham placebo, which was not related to treatment. No substantial changes in medications were noted, and participants in the DTxP group reported positive gaming experiences.
Collapse
Affiliation(s)
- Christopher Eccleston
- Department for Health, Centre for Pain Research, University of Bath, Bath, United Kingdom
- Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Emma Fisher
- Department for Health, Centre for Pain Research, University of Bath, Bath, United Kingdom
- Cochrane Pain, Palliative, and Supportive Care Review Groups, Oxford University Hospitals, Oxford, United Kingdom
| | | | | | | | - Satu K. Jääskeläinen
- Department of Clinical Neurophysiology, Turku University Hospital and University of Turku, Turku, Finland
| | - Andrew S.C. Rice
- Department of Surgery and Cancer, Pain Research, Faculty of Medicine, Imperial College, London, United Kingdom
| | | | - Taru Blom
- Orion Corporation Orion Pharma, R&D, Espoo, Finland
| | | |
Collapse
|
16
|
The impact of comorbid spinal pain in depression on work participation and clinical remission following brief or short psychotherapy. Secondary analysis of a randomized controlled trial with two-year follow-up. PLoS One 2022; 17:e0273216. [PMID: 35994437 PMCID: PMC9394798 DOI: 10.1371/journal.pone.0273216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/08/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives This explorative study analyses the influence of baseline comorbid long-lasting spinal pain (CSP) on improvement of long term work participation and clinical remission of mental health illness following either brief coping-focussed or short-term psychotherapy for depression. Whether type of treatment modifies outcome with or without CSP is also analysed. Design A secondary post hoc subgroup analysis of a pragmatic randomised controlled trial. Interventions Brief or standard short psychotherapy. Methods Based on baseline assessment, the sample was subdivided into a subgroup with and a subgroup without CSP. Work participation and clinical remission of depression and anxiety were assessed as treatment outcome at two-year follow-up. Simple and multivariate logistic regression analyses, across the intervention arms, were applied to evaluate the impact of CSP on treatment outcome. Selected baseline variables were considered as potential confounders and included as variates if relevant. The modifying effect of CSP on treatment outcome was evaluated by including intervention modality as an interaction term. Main results Among the 236 participants with depressive symptoms, 83 participants (35%) were identified with CSP. In simple logistic regression analysis, CSP reduced improvements on both work participation and clinical remission rate. In the multivariate analysis however, the impact of CSP on work participation and on clinical remission were not significant after adjusting for confounding variables. Reduction of work participation was mainly explained by the higher age of the CSP participants and the reduced clinical remission by the additional co-occurrence of anxiety symptoms at baseline. The occurrence of CSP at baseline did not modify long term outcome of brief compared to short psychotherapy. Conclusions CSP at baseline reduced work participation and worsened remission of mental health symptoms two-year following psychotherapy. Older age and more severe baseline anxiety are associated to reduced effectiveness. Type of psychotherapy received did not contribute to differences.
Collapse
|
17
|
Hybelius J, Gustavsson A, Af Winklerfelt Hammarberg S, Toth-Pal E, Johansson R, Ljótsson B, Axelsson E. A unified Internet-delivered exposure treatment for undifferentiated somatic symptom disorder: single-group prospective feasibility trial. Pilot Feasibility Stud 2022; 8:149. [PMID: 35854392 PMCID: PMC9294766 DOI: 10.1186/s40814-022-01105-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/24/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Exposure-based psychological treatment appears to have beneficial effects for several patient groups that commonly report distress related to persistent somatic symptoms. Yet exposure-based treatment is rarely offered in routine care. This may be because existing treatment protocols have been developed for specific symptom clusters or specific unwanted responses to somatic symptoms, and many clinics do not have the resources to offer all these specialised treatments in parallel. In preparation for a randomised controlled trial, we investigated the feasibility of a new and unified Internet-delivered exposure treatment (OSF.io: cnbwj) for somatic symptom disorder regardless of somatic symptom domain (e.g. cardiopulmonary, fatigue, gastrointestinal, pain), combination of unwanted emotions (e.g. anger, anxiety, fear, shame) and whether somatic symptoms are medically explained or not. We hypothesised that a wide spectrum of subgroups would show interest, that the treatment would be rated as credible, that adherence would be adequate, that the measurement strategy would be acceptable and that there would be no serious adverse events. METHODS Single-group prospective cohort study where 33 self-referred adults with undifferentiated DSM-5 somatic symptom disorder took part in 8 weeks of unified Internet-delivered exposure treatment delivered via a web platform hosted by a medical university. Self-report questionnaires were administered online before treatment, each week during treatment, post treatment and 3 months after treatment. RESULTS Participants reported a broad spectrum of symptoms. The Credibility/Expectancy mean score was 34.5 (SD = 7.0, range: 18-47). Participants completed 91% (150/165) of all modules and 97% of the participants (32/33) completed at least two exposure exercises. The average participant rated the adequacy of the rationale as 8.4 (SD = 1.5) on a scale from 0 to 10. The post-treatment assessment was completed by 97% (32/33), and 84% (27/32) rated the measurement strategy as acceptable. The Client Satisfaction Questionnaire mean score was 25.3 (SD = 4.7, range: 17-32) and no serious adverse events were reported. Reductions in subjective somatic symptom burden (the Patient Health Questionnaire 15; d = 0.90) and symptom preoccupation (the somatic symptom disorder 12; d = 1.17) were large and sustained. CONCLUSIONS Delivering a unified Internet-delivered exposure-based treatment protocol for individuals with undifferentiated somatic symptom disorder appears to be feasible. TRIAL REGISTRATION ClinicalTrials.gov, NCT04511286 . Registered on August 13, 2020.
Collapse
Affiliation(s)
- Jonna Hybelius
- Department of Psychology, Stockholm University, Stockholm, Sweden
- Liljeholmen Primary Health Care Center, Region Stockholm, Liljeholmstorget 7, Stockholm, 117 63, Sweden
- Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Anton Gustavsson
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Sandra Af Winklerfelt Hammarberg
- Liljeholmen Primary Health Care Center, Region Stockholm, Liljeholmstorget 7, Stockholm, 117 63, Sweden
- Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Eva Toth-Pal
- Liljeholmen Primary Health Care Center, Region Stockholm, Liljeholmstorget 7, Stockholm, 117 63, Sweden
- Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Robert Johansson
- Department of Psychology, Stockholm University, Stockholm, Sweden
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erland Axelsson
- Liljeholmen Primary Health Care Center, Region Stockholm, Liljeholmstorget 7, Stockholm, 117 63, Sweden.
- Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden.
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
18
|
Meijer S, van Middendorp H, Peerdeman KJ, Evers AWM. Counterconditioning as Treatment to Reduce Nocebo Effects in Persistent Physical Symptoms: Treatment Protocol and Study Design. Front Psychol 2022; 13:806409. [PMID: 35774946 PMCID: PMC9237388 DOI: 10.3389/fpsyg.2022.806409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 05/17/2022] [Indexed: 11/24/2022] Open
Abstract
Persistent physical symptoms have a high prevalence and a large impact for patients and society. To date, treatment effects for these symptoms are often limited. Nocebo effects (i.e., negative outcomes that are not attributable to active treatment components) have a substantial influence on treatment success and can be established via learning through classical conditioning. Therefore, interventions aimed at reducing nocebo effects by means of counterconditioning, in which an alternative association (inhibiting the previous association) is learned, could be a promising method for improving physical symptoms. In experimental studies, counterconditioning has been shown promising in reducing experimentally-induced nocebo effects on pain and itch. Application of counterconditioning procedures to reduce nocebo effects on clinical symptoms has yet to be researched. This paper provides a protocol of a 6-week counterconditioning intervention aimed at reducing nocebo effects and clinical pain in patients with fibromyalgia. A study in patients with fibromyalgia is proposed to examine the feasibility and potential effectiveness of this counterconditioning intervention as a novel treatment method for reducing nocebo effects and generalization to clinical pain symptoms. Results can help design an optimized treatment protocol for reducing nocebo effects, based on the experiences of participants and the first indications of treatment efficacy.
Collapse
Affiliation(s)
- Simone Meijer
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
- Leiden Institute for Brain and Cognition, Leiden, Netherlands
| | - Henriët van Middendorp
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
- Leiden Institute for Brain and Cognition, Leiden, Netherlands
| | - Kaya J. Peerdeman
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
- Leiden Institute for Brain and Cognition, Leiden, Netherlands
| | - Andrea W. M. Evers
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
- Leiden Institute for Brain and Cognition, Leiden, Netherlands
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
- Medical Delta Healthy Society, Leiden University, Technical University Delft, & Erasmus University Rotterdam, Leiden, Netherlands
| |
Collapse
|
19
|
Kube T, Körfer K, Riecke J, Glombiewski JA. How expectancy violations facilitate learning to cope with pain - An experimental approach. J Psychosom Res 2022; 157:110807. [PMID: 35390722 DOI: 10.1016/j.jpsychores.2022.110807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Expectations of painful sensations constitute a core feature of chronic pain. An important clinical question is whether such expectations are revised when disconfirming experiences are made (e.g., less pain than expected). This study examined how people adjust their pain expectations when the experience of decreasing pain is expected vs. unexpected. METHODS In a novel randomized between-subjects design, a subclinical sample of people who frequently experience pain was provided with painful thermal stimulations. Unbeknownst to participants, the temperature applied was decreased from trial to trial. Based on the experimental instructions provided, this experience of decreasing pain was expected in one condition (expectation-confirmation; n = 34), whereas it was unexpected in another (expectation-disconfirmation; n = 39). RESULTS Perceived pain intensity was lower in the expectation-confirmation condition than in the expectation-disconfirmation condition (p = .014, ηp2 = 0.083). The expectation-confirmation condition also showed a greater adjustment of their pain expectations than the expectation-disconfirmation condition (p = .046, ηp2 = 0.047). Across groups, large expectation violations (i.e., less pain than expected) were associated with increases in pain tolerance and the ability to cope with pain at a one-week follow-up. CONCLUSIONS In terms of assimilation, perceived pain intensity was shaped in the direction of pain expectations. The greater adjustment of expectations in the expectation-confirming condition is consistent with a confirmation bias in pain perception. Though participants who experienced large discrepancies between expected and experienced pain were hesitant to adjust their pain expectations immediately, expectation violations increased their ability to cope with pain one week later, suggesting some beneficial longer-term effects of expectation violations.
Collapse
Affiliation(s)
- Tobias Kube
- Pain and Psychotherapy Research Lab, University of Koblenz-, Landau, Germany.
| | - Karoline Körfer
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Germany
| | - Jenny Riecke
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Germany
| | - Julia A Glombiewski
- Pain and Psychotherapy Research Lab, University of Koblenz-, Landau, Germany
| |
Collapse
|
20
|
Hein HJ, Glombiewski JA, Rief W, Riecke J. Effects of a video intervention on physicians' acceptance of pain apps: a randomised controlled trial. BMJ Open 2022; 12:e060020. [PMID: 35470200 PMCID: PMC9039411 DOI: 10.1136/bmjopen-2021-060020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The aim of our study was to determine and enhance physicians' acceptance, performance expectancy and credibility of health apps for chronic pain patients. We further investigated predictors of acceptance. DESIGN Randomised experimental trial with a parallel-group repeated measures design. SETTING AND PARTICIPANTS 248 physicians working in various, mainly outpatient settings in Germany. INTERVENTION AND OUTCOME Physicians were randomly assigned to either an experimental group (short video about health apps) or a control group (short video about chronic pain). Primary outcome measure was acceptance. Performance expectancy and credibility of health apps were secondary outcomes. In addition, we assessed 101 medical students to evaluate the effectiveness of the video intervention in young professionals. RESULTS In general, physicians' acceptance of health apps for chronic pain patients was moderate (M=9.51, SD=3.53, scale ranges from 3 to 15). All primary and secondary outcomes were enhanced by the video intervention: A repeated-measures analysis of variance yielded a significant interaction effect for acceptance (F(1, 246)=15.28, p=0.01), performance expectancy (F(1, 246)=6.10, p=0.01) and credibility (F(1, 246)=25.61, p<0.001). The same pattern of results was evident among medical students. Linear regression analysis revealed credibility (β=0.34, p<0.001) and performance expectancy (β=0.30, p<0.001) as the two strongest factors influencing acceptance, followed by scepticism (β=-0.18, p<0.001) and intuitive appeal (β=0.11, p=0.03). CONCLUSIONS AND RECOMMENDATIONS Physicians' acceptance of health apps was moderate, and was strengthened by a 3 min video. Besides performance expectancy, credibility seems to be a promising factor associated with acceptance. Future research should focus on ways to implement acceptability-increasing interventions into routine care.
Collapse
Affiliation(s)
- Hauke Jeldrik Hein
- Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Julia Anna Glombiewski
- Pain and Psychotherapy Research Lab, Department of Psychology, University of Koblenz-Landau, Landau, Germany
| | - Winfried Rief
- Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Jenny Riecke
- Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| |
Collapse
|
21
|
Gatzounis R, Meulders A. Pain and avoidance: The potential benefits of imagining your best possible self. Behav Res Ther 2022; 153:104080. [DOI: 10.1016/j.brat.2022.104080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 11/02/2022]
|
22
|
Bontinck J, den Hollander M, Kaas AL, De Jong JR, Timmers I. Individual Patterns and Temporal Trajectories of Changes in Fear and Pain during Exposure In Vivo: A Multiple Single-Case Experimental Design in Patients with Chronic Pain. J Clin Med 2022; 11:1360. [PMID: 35268453 PMCID: PMC8911417 DOI: 10.3390/jcm11051360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Exposure in vivo (EXP) is an effective treatment to reduce pain-related fear and disability in chronic pain populations. Yet, it remains unclear how reductions in fear and pain relate to each other. This single-case experimental design study attempted to identify patterns in the individual responses to EXP and to unravel temporal trajectories of fear and pain. Daily diaries were completed before, during and after EXP. Multilevel modelling analyses were performed to evaluate the overall effect. Temporal effects were scrutinized by individual regression analyses and determination of the time to reach a minimal clinically important difference. Furthermore, individual graphs were visually inspected for potential patterns. Twenty patients with chronic low back pain and complex regional pain syndrome type I were included. On a group level, both fear and pain were reduced following EXP. Individually, fear was significantly reduced in 65% of the patients, while pain in only 20%. A decrease in fear was seen mostly in the first weeks, while pain levels reduced later or remained unchanged. Daily measurements provided rich data on temporal trajectories of reductions in fear and pain. Overall, reductions in fear preceded pain relief and seemed to be essential to achieve pain reductions.
Collapse
Affiliation(s)
- Jente Bontinck
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, 9000 Ghent, Belgium;
- Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Marlies den Hollander
- Department of Rehabilitation Medicine, Maastricht University, 6211 LK Maastricht, The Netherlands; (M.d.H.); (J.R.D.J.)
- Adelante Centre of Expertise in Rehabilitation and Audiology, 6430 AB Hoensbroek, The Netherlands
| | - Amanda L. Kaas
- Department of Cognitive Neuroscience, Maastricht University, 6229 EV Maastricht, The Netherlands;
| | - Jeroen R. De Jong
- Department of Rehabilitation Medicine, Maastricht University, 6211 LK Maastricht, The Netherlands; (M.d.H.); (J.R.D.J.)
- Intergrin Academy for Specialized Healthcare, 6167 AC Geleen, The Netherlands
| | - Inge Timmers
- Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium
- Department of Rehabilitation Medicine, Maastricht University, 6211 LK Maastricht, The Netherlands; (M.d.H.); (J.R.D.J.)
| |
Collapse
|
23
|
André M, Lundberg M. Thoughts on Pain, Physical Activity, and Body in Patients With Recurrent Low Back Pain and Fear: An Interview Study. Phys Ther 2022; 102:6533384. [PMID: 35188967 DOI: 10.1093/ptj/pzab275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 08/03/2021] [Accepted: 11/07/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The purpose of this study was to explore thoughts and ideas about the body and pain in patients with nonspecific low back pain (LBP) who have a high degree of fear of movement. METHODS Patients with nonspecific LBP and a high degree of fear of movement, as measured using the Tampa Scale of Kinesiophobia, were asked to participate in the study. Individual semistructured in-depth interviews were conducted with 11 participants. The material was analyzed using content analysis with an inductive approach. RESULTS From these patients' stories, an overarching theme-decreased confidence in the body becomes a barrier to living life to the fullest-emerged. This theme was further divided into 4 subthemes: (1) "What is wrong with my body?"-the constant search for an explanation; (2) searching for the right way to move; (3) loss of mobility means a lack of meaning in life; and (4) the message from health care professionals guides feelings, thoughts, and movement behavior. CONCLUSION This study indicates that the message of keeping physically active when experiencing LBP has succeeded, but patients with fear require support to feel secure and have enough confidence in their body to move and exercise. Clinicians need to better incorporate evidence-based practice for patients with fear and support them so that they can apply an understanding of pain to their bodies and their every day life. IMPACT These results offer guidance for health care professionals to enhance their practice by providing more updated information to their patients who have recurrent LBP and fear. With better support, patients may be able to regain confidence in their bodies and live their lives to the fullest. LAY SUMMARY If you have recurrent LBP and fear of moving your body, ask your health care professional to provide you with updated knowledge on pain and to help you regain confidence in your body so that you can live your life to the fullest.
Collapse
Affiliation(s)
- Maria André
- Närhälsan Sannegården Rehabilitation Clinic, Gothenburg, Region Västra Götaland, Sweden.,Back in Motion Research Group, Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
| | - Mari Lundberg
- Back in Motion Research Group, Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden.,University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Sweden
| |
Collapse
|
24
|
Krypotos AM, Crombez G, Alves M, Claes N, Vlaeyen JWS. The exploration-exploitation dilemma in pain: an experimental investigation. Pain 2022; 163:e215-e233. [PMID: 34108434 DOI: 10.1097/j.pain.0000000000002352] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Daily life consists of a chain of decisions. Typically, individuals may choose to pursue what they already know (exploitation) or to search for other options (exploration). This exploration-exploitation dilemma is a topic of interest across multiple scientific fields. Here we propose that investigating how individuals solve this dilemma may improve our understanding of how individuals make behavioral decisions (eg, avoidance) when facing pain. To this end, we present the data of 3 experiments in which healthy individuals were given the opportunity to choose between 4 different movements, with each movement being associated with different probabilities of receiving a painful outcome only (experiment 1) or pain and/or a reward (experiment 2). We also investigated whether participants stuck to their decisions when the contingencies between each movement and the painful/rewarding outcome changed during the task (experiment 3). The key findings across all experiments are the following: First, after initial exploration, participants most often exploited the safest option. Second, participants weighted rewards more heavily than receiving pain. Finally, after receiving a painful outcome, participants were more inclined to explore than to exploit a rewarding movement. We argue that by focusing more on how individuals in pain solve the exploration-exploitation dilemma is helpful in understanding behavioral decision making in pain.
Collapse
Affiliation(s)
- Angelos-Miltiadis Krypotos
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
- Department of Clinical Psychology, Utrecht University
| | - Geert Crombez
- Department of Experimental-Clinical and Heath Psychology, Ghent University, Ghent, Belgium
| | - Maryna Alves
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
| | - Nathalie Claes
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
| | - Johan W S Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
- Experimental Health Psychology, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
25
|
den Hollander M, Smeets RJEM, van Meulenbroek T, van Laake-Geelen CCM, Baadjou VA, Timmers I. Exposure in Vivo as a Treatment Approach to Target Pain-Related Fear: Theory and New Insights From Research and Clinical Practice. Phys Ther 2022; 102:6515749. [PMID: 35084025 DOI: 10.1093/ptj/pzab270] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 09/21/2021] [Accepted: 11/07/2021] [Indexed: 01/07/2023]
Abstract
UNLABELLED Pain-related fear (PRF) can be a significant factor contributing to the development and maintenance of pain-related disability in individuals with persistent pain. One treatment approach to target PRF and related avoidance behavior is exposure in vivo (EXP). EXP has a long history in the field of anxiety, a field that is constantly evolving. This Perspective outlines recent theoretical advancements and how they apply to EXP for PRF, including suggestions for how to optimize inhibitory learning during EXP; reviews mechanistic work from neuroimaging supporting the targeting of PRF in people with chronic pain; and focuses on clinical applications of EXP for PRF, as EXP is moving into new directions regarding who is receiving EXP (eg, EXP in chronic secondary pain) and how treatment is provided (EXP in primary care with a crucial role for physical therapists). Considerations are provided regarding challenges, remaining questions, and promising future perspectives. IMPACT For patients with chronic pain who have elevated pain-related fear (PRF), exposure is the treatment of choice. This Perspective highlights the inhibitory learning approach, summarizes mechanistic work from experimental psychology and neuroimaging regarding PRF in chronic pain, and describes possible clinical applications of EXP in chronic secondary pain as well as in primary care.
Collapse
Affiliation(s)
- Marlies den Hollander
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, the Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Rob J E M Smeets
- Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands.,CIR Revalidatie, location Eindhoven, the Netherlands
| | - Thijs van Meulenbroek
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, the Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Charlotte C M van Laake-Geelen
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, the Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Vera A Baadjou
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, the Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Inge Timmers
- Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
26
|
Moraes ÉBD, Martins Junior FF, Silva LBD, Garcia JBS, Mattos-Pimenta CAD. Self-efficacy and fear of pain to movement in chronic low back pain: an intervention developed by nurses. Rev Gaucha Enferm 2021; 42:e20200180. [PMID: 34878010 DOI: 10.1590/1983-1447.2021.20200180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 05/31/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To test the effect of interventions to chronic low back pain developed by nurses in the Program to Increase Self-efficacy and Reduce the Fear of Pain and Avoidance of Movement. METHOD Clinical trial, with 81 patients, carried out in 2016, at the Pain Outpatient Clinic in São Luís, Maranhão, Brazil. The groups received: A (education and exposure), B (education) and C (control). Chi-square, Fisher's Exact, ANOVA and Kruskal Wallis tests were performed. RESULTS Patients in groups A and B improved self-efficacy, anxiety, depression, and disability, compared to group C. The reduction in fear of pain and avoidance of movement was greater in Group A, which also showed a decrease in current pain and overall scores compared to Group B and C. CONCLUSION Education was effective in increasing the Self-Efficacy Belief. For the Belief of Fear of Pain and Avoidance of Movement and pain intensity, the association with exposure showed better results.
Collapse
Affiliation(s)
- Érica Brandão de Moraes
- Universidade Federal Fluminense (UFF), Escola de Enfermagem Aurora de Afonso Costa, Departamento de Fundamentos de Enfermagem e Administração. Niterói, Rio de Janeiro, Brasil
| | | | - Larissa Barros da Silva
- Universidade Federal do Maranhão (UFMA), Programa de Pós-graduação em Ciências da Saúde. São Luís, Maranhão, Brasil
| | - João Batista Santos Garcia
- Universidade Federal do Maranhão (UFMA), Faculdade de Medicina, Departamento de Medicina II. São Luís, Maranhão, Brasil
| | | |
Collapse
|
27
|
Feldmann M, Hein HJ, Voderholzer U, Doerr R, Hoff T, Langs G, Herzog P, Kaiser T, Rief W, Riecke J, Brakemeier EL. Cognitive Change and Relaxation as Key Mechanisms of Treatment Outcome in Chronic Pain: Evidence From Routine Care. Front Psychiatry 2021; 12:617871. [PMID: 34413794 PMCID: PMC8368979 DOI: 10.3389/fpsyt.2021.617871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 07/05/2021] [Indexed: 12/28/2022] Open
Abstract
Despite effective treatment approaches within the cognitive behavioral framework general treatment effects for chronic pain are rather small to very small. Translation from efficacy trials to naturalistic settings is questionable. There is an urgent need to improve the effectiveness of well-established treatments, such as cognitive-behavior therapy (CBT) and the investigation of mechanisms of change is a promising opportunity. We performed secondary data analysis from routine data of 1,440 chronic pain patients. Patients received CBT in a multidisciplinary setting in two inpatient clinics. Effect sizes and reliable change indices were computed for pain-related disability and depression. The associations between changes in the use of different pain coping skills (cognitive restructuring, activity despite pain, relaxation techniques and mental distraction) and changes in clinical outcomes were analyzed in structural equation models. Pre-post effect sizes range from g = 0.47 (disability) to g = 0.89 (depression). Changes in the use of cognitive restructuring, relaxation and to a lesser degree mental distraction were associated with changes in disability and depression. Effects from randomized trials can be translated to naturalistic settings. The results complement experimental research on mechanisms of change in the treatment of chronic pain and indicate an important role of cognitive change and relaxation as mechanisms of change. Our findings cautiously suggest that clinicians should optimize these processes in chronic pain patients to reduce their physical and emotional disability.
Collapse
Affiliation(s)
- Matthias Feldmann
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
- Department of Clinical Psychology and Psychotherapy, University of Greifswald, Greifswald, Germany
| | - Hauke Jeldrik Hein
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Ulrich Voderholzer
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
- Department of Psychiatry and Psychotherapy, University Hospital Munich, Munich, Germany
| | - Robert Doerr
- Schoen Clinic Berchtesgadener Land, Schönau am Königsee, Germany
| | - Thomas Hoff
- Schoen Clinic Bad Bramstedt, Bad Bramstedt, Germany
| | - Gernot Langs
- Schoen Clinic Bad Bramstedt, Bad Bramstedt, Germany
| | - Philipp Herzog
- Department of Clinical Psychology and Psychotherapy, University of Greifswald, Greifswald, Germany
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Tim Kaiser
- Department of Clinical Psychology and Psychotherapy, University of Greifswald, Greifswald, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Jenny Riecke
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Eva-Lotta Brakemeier
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
- Department of Clinical Psychology and Psychotherapy, University of Greifswald, Greifswald, Germany
| |
Collapse
|
28
|
Timmers I, van de Ven VG, Vlaeyen JW, Smeets RJ, Verbunt JA, de Jong JR, Kaas AL. Corticolimbic Circuitry in Chronic Pain Tracks Pain Intensity Relief Following Exposure In Vivo. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2021; 1:28-36. [PMID: 36324433 PMCID: PMC9616294 DOI: 10.1016/j.bpsgos.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 12/28/2022] Open
Abstract
Background A subset of patients with chronic pain who receive exposure in vivo (EXP) treatment experience clinically relevant relief of pain intensity. Although pain relief is not an explicit therapeutic target, it is important to understand how and why this concomitant effect occurs in some patients but not others. This longitudinal study therefore aimed to characterize brain plasticity as well as to explore pretreatment factors related to pain relief. Methods Resting-state functional magnetic resonance imaging data were acquired in 30 patients with chronic pain. Twenty-three patients completed EXP, and 6-month follow-up data were available in 20 patients (magnetic resonance imaging data in 17 patients). Pain-free control data were acquired at two time points (n = 29, n = 21). Seed-based resting-state functional connectivity (rsFC) analyses were performed, with seeds in the amygdala, hippocampus, and nucleus accumbens. Results Pain relief after EXP was highly variable, with 60% of patients reporting a clinically relevant improvement. Amygdala rsFC with the middle frontal gyrus decreased significantly over time in patients but was not associated with pain relief. In contrast, greater pain relief was associated with greater decreases over time in hippocampus rsFC with the precuneus, which was related to reductions in catastrophizing (EXP therapeutic target) as well. Greater pain relief was also associated with lower pretreatment rsFC between nucleus accumbens and postcentral gyrus. Conclusions While changes in hippocampus rsFC were associated with pain relief after EXP, pretreatment nucleus accumbens rsFC showed potential prognostic value. Our findings further support the importance of corticolimbic circuitry in chronic pain, emphasizing its relation to pain relief and identifying potential underlying mechanisms and prognostic factors, warranting further testing in independent samples.
Collapse
|
29
|
Optimizing Long-term Outcomes of Exposure for Chronic Primary Pain from the Lens of Learning Theory. THE JOURNAL OF PAIN 2021; 22:1315-1327. [PMID: 34029684 DOI: 10.1016/j.jpain.2021.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 01/04/2023]
Abstract
Exposure in vivo is a theory-driven and widely used treatment to tackle functional disability in people with chronic primary pain. Exposure is quite effective; yet, in line with exposure outcomes for anxiety disorders, a number of patients may not profit from it, or relapse. In this focus article, we critically reflect on the current exposure protocols in chronic primary pain, and provide recommendations on how to optimize them. We propose several adaptations that are expected to strengthen inhibitory learning and/or retrieval of the extinction memory, thus likely decreasing relapse. We summarize the limited, but emerging experimental data in the pain domain, and draw parallels with experimental evidence in the anxiety literature. Our reflections and suggestions pertain to the use of the fear hierarchy, reassurance, positive psychology interventions, exposure with a range of stimuli and within different contexts, and the use of safety behaviors during treatment, as well as associating the fear-inducing stimuli with novel outcomes. In addition, we reflect on the importance of specifically tackling (the return of) pain-related avoidance behavior with techniques such as disentangling fear from avoidance and reinforcing approach behaviors. Finally, we discuss challenges in the clinical application of exposure to improve functioning in chronic primary pain and possible avenues for future research. Perspectives: Inspired by recent advances in learning theory and its applications on the treatment of anxiety disorders, we reflect on the delivery of exposure treatment for chronic primary pain and propose strategies to improve its long-term outcomes.
Collapse
|
30
|
Predicting pain: differential pain thresholds during self-induced, externally induced, and imagined self-induced pressure pain. Pain 2021; 162:1539-1544. [PMID: 33252451 PMCID: PMC8054540 DOI: 10.1097/j.pain.0000000000002151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/17/2020] [Indexed: 12/23/2022]
Abstract
Supplemental Digital Content is Available in the Text. Imagining pressure pain to be self-induced led to increased pressure pain thresholds. Such sensory attenuation of pain was also seen in actual self-induced pressure. During self-induced pain, a copy of the motor information from the body's own movement may help predict the painful sensation and cause downregulation of pain. This phenomenon, called sensory attenuation, enables the distinction between self-produced stimuli vs stimuli produced by others. Sensory attenuation has been shown to occur also during imagined self-produced movements, but this has not been investigated for painful sensations. In the current study, the pressure pain thresholds of 40 healthy participants aged 18 to 35 years were assessed when pain was induced by the experimenter (other), by themselves (self), or by the experimenter while imagining the pressure to be self-induced (imagery). The pressure pain was induced on the participants left lower thigh (quadriceps femoris) using a handheld algometer. Significant differences were found between all conditions: other and self (P < 0.001), other and imagery (P < 0.001), and self and imagery (P = 0.004). The mean pressure pain threshold for other was 521.49 kPa (SE = 38.48), for self 729.57 kPa (SE = 32.32), and for imagery 618.88 kPa (SE = 26.67). Thus, sensory attenuation did occur both in the self condition and the imagery condition. The results of this study may have clinical relevance for understanding the mechanisms involved in the elevated pain thresholds seen in patients with self-injury behavior and the low pain thresholds seen in patients with chronic pain conditions. Imagery of sensory attenuation might also be used to alleviate the pain experience for patients undergoing procedural pain.
Collapse
|
31
|
Behavioral Test (BAT-Back): Preliminary Evidence for a Successful Predictor of Treatment Outcome After Exposure Treatment for Chronic Low Back Pain. Clin J Pain 2021; 37:265-269. [PMID: 33555697 DOI: 10.1097/ajp.0000000000000920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 01/19/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although several questionnaires assessing fear of movement exist, it is still a challenge to identify individuals who might benefit more from exposure for chronic pain than from other psychological approaches and vice versa. Psychological approaches to chronic pain cannot advance toward the often called-for "tailored approaches" because of limited knowledge about treatment predictors. Our aim was to evaluate the additional predictive value of avoidance behavior based on behavioral observation. METHODS This study examined pretreatment self-report and behavioral measures as predictors of treatment outcome for n=43 patients experiencing disabling chronic low back pain, who took part in a randomized controlled trial in which they received 10 to 15 sessions of exposure treatment. Only patients with elevated fear avoidance based on self-report measures were included. Data were analyzed using regression analyses and classification and regression trees. RESULTS Regression analyses showed that higher avoidance behavior at pretreatment as measured by the Behavioral Avoidance Test-Back Pain (BAT-Back) significantly predicted reduction in global disability (with a small to medium effect), but not in specific disability. Self-report measures failed to predict treatment success for both outcome measures. Classification and regression trees divide subgroups who might benefit from exposure treatment through a BAT-Back score of >22 for Pain Disability Index. DISCUSSION There is some preliminary evidence that pretreatment avoidance behavior might be an indicator for reduction in global disability after exposure treatments in patients experiencing disabling chronic low back pain and elevated fear avoidance. We identified preliminary cutoff scores that need further investigation.
Collapse
|
32
|
Abstract
Purpose of Review Chronic pain is a widespread public and physical health crisis, as it is one of the most common reasons adults seek medical care and accounts for the largest medical reason for disability in the USA (Glombiewski et al., J Consult Clin Psychol. 86(6):533-545, 2018; Schemer et al., Eur J Pain. 23(3):526-538, 2019). Chronic pain is associated with decreased functional status, opioid dependence and substance abuse disorders, mental health crises, and overall lower perceived quality of life (Korff et al., J Pain. 17(10):1068-1080, 2016). For example, the leading cause of chronic pain and the leading cause of long-term disability is low back pain (LBP) (Bjorck-van Dijken et al. J Rehabil Med. 40:864–9, 2008). Evidence suggests that persistent low back pain (pLBP) is a multidimensional biopsychosocial problem with various contributing factors (Cherkin et al., JAMA. 315(12):1240-1249, 2016). Emotional distress, pain-related fear, and protective movement behaviors are all unhelpful lifestyle factors that previously were more likely to go unaddressed when assessing and treating patient discomfort (Pincus et al., Spine. 38:2118–23, 2013). Those that are not properly assisted with these psychosocial issues are often unlikely to benefit from treatment in the primary care setting and thus are referred to multidisciplinary pain rehabilitation physicians. This itself increases healthcare costs, and treatments can be invasive and have risks of their own. Therefore, less expensive and more accessible management strategies targeting these psychosocial issues should be started to facilitate improvement early. As a biopsychosocial disorder, chronic pain is influenced by a range of factors including lifestyle, mental health status, familial culture, and socioeconomic status. Physicians have moved toward multi-modal pain approaches in order to combat this public health dilemma, ranging from medications with several different mechanisms of action, lifestyle changes, procedural pain control, and psychological interventions (Fashler et al., Pain Res Manag. 2016:5960987, 2016). Part of the rehabilitation process now more and more commonly includes cognitive behavioral and cognitive functional therapy. Cognitive functional therapy (CFT) and cognitive behavioral therapy (CBT) are both multidimensional psychological approaches to combat the mental portion of difficult pain control. While these therapies are quite different in their approach, they lend to the idea that chronic pain can and should be targeted using coping mechanisms, helping patients understand the pathophysiological process of pain, and altering behavior. Recent Findings CFT differs from CBT functionally, as instead of improving managing/coping mechanisms of pain control from a solely mental approach, CFT directly points out maladaptive behaviors and actively challenges the patient to change them in a cognitively integrated, progressive overloading functional manner (Bjorck-van Dijken et al. J Rehabil Med. 40:864–9, 2008). This allows CFT to be targeted to each individual patient, with the goal of personalized reconceptualization of the pain response. The end goal is to overcome the barriers that prevent functional status improvement, a healthy lifestyle, and reaching their personal goals. Summary Chronic pain is a major public health issue. Cognitive functional therapy (CFT) and cognitive behavioral therapy (CBT) are both multidimensional psychological approaches to combat the mental portion of difficult pain control. While these therapies are quite different in their approach, they lend to the idea that chronic pain can and should be targeted using coping mechanisms, helping patients understand the pathophysiological process of pain, and altering behavior.
Collapse
|
33
|
Gatzounis R, van Vliet C, Meulders A. Will that hurt? A contingency learning task to assess pain-expectancy judgments for low back postures. J Behav Ther Exp Psychiatry 2021; 70:101622. [PMID: 33129131 DOI: 10.1016/j.jbtep.2020.101622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 10/02/2020] [Accepted: 10/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Contingency learning, i.e. learning that a cue predicts the presence (or absence) of an event, is central to the formation of beliefs regarding painfulness of body postures. Such beliefs may spread to safe cues due to compromised learning (e.g., excessive generalization, impaired safety learning), prompting avoidance and leading to disability. Despite its importance, compromised learning about low back pain is underinvestigated. We propose a low back pain scenario contingency learning task for the investigation of back pain-related learning. METHODS Sixty healthy participants viewed pictures of an avatar in various back postures, and for each posture gave pain-expectancy judgments and viewed the verbal outcome (pain/no pain) for a fictive back pain patient. During acquisition, one posture was followed by pain (conditioned stimulus; CS+), whereas another was not (CS-). During generalization, unreinforced novel intermediate back postures (generalization stimuli; GSs) were tested. During extinction, only the CSs were presented, not followed by pain. During generalization of extinction, only the GSs were presented, not followed by pain. RESULTS Participants expected pain more for the CS + than the CS- (differential acquisition) and generalized their pain-expectancy to the GS most similar to the CS+ (generalization). During extinction, pain-expectancy for the CS + decreased and generalized to the GS most similar to the CS+ (generalization of extinction). LIMITATIONS Future research should investigate generalizability of findings to clinical samples and consider the role of pre-existing pain threat beliefs. CONCLUSIONS This task is an easily applicable, non-invasive way to investigate the formation of back pain-related threat beliefs.
Collapse
Affiliation(s)
- Rena Gatzounis
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands.
| | - Christine van Vliet
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands; Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
| | - Ann Meulders
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands; Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
| |
Collapse
|
34
|
Emmerich AC, Friehs T, Crombez G, Glombiewski JA. Self-compassion predicting pain, depression and anger in people suffering from chronic pain: A prospective study. Eur J Pain 2021; 24:1902-1914. [PMID: 33448520 DOI: 10.1002/ejp.1638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/15/2020] [Accepted: 07/25/2020] [Indexed: 01/05/2023]
Abstract
Self-compassion is associated with disability, pain-related anxiety as well as depression and anger in patients with chronic pain. However, the unique value of self-compassion versus other concepts such as psychological flexibility and self-esteem is unknown. The present study therefore aimed to clarify these relationships. Individuals with chronic pain (NCP = 872) and without chronic pain (NNP = 356) took part in a longitudinal study. Participants completed self-report instruments: Pain Disability Index (PDI), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptom Scale (PASS-20), Patient Health Questionnaire (PHQ-9), State Trait Anger Expression Inventory (STAXI), Self-Compassion Scale (SCS), Psychological Inflexibility in Pain Scale (PIPS) and Rosenberg Self-Esteem Scale (RSES). Assessments were repeated after 8 weeks. We found differences in baseline levels of all relevant variables except for anger-out and anger-control between people with and without chronic pain. Subsequently, we computed a path model analysis regarding individuals suffering from chronic pain (NCP), addressing the predictive value of reduced uncompassionate self-responding (RUS), compassionate self-responding (CS), avoidance (PIPS), cognitive fusion (PIPS) and self-esteem (RSES) regarding pain-related (PDI, PCS, PASS) and emotional variables (PHQ-9, STAXI). Avoidance predicted disability, catastrophizing, anxiety and depression. RUS predicted catastrophizing and pain-related anxiety. Self-esteem predicted depression. CS and cognitive fusion had no unique predictive value. The model explained 65.4%-72.1% of the variance in pain-related variables, 68.7% of the variance in depression and 38.7%-60.7% in the variance of anger-related variables. In conclusion, psychological flexibility, in terms of avoidance, seems to be more relevant for chronic pain than self-compassion. Future research should focus on subgroups and tailored-treatment approaches. SIGNIFICANCE: Applying a longitudinal design, this study examined the predictive value of self-compassion regarding pain, depression and anger. The relevance of self-compassion was compared to psychological flexibility and self-esteem. We can conclude that psychological flexibility, in terms of avoidance behaviour, is the most relevant predictor concerning pain.
Collapse
Affiliation(s)
- Anja Carina Emmerich
- Pain and Psychotherapy Research Lab, Department of Clinical Psychology and Psychotherapy, University Koblenz-Landau, Landau, Germany
| | - Thilo Friehs
- Pain and Psychotherapy Research Lab, Department of Clinical Psychology and Psychotherapy, University Koblenz-Landau, Landau, Germany
| | - Geert Crombez
- Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Julia Anna Glombiewski
- Pain and Psychotherapy Research Lab, Department of Clinical Psychology and Psychotherapy, University Koblenz-Landau, Landau, Germany
| |
Collapse
|
35
|
Körfer K, Schemer L, Kube T, Glombiewski JA. An Experimental Analogue Study on the "Dose-Response Relationship" of Different Therapeutic Instructions for Pain Exposures: The More, The Better? J Pain Res 2020; 13:3181-3193. [PMID: 33293855 PMCID: PMC7719044 DOI: 10.2147/jpr.s265709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/20/2020] [Indexed: 01/05/2023] Open
Abstract
Objective Novel suggestions derived from the inhibitory learning model on how to optimize exposure therapy have been debated with enthusiasm in the last few years, particularly with respect to the focus on expectancy violations. However, little is known about how this new approach directly compares to the traditional habituation rationale of exposure therapy. In the present study, we examined these two competing therapeutic instructions among healthy female participants in an experimental heat pain paradigm. Design and Methods Participants (N= 116) received a therapeutic instruction derived from either a habituation-based approach or the inhibitory learning model (expectation violation). Participants were repeatedly exposed to painful thermal stimulations until a predefined exposure goal was reached. Results The expectation violation instruction led to faster goal attainment and higher response rates than the habituation instruction. Both instructions led to increased pain tolerance in the short and long term (one-week follow-up). Conclusion Our results suggest that exposure treatments using an expectation violation instruction are especially time-effective. Although the findings from this analogue design cannot be directly generalized to populations with clinically relevant levels of chronic pain, they do point to some important theoretical and clinical implications for the treatment of pain.
Collapse
Affiliation(s)
- Karoline Körfer
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Lea Schemer
- Department of Clinical Psychology and Psychotherapy, University of Koblenz - Landau, Landau, Germany
| | - Tobias Kube
- Department of Clinical Psychology and Psychotherapy, University of Koblenz - Landau, Landau, Germany
| | - Julia A Glombiewski
- Department of Clinical Psychology and Psychotherapy, University of Koblenz - Landau, Landau, Germany
| |
Collapse
|
36
|
Ryum T, Hartmann H, Borchgrevink P, de Ridder K, Stiles TC. The effect of in-session exposure in Fear-Avoidance treatment of chronic low back pain: A randomized controlled trial. Eur J Pain 2020; 25:171-188. [PMID: 32964624 DOI: 10.1002/ejp.1659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/18/2020] [Accepted: 09/13/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Treatment based on the Fear-Avoidance (FA) model has been found to be effective with chronic low back pain (CLBP), and in-vivo exposure of fear evoking movements is proposed as a key change mechanism. Exposure tasks may be conducted in the session (in-session exposure; ISE), in other real-life situations (between sessions exposure) as part of homework assignments, or both. Utilising a randomized, controlled dismantling study design, the aim of this study was to examine the unique effects of ISE in FA-treatment of CLBP. METHODS Patients (N = 90) with CLBP as primary medical complaints were randomized to receive six sessions of either (a) FA-treatment with ISE (FA-ISE) or (b) FA-treatment without ISE (FA), allowing for between sessions exposure in both treatment groups. Patients were assessed with a large battery of outcome measures at four time-points (pre-treatment, post-treatment, after a booster-session and at 1-year follow-up) including pain intensity, pain catastrophising, self-efficacy, physical performance and quality of life. RESULTS Both treatment groups (FA-ISE, FA) demonstrated statistically significant improvements on primary and most secondary outcomes, with mostly non-significant between-group differences. CONCLUSIONS No added benefit was found for the inclusion of ISE of feared movements in FA-treatment for CLBP, delivered in a group format to participants with moderately elevated levels of fear-avoidance beliefs. Clinical trials: NCT01158339. SIGNIFICANCE This study adds to the existing research literature demonstrating FA-treatment to be effective with CLBP, but further experimental studies are needed in order to examine under what circumstances ISE of feared movements may add to positive treatment outcomes.
Collapse
Affiliation(s)
- Truls Ryum
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Helge Hartmann
- Department of Physical Medicine and Rehabilitation, Levanger Hospital, Levanger, Norway
| | - Petter Borchgrevink
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Karin de Ridder
- Department of Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium
| | - Tore C Stiles
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
37
|
Schemer L, Riecke J, Glombiewski J. Expositionstherapie bei chronischen Rückenschmerzen: Nicht ohne Verhaltensexperimente. VERHALTENSTHERAPIE 2020. [DOI: 10.1159/000510169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
38
|
Williams ACDC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2020; 8:CD007407. [PMID: 32794606 PMCID: PMC7437545 DOI: 10.1002/14651858.cd007407.pub4] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012. OBJECTIVES To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU). SEARCH METHODS We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials. SELECTION CRITERIA RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end. DATA COLLECTION AND ANALYSIS Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment. MAIN RESULTS We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned. AUTHORS' CONCLUSIONS We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.
Collapse
Affiliation(s)
- Amanda C de C Williams
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Emma Fisher
- Cochrane Pain, Palliative and Supportive Care Group, Pain Research Unit, Churchill Hospital, Oxford, UK
- Centre for Pain Research, University of Bath, Bath, UK
| | - Leslie Hearn
- Cochrane Pain, Palliative and Supportive Care Group, Pain Research Unit, Churchill Hospital, Oxford, UK
| | | |
Collapse
|
39
|
Meulders A. Fear in the context of pain: Lessons learned from 100 years of fear conditioning research. Behav Res Ther 2020; 131:103635. [DOI: 10.1016/j.brat.2020.103635] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023]
|
40
|
Moraes ÉBD, Martins Júnior FF, Mattos-Pimenta CAD. In vivo exposure for fear of pain and avoidance of movement in low back pain. Rev Bras Enferm 2020; 73:e20190125. [PMID: 32638936 DOI: 10.1590/0034-7167-2019-0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 10/12/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES to verify the effects of hierarchization and in vivo exposure for fear of pain, avoidance of movement, and anxiety in chronic low back pain. METHODS quasi-experimental study. The 27 patients who participated graded the damage associated with the movements in each of the 40 activities of daily living depicted in pictures using a scale from 0 to 100. The patients chose five out of all the activities that received a score higher than 50 to carry out the exposure. The intensities of fear and anxiety were measured before and after each exposure session. RESULTS the frequencies of the gender were equal, and the mean age was 44.9 years. The activities chosen more frequently for the exposure were shoveling (33.3%) and running (33.3%). There was reduction of fear and anxiety before and after exposure (p<0.001). CONCLUSIONS hierarchization and in vivo exposure were effective in reducing fear and anxiety.
Collapse
|
41
|
Baadjou VA, Hollander MD, Meulenbroek TV, Verbunt JA, Timmers I. Clinicians' Initial Experiences of Transition to Online Interdisciplinary Pain Rehabilitation During the Covid-19 Pandemic. JOURNAL OF REHABILITATION MEDICINE - CLINICAL COMMUNICATIONS 2020; 3:1000036. [PMID: 33884138 PMCID: PMC8008721 DOI: 10.2340/20030711-1000036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 12/23/2022]
Abstract
Objective Public health legislation during the CO-VID-19 pandemic has resulted in forced transitioning to the use of remote care in order to continue the provision of pain rehabilitation worldwide. The objective of this study was to gain insight into clinicians’ initial experiences with the provision of interdisciplinary pain rehabilitation via videoconferencing. Design Observational, cross-sectional design. Participants Twelve team members (specialists in rehabilitation medicine -MD-, psychologists, physiotherapists and occupational therapists) from a tertiary expertise centre in pain rehabilitation. Methods Quantitative and qualitative data were collected via a digital survey. Theme-based content analysis was performed for qualitative data. Results The themes that emerged were: the compulsory context; prerequisites for proper use of videoconferencing methods, which are strongly associated with the clinicians’ experiences; changes experienced in specific components of pain rehabilitation; and overarching changes experienced, including opportunities and limitations (sub-themes: therapeutic relationship, system involvement, efficiency, hands-on possibilities, interdisciplinary teamwork, and formalities). Overall, clinicians expressed moderate agreement with the statements that the quality of the pain rehabilitation programme can be maintained using videoconferencing, and that the COVID-19 pandemic offers opportunities for growth and innovation in telehealth. Conclusion It is feasible to provide valid and satisfactory pain rehabilitation via videoconferencing. This study identified facilitators and barriers to the use of videoconferencing, and great potential for integrating aspects of telehealth into standard care after the pandemic.
Collapse
Affiliation(s)
- Vera A Baadjou
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Marlies Den Hollander
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Thijs Van Meulenbroek
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Jeanine A Verbunt
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Inge Timmers
- Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
42
|
Riecke J, Rief W, Vlaeyen JW, Glombiewski JA. Generalizability of harm and pain expectations after exposure in chronic low back pain patients. Eur J Pain 2020; 24:1495-1504. [DOI: 10.1002/ejp.1604] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/10/2020] [Accepted: 05/15/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Jenny Riecke
- Department of Clinical Psychology and Psychotherapy Philipps‐University Marburg Marburg Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy Philipps‐University Marburg Marburg Germany
| | - Johan W.S. Vlaeyen
- KU Leuven Health Psychology Research GroupLeuven Belgium
- Department of Experimental Health Psychology Maastricht University Maastricht Netherlands
| | | |
Collapse
|
43
|
Abstract
Pain is considered a hardwired signal of bodily disturbance belonging to a basic motivational system that urges the individual to act and to restore the body's integrity, rather than just a sensory and emotional experience. Given its eminent survival value, pain is a strong motivator for learning. Response to repeated pain increases when harm risks are high (sensitization) and decreases in the absence of such risks (habituation). Discovering relations between pain and other events provides the possibility to predict (Pavlovian conditioning) and control (operant conditioning) harmful events. Avoidance is adaptive in the short term but paradoxically may have detrimental long-term effects. Pain and pain-related responses compete with other demands in the environment. Exposure-based treatments share the aim of facilitating or restoring the pursuit of individual valued life goals in the face of persistent pain, and further improvements in pain treatment may require a paradigm shift toward more personalized approaches.
Collapse
Affiliation(s)
- Johan W S Vlaeyen
- Research Group on Health Psychology, Faculty of Psychology and Educational Sciences, University of Leuven, 3000 Leuven, Belgium; .,Experimental Health Psychology, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Geert Crombez
- Department of Experimental-Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, Ghent University, 9000 Ghent, Belgium.,Centre for Pain Research, University of Bath, Bath BA2 7AY, United Kingdom
| |
Collapse
|
44
|
McCracken LM. Necessary components of psychological treatment for chronic pain: More packages for groups or process-based therapy for individuals? Eur J Pain 2020; 24:1001-1002. [PMID: 32227418 DOI: 10.1002/ejp.1568] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lance M McCracken
- Division of Clinical Psychology, Psychology Department, Uppsala University, Uppsala, Sweden
| |
Collapse
|
45
|
Kube T, Rozenkrantz L, Rief W, Barsky A. Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts. Clin Psychol Rev 2020; 76:101829. [PMID: 32062101 DOI: 10.1016/j.cpr.2020.101829] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 01/11/2023]
Abstract
Persistent physical symptoms (PPS) are distressing, difficult to treat, and pose a major challenge to health care providers and systems. In this article, we review two disparate bodies of literature on PPS to provide a novel integrative model of this elusive condition. First, we draw on the clinical-psychological literature on the role of expectations to suggest that people with PPS develop dysfunctional expectations about health and disease that become increasingly immune to disconfirmatory information (such as medical reassurance) through cognitive reappraisal. Second, we invoke neuroscientific predictive processing accounts and propose that the psychological process of 'cognitive immunization' against disconfirmatory evidence corresponds, at the neurobiological and computational level, to too much confidence (i.e. precision) afforded to prior predictions. This can lead to an attenuation of disconfirming sensory information so that strong priors override benign bodily signals and make people believe that something serious is wrong with the body. Combining these distinct accounts provides a unifying framework for persistent physical symptoms and shifts the focus away from their causes to the sustaining mechanisms that prevent symptoms from subsiding spontaneously. Based on this integrative model, we derive new avenues for future research and discuss implications for treating people with PPS in clinical practice.
Collapse
Affiliation(s)
- Tobias Kube
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstr. 18, 35032 Marburg, Germany; Pain and Psychotherapy Research Lab, University of Koblenz-Landau, Ostbahnstr. 10, 76829 Landau, Germany.
| | - Liron Rozenkrantz
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstr. 18, 35032 Marburg, Germany
| | - Arthur Barsky
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Psychiatry, Harvard Medical School, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
| |
Collapse
|
46
|
|
47
|
Timmers I, de Jong JR, Goossens M, Verbunt JA, Smeets RJ, Kaas AL. Exposure in vivo Induced Changes in Neural Circuitry for Pain-Related Fear: A Longitudinal fMRI Study in Chronic Low Back Pain. Front Neurosci 2019; 13:970. [PMID: 31607840 PMCID: PMC6758595 DOI: 10.3389/fnins.2019.00970] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/29/2019] [Indexed: 12/14/2022] Open
Abstract
Exposure in vivo (EXP) is a cognitive-behavioral treatment aimed at reducing pain-related fear in chronic pain, and has proven successful in reducing pain-related disability in patients with chronic low back pain (cLBP). The current longitudinal study aimed to reveal the neural correlates of changes in pain-related fear as a result of EXP. Twenty-three patients with cLBP were included in this study. Patients with cLBP underwent MRI scanning pre-treatment (pre-EXP), post-treatment (post-EXP), and 6 months after end of treatment (FU-EXP). Pain-free controls were scanned at two time points. In the scanner, participants were presented with pictures involving back-related movements, evoking pain-related fear in patients. Pre-treatment, functional MRI revealed increased activation in right posterior insula and increased deactivation in medial prefrontal cortex (mPFC) in patients compared to controls. Post-treatment, patients reported reduced fear and pre-EXP group differences were no longer present. Contrasting pre- to post- and FU-EXP in patients revealed that stimulus-evoked neural responses changed in sensorimotor as well as cognitive/affective brain regions. Lastly, exploratory analyses revealed a tendency toward an association between changes in neural activation and changes in fear ratings, including the hippocampus and temporal lobe (pre- to post-EXP changes), and mPFC and posterior cingulate cortex (pre- to FU-EXP changes). Taken together, we show evidence that neural circuitry for pain-related fear is modulated by EXP, and that changes are associated with self-reported decreases in pain-related fear.
Collapse
Affiliation(s)
- Inge Timmers
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,Department of Cognitive Neuroscience, Maastricht University, Maastricht, Netherlands.,Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, United States
| | - Jeroen R de Jong
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,Department of Rehabilitation Medicine, Maastricht University Medical Center, Maastricht, Netherlands.,Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, Netherlands
| | - Mariëlle Goossens
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
| | - Jeanine A Verbunt
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,Department of Rehabilitation Medicine, Maastricht University Medical Center, Maastricht, Netherlands.,Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, Netherlands
| | - Rob J Smeets
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,CIR Revalidatie, Zwolle/Eindhoven, Netherlands
| | - Amanda L Kaas
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, Netherlands
| |
Collapse
|
48
|
Abstract
Exposure therapy is an economical and promising psychological method for the treatment of chronic back pain, although little research has been done and its evidence needs further clarification. Exposure therapy has so far been little used in practice, which is partly due to the few published studies on this topic and partly to the uncertainty of the practitioners as to whether exposure therapy can be carried out without risk. Exposure therapy can be classified as a "tailored treatment" approach, in which patients with certain profiles (here: increased fear of movement) receive specific treatments. In this review article, the theoretical principles of exposure therapy are presented. Subsequently, possibilities for the identification of those patients suitable for exposure treatment are explained. The practical procedure is presented using a case study. The four randomized controlled trials available to date are described in detail and discussed.
Collapse
Affiliation(s)
- J A Glombiewski
- Klinische Psychologie und Psychotherapie, Fachbereich Psychologie, Universität Koblenz-Landau, Ostbahnstr. 10, 76829, Landau, Deutschland.
| |
Collapse
|
49
|
Jalali ZM, Farghadani A, Ejlali-Vardoogh M. Effect of Cognitive-Behavioral Training on Pain Self-Efficacy, Self-Discovery, and Perception in Patients with Chronic Low-Back Pain: A Quasi-Experimental Study. Anesth Pain Med 2019; 9:e78905. [PMID: 31341821 PMCID: PMC6614783 DOI: 10.5812/aapm.78905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 11/26/2018] [Accepted: 12/01/2018] [Indexed: 12/20/2022] Open
Abstract
Background Correcting false cognitions and establishing preventive behaviors in patients with chronic low-back pain can improve self-efficacy and self-discovery of these patients against the physical and psychological consequences of chronic back pain through reinforcing thoughts and constructive behaviors. Objectives This study aimed to investigate the effectiveness of cognitive-behavioral training in self-efficacy, self-discovery, and pain perception of patients with chronic low-back pain. Methods Based on a quasi-experimental design, 40 patients with chronic low-back were selected through purposive sampling and assigned into two groups of intervention (n = 20) and control (n = 20). After administering the pain self-efficacy (PSE) scale, the self-discovery scale (SDS), and the pain perception questionnaire (MPQ) to both groups, the intervention group received the cognitive-behavioral training while the control group did not receive the intervention. The post-test was performed on both groups and the data were analyzed using SPSS. Results The scores of pain self-efficacy and self-discovery (self-awareness and acceptance, commitment and attraction, transcendence and development, and personal growth) were higher in the intervention group than in the control group (P < 0.01). The highest increase with an effect size of 0.514 was related to the self-awareness and acceptance subscale. In addition, the pain assessment perception was the only reduced subscale among the other dimensions of pain perception (P < 0.01). Conclusions Psychosocial complementary therapies can provide patients suffering from chronic pain with better physical and mental conditions to have a higher quality of life.
Collapse
Affiliation(s)
- Zahra Mirbolook Jalali
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Azadeh Farghadani
- Department of Psychology, Saveh Branch, Islamic Azad university, Saveh, Iran
| | | |
Collapse
|
50
|
Meulders A. From fear of movement-related pain and avoidance to chronic pain disability: a state-of-the-art review. Curr Opin Behav Sci 2019. [DOI: 10.1016/j.cobeha.2018.12.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|