Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review

Psychological and behavioural interventions delivered by non-psychologists

Psychologically Informed Practice (PiP) is best understood as enhanced physiotherapy in which identification and management of psychological factors is central to reactivation. The PiP approach has been investigated in trials of stratified care linking psychological screening with targeted treatment, but there have been challenges in its implementation in routine musculoskeletal care. The possible reasons for this have been carefully explored and raise questions about both the adequacy of training and the feasibility of implementation of PiP in clinical practice. Recommendations are made for the further development of PiP, the management of psychological obstacles to recovery, and the role of psychologists in this process.

Online Acceptance and Commitment Therapy for Chronic Pain in an Older Adult: A Telehealth Approach Amid COVID-19

OBJECTIVES

This case study evaluates the effectiveness of online Acceptance and Commitment Therapy (ACT) for chronic pain management in an older adult, expanding on prior research (Campbell, Podugu, and Morris, 2021) by assessing its adaptation for telehealth during COVID-19.

METHODS

A 78-year-old woman with chronic pain completed a structured, eight-session ACT program delivered via telehealth. Quality of life (QoL), depression, physical activity, and ACT-specific measures were assessed at baseline, post-treatment, and across multiple phases.

RESULTS

Online ACT was associated with improvements in chronic pain and overall functioning. The participant demonstrated excellent therapy adherence, achieved clinically significant gains in physical activity, and improvement in pain. Positive outcomes were observed across key variables.

CONCLUSIONS

Online ACT is a feasible and effective approach for chronic pain management in older adults. Telehealth adaptations can enhance accessibility and treatment outcomes, addressing barriers such as mobility limitations and geographical constraints. These findings align with existing evidence supporting ACT for chronic pain in older adults.

CLINICAL IMPLICATIONS

Findings support the role of online ACT in chronic pain management for older adults, and its potential in telehealth-based interventions. Further research is needed to evaluate its long-term effectiveness and generalizability across diverse populations.

Feasibility and acceptability of a single-session perioperative acceptance and commitment therapy workshop for preventing chronic postsurgical pain: a single-arm, non-randomized pilot trial

Objective

This pilot trial evaluated the feasibility, acceptability, and preliminary effects of a single-session, group-based Acceptance and Commitment Therapy (ACT) intervention for patients undergoing spine surgery (SS) to prevent chronic postsurgical pain (CPSP).

Methods

Forty-five adults (Mage = 64 years) scheduled for SS enrolled and were asked to complete baseline questionnaires, and 28 attended a 5 h virtual ACT workshop, which focused on enhancing psychological flexibility and acceptance. Feasibility was assessed by tracking enrollment and attendance, while treatment credibility, expectancy, and helpfulness were evaluated using the Credibility and Expectancy Questionnaire (CEQ) and the Treatment Helpfulness Questionnaire (THQ). Health-related outcomes, including pain severity and interference (Brief Pain Inventory; BPI), anxiety, and depression (PROMIS-29), were measured at baseline, 1-month, 3-months, and 6-months post-surgery.

Results

Of the enrolled participants, 58% attended the workshop, all of whom completed the entire workshop. CEQ and THQ scores indicated high credibility and helpfulness immediately after the intervention and at 1-month post-surgery. Exploratory analyses examining health outcome changes following ACT during the post-surgery period revealed that pain severity and interference, depression and anxiety all decreased over time.

Discussion

These findings suggest that a single-session ACT intervention is feasible and acceptable for patients undergoing SS and may enhance both pain-related functioning and improve psychological outcomes following surgery. Future research should explore the efficacy of this approach in larger, randomized controlled trials to further establish its impact on CPSP prevention.

Positive psychology interventions can improve mental health for chronic pain patients: a systematic review and meta-analysis

OBJECTIVE

This study examines the efficacy of positive psychology interventions (PPIs) for patients with chronic pain through a systematic review and meta-analysis. PPIs are defined as strategies that involve focusing on positive emotions, thoughts, and behaviors that improve mental health by increasing mental well-being and reducing psychological distress.

DESIGN

The search was conducted using the PubMed, Scopus, PsycINFO, and Cochrane Library databases.

MAIN OUTCOME MEASURES

Subjective, psychological, and social well-being were used as indicators of mental well-being, and depression, anxiety, and stress symptoms were used as indicators of psychological distress. Results: Nine studies were included. Eight studies evaluated subjective well-being, seven evaluated depression, and three evaluated anxiety symptoms. No studies examined psychological well-being, social well-being, or stress. PPIs were found to be effective in promoting subjective well-being post-treatment (Hedges' g = 0.40; 95% CI [0.06, 0.73]) and reducing anxiety (Hedges' g = -0.32, 95% CI [-0.59, -0.06]), but no significant results were found for depression (Hedges' g = -0.23, 95% CI [-0.50, 0.04]).

CONCLUSION

The included investigations, while limited, suggest the utility of PPIs in mitigating the psychological consequences of chronic pain. Researchers and practitioners are encouraged to implement PPI practices.

Which type and dosage of mindfulness-based interventions are most effective for chronic pain? A systematic review and network meta-analysis

Chronic pain exerts an enormous personal and economic burden worldwide. While clinical trials have confirmed the benefits of mindfulness-based interventions (MBIs) in chronic pain management, knowledge on the best type and dosage remains unknown. This study aims to compare the clinical effectiveness of different MBIs on chronic pain and to identify the optimal dosage of MBIs. The primary outcome was pain intensity and secondary outcomes were physical function and depression. We applied a random-effect pairwise meta-analysis to synthesize data, and network meta-analysis to compare effectiveness among different types and dosages of MBIs. The findings were further categorized according to the partially contextualized framework. A total of 68 studies with 5,339 participants were included. Mindfulness-based stress reduction demonstrated the most promising results for improving pain intensity (SMD -0.76, 95 % CI -1.06 to -0.46, Surface Under the Cumulative Ranking Area (SUCRA) 0.75) and depression (SMD -0.77, 95 % CI -0.98 to -0.56, SUCRA 0.86), supported by moderate and high certainty of evidence, respectively. On the other hand, mindfulness-oriented recovery enhancement emerged as the most effective for enhancing physical function (SMD -1.42, 95 % CI -2.28 to -0.57, SUCRA 0.96), albeit with low certainty of evidence. An 8-week course, conducted once per week, with sessions lasting between 90 and 120 min, appeared to be the optimal dosage for addressing pain intensity, physical function, and depression. Our findings contribute to the evidence supporting the use of MBIs in chronic pain management and informing the development of evidence-based guidelines and standardizing the course structures of MBIs. Systematic review registration: PROSPERO CRD42021293938.

Using intensive longitudinal assessment to study mechanisms of the Native American pain inequity among persons experiencing depression and/or anxiety: The role of interpersonal discrimination and stress

Native Americans (NA) experience higher rates of chronic pain than other U.S. racial/ethnic groups. Our research has indicated discrimination and stress play a role in chronic pain onset. However, chronic pain research has mostly relied on retrospective reports that may be impacted by recall bias. The current study was a secondary analysis of data from 208 NA, 206 Black, 202 Latinx, and 206 non-Hispanic White (NHW) participants from an efficacy trial of a mobile health intervention for depression and anxiety. Participants were prompted to complete 6 months of twice daily ecological momentary assessments (EMAs) that included stress and pain. Discrimination was assessed at baseline. Pain EMAs were used to reduce recall bias and estimate chronic pain prevalence. Dynamic structural equation modeling assessed the impact of race/ethnicity and discrimination on stress-pain relationships, as well as pain and stress dynamics. To assess chronic pain (pain ≥3-months), participants had to complete ≥3-months of consecutive EMAs, leaving 578 participants available for primary analyses (there were no racial/ethnic differences in EMA completion). Results showed NAs had the highest rate of chronic pain that was statistically significantly higher than NHW and Black participants. Controlling discrimination eliminated the NA-NHW, but not the NA-Black, pain inequity. Moreover, a reciprocal stress-pain relationship was found and was stronger in NAs than other groups. Discrimination did not exacerbate stress-pain relationships but was associated with higher rates of chronic pain and greater pain fluctuations, regardless of race/ethnicity. These findings indicate that targeting stress and discrimination could help reduce the NA pain inequity. PERSPECTIVE: Native Americans experienced a self-reinforcing stress-pain cycle in which stress predicted future pain and pain predicted future stress. This cycle was stronger than Black, Latinx, and non-Hispanic White groups. Discrimination was associated with chronic pain but not stronger stress-pain relationships. These findings have implications for treatment.

To Move or Not to Move: Factors of Mind-Body Practice Engagement in a Population-Based Study

Background: Mind-body practices (MBPs), which include seated- (meditation) and movement-based practices (yoga, Tai Chi, qigong), have grown increasingly popular in the United States for improving mental and physical wellness. While literature has identified socioeconomic and health-related factors related to seated- and movement-MBP engagement separately, no studies have explored the factors associated with combined-MBP use. This study accordingly used Anderson's behavioral model of health service utilization to explore sociodemographic and health-related factors associated with seated-, movement-, and combined-MBP engagement among a representative adult sample in the 2017 National Health Interview Survey. Methods: Descriptive statistics were used to summarize sample characteristics. Multinomial logistic regression using survey weights examined associations between predisposing (race-ethnicity, age, geographic region, sex, sexual minority status, and marital status), enabling (educational attainment, income, having continuous health insurance coverage, and having flexible spending accounts), and needs factors (psychological distress, self-reported health, and chronic pain) with type of MBP engagement. Results: Nearly 6% (5.8%) of the U.S. adult population practiced combined-MBPs. Results also showed that educational attainment was associated with increasingly higher odds of utilizing all forms of MBPs and revealed racial-ethnic disparities in movement- and combined-MBP engagement. Combined-MBP engagement was roughly two times higher among those with moderate psychological distress (relative risk ratio [RRR] = 1.92; 95% confidence interval [CI]: 1.58-2.32; p < 0.001), severe psychological distress (RRR = 1.96; 95% CI: 1.35-2.85; p < 0.001), and chronic pain. Conclusions and Implications: Findings suggest that combined-MBPs are utilized by a significant portion of the U.S. population and that engagement has varied distribution across sociodemographic and health factors. Considering the association of combined-MBP usage with mental and physical health needs, the authors recommend that health care providers suggest combined-MBPs as an additional resource for patients with psychological distress or mild chronic pain. Future practice and research can focus on increasing accessibility to MBPs in education settings to reduce racial-ethnic disparities.

Reviewing Psychological Practices to Enhance the Psychological Resilience Process for Individuals with Chronic Pain: Clinical Implications and Neurocognitive Findings

PURPOSE OF REVIEW

Psychological practices have emerged as promising treatments for coping with chronic pain (CP) as a psychological resilience (PR) enhancer mechanism. These practices contain cognitive, behavioral and emotional modulation of pain. In this regard, classical cognitive-behavioral therapy (CBT) and current trends in CBT, including acceptance and commitment therapy and mindfulness-based practices may demonstrate significant improvements in pain perception, physical functioning, catastrophic beliefs and fear-avoidance behaviors among patients with CP. However, understanding the neurocognitive mechanisms of these practices includes challenges, such as the need to identify associated brain regions with PR to CP. Our review explored psychological practices to enhance PR as a dynamic neurocognitive process (e.g., changing affect) rather than only being a static trait.

RECENT FINDINGS

Psychological practices have promising results in improving positive outcomes for CP sufferers. To illustrate, along with superior PR scores, higher positive affect, adaptive pain beliefs, and physical functioning were reported after these practices. Conversely, lower pain catastrophizing, pain-related fear-avoidance, and self-reported pain ratings were seen as PR factors. Moreover, enhanced PR process may be associated with increased activity of the brain regions, including prefrontal cortex and orbitofrontal cortex, whereas diminished activity, reactivity, and functional connectivity in the anterior cingulate cortex, amygdala and insula. This review discusses the neurocognitive modulation of CP through psychological practices and highlights the role of enhancing the PR process for individuals with CP. As the field continues to evolve, understanding the importance of psychological practices to develop PR-related factors is crucial for increasing pain management outcomes.

Two in one: a randomized controlled trial on an internet-based intervention (Lenio) for management of both chronic pain and depressive symptoms

The high prevalence of chronic pain and comorbid depression, along with their negative impacts on individuals and society, highlights the need for accessible and effective interventions. This study examined the feasibility, efficacy, and acceptability of Lenio, an Internet-based self-help intervention, combined with the COGITO smartphone application for managing these conditions. The randomized controlled trial involved an intervention group (IG) using Lenio and COGITO, an active control group (ACG) using a transdiagnostic app, and a wait-list control group (WCG) receiving usual treatment. Lenio incorporates cognitive behavioral therapy and third-wave techniques, supported by COGITO's gamified daily exercises to enhance adherence. Across 263 participants assessed at three intervals over 16 weeks, the IG showed significant improvement in somatic-affective depressive symptoms compared to the WCG post-intervention and both control groups at follow-up. However, the ACG outperformed the IG in managing pain at post-intervention though these effects did not persist until follow-up. The interventions were well-received and feasible, with older participants benefiting more from the Lenio/COGITO combination. Lenio and COGITO could bridge gaps to conventional therapy, potentially easing pain by enhancing psychological well-being and coping strategies. Future studies should investigate tailored interventions for chronic pain and their long-term effectiveness.

Protocol

Full trial protocol can be accessed via DOI: 10.1186/s13063-023-07440-8.

Clinical trial registration

https://drks.de/register/de/trial/DRKS00026722/preview, identifier DRKS-IDDRKS00026722.

Temporomandibular disorders and mental health: shared etiologies and treatment approaches

The biopsychosocial model suggests that temporomandibular disorders (TMDs) often coexist with mental health disorders, particularly depression and anxiety, affecting a significant portion of the global population. The interplay between TMDs and mental health disorders contributes to a complex comorbidity, perpetuating a cycle of mutual influence and reinforcement. This review investigates the neurobiological mechanisms and epidemiological evidence supporting the shared etiology of TMDs and mental health disorders, exploring potential shared vulnerabilities and bidirectional causal relationships. Shared vulnerabilities between TMDs and mental health disorders may stem from genetic and epigenetic predispositions, psychosocial factors, and behavioral aspects. Inflammatory cytokines, neurotransmitters, neurotrophins, and neuropeptides play pivotal roles in both peripheral and central sensitization as well as neuroinflammation. Brain imaging studies suggest that TMDs and mental health disorders exhibit overlapping brain regions indicative of reward processing deficits and anomalies within the triple network model. Future research efforts are crucial for developing a comprehensive understanding of the underlying mechanisms and confirming the reciprocal causal effects between TMDs and mental health disorders. This review provides valuable insights for oral healthcare professionals, stressing the importance of optimizing treatment strategies for individuals dealing with concurrent TMDs and mental health issues through a personalized, holistic, and multidisciplinary approach.

Mindfulness-Based Cognitive Therapy in Clinical Practice: A Systematic Review of Neurocognitive Outcomes and Applications for Mental Health and Well-Being

Background/Objectives: This systematic review outlines the neurocognitive outcomes and mechanisms of mindfulness-based cognitive therapy (MBCT) that influence subjective well-being. MBCT is a clinical intervention that integrates cognitive therapy with mindfulness practices to prevent depression relapses and improve mental health. Methods: The review focuses on the effects of MBCT on brain structure changes, cognitive processes, and emotional regulation, which are related to improvements in subjective well-being. A total of 87 studies were included in the review to assess the effectiveness of MBCT. Results: Evidence from the studies highlights the effectiveness of MBCT in reducing symptoms of depression, anxiety, and stress. MBCT was also shown to enhance cognitive functions and emotional regulation across diverse populations. These findings point to the potential for MBCT to induce neuroplastic changes in the brain and widen the applicability of the treatment for a variety of disorders, calling for further research into long-term benefits and underlying neurobiological mechanisms. Conclusions: The review emphasizes the potential of MBCT to bring about neuroplastic changes, calling for further research into its long-term benefits and the underlying neurobiological mechanisms. This study underlines the need to incorporate multidisciplinary measures by integrating psychology and neuroscience to comprehend comprehensively the effects of MBCT.

Updates in the Management of Chronic Pancreatitis: Navigating Through Recent Advances

This article provides an up-to-date review of the management of chronic pancreatitis, highlighting advancements in medical therapy, nutritional support, endoscopic and surgical approaches, and emerging treatments. Nutritional management accentuates addressing malabsorption and nutrient deficiencies. Advances in endoscopy and parenchyma-sparing surgical techniques have opened new avenues for improved patient outcomes, with total pancreatectomy and islet autotransplantation offering the only definitive solution for selected patients. Additionally, emerging therapies, including anti-inflammatory and immune-modulating agents, show promise for future treatment options. Emphasizing a multidisciplinary approach, this review aims to equip health care professionals with a comprehensive overview of current management strategies and future directions.

Mindfulness- and acceptance-based programmes for obsessive-compulsive disorder: A systematic review and meta-analysis

Mindfulness- and acceptance-based programmes (MABPs) in the treatment of obsessive-compulsive disorder (OCD) are increasingly gaining research interest, yet a comprehensive systematic review and meta-analysis is missing. To fill this gap, we analysed 46 trials involving 2221 patients. Two independent reviewers screened records, extracted data, assessed risk of bias, and rated overall quality of evidence. MABPs were associated with large reductions in OCD-severity in between-group analysis in randomised controlled trials (k = 33; g = -.87; CI = -1.13,-.60) and within-group pre-post analysis in all MABPs (k = 49; g = -1.72; CI = -2.00,-1.44). Depressive symptoms decreased between- and within-group with a small to moderate effect, with maintained reductions at follow-up for both OCD and depression. Moderate to large pre-post improvements were also observed in anxiety, obsessive beliefs, and quality of life. MABPs did not differ from cognitive behavioural therapy and exposure and response prevention (k = 9; g=.02; CI = -.23,.26) but were superior to medication (k = 5; g = -.77; CI = -1.44,-.11) and waitlist (k = 16; g = -1.66; CI = -2.1,-1.24). Symptom reductions were observed across world regions, but to varying degrees. When combined, increases in mindfulness and psychological flexibility predicted reductions in OCD symptoms. Outcomes were not moderated by treatment duration, samples', and therapists' characteristics. MABPs can reduce OCD-severity, but further high-quality trials with long-term follow-ups are needed to confirm results.

Move, connect and go outside! A randomized controlled trial of two online interventions and analysis of helpful coping strategies in COVID-19 "homestayers"

The COVID-19 pandemic has led to a global health crisis and a significant increase in psychological distress and psychopathological symptoms. We conducted a randomized controlled trial with two online interventions derived from positive psychology (PP) and acceptance and commitment therapy (ACT) in N = 138 "homestayers" during the first lock-down period in Germany. PP exercises had a positive impact on anxiety scores, which decreased significantly during the intervention, particularly in participants without access to a garden. Direct or indirect social contact, movement/exercise, and exposure to nature were the most frequently reported helpful coping strategies. We conclude that low-threshold online interventions with a focus on positive aspects of people's lives may be helpful to support mental health during pandemic crises. From a mental health perspective, the results also reinforce the approach of countries that allow their citizens to, for example, still go for walks during periods of contact restrictions, compared to full lock-down conditions.

The multidisciplinary team in the management of chronic pain and pain-related fear: an evidence-based approach in a clinical case

PURPOSE

Pain is a complex, intimate, and subjective experience influenced by biological, psychological, and social factors. This case report investigates the effectiveness of a multidisciplinary team approach in addressing chronic pain and pain-related fear.

CASE DESCRIPTION

The case report describes a 22-year-old female who experienced anterior knee pain for seven years, despite undergoing two knee surgeries and physiotherapy without improvement. Following a comprehensive assessment, which included a detailed medical history, clinical examination, and thoughtful clinical analysis, a multidisciplinary approach was recommended. Employing an evidence-based methodology that integrated neurocognitive rehabilitation techniques, including Pain Neuroscience Education, Graded Motor Imagery, and Tactile Discrimination Training, alongside psychological rehabilitation strategies such as Mindfulness, Acceptance and Commitment Therapy, and Problem-Solving Therapy, the report presents a comprehensive in-depth rehabilitation plan exemplifying the application of this multimodal approach within a clinical setting in a patient with chronic pain. This approach is designed not to address the biomechanical aspects but to delve into the cognitive facets associated with pain perception and avoidance, as well as potential psychological factors that may be influencing the onset and persistence of symptoms.

OUTCOMES

The scores from the rating scales provided valuable insights into patient progress in pain management, functional improvement, fear of movement, and overall physical, psychological, and emotional well-being, at six months.

CONCLUSION

This case report offers valuable insights into the usefulness of this multidisciplinary and multimodal approach, highlighting its potential as an avenue in the management of chronic pain and pain-related fear.

A one-day acceptance and commitment therapy workshop for the prevention of chronic post-surgical pain and long-term opioid use following spine surgery: Protocol for a pilot feasibility randomized controlled trial

BACKGROUND

Back pain is increasingly common, leading to more spine surgeries. While most people experience pain relief and improved function after surgery, many continue to suffer from chronic post-surgical pain (CPSP) with limited functional improvement. CPSP is often treated with opioids, raising concerns about misuse, poor functional outcomes, and broader public health impacts. Therefore, perioperative interventions are needed to enhance outcomes and reduce the risk of opioid misuse after surgery.

OBJECTIVE

This article outlines a study protocol evaluating the feasibility, acceptability, and preliminary efficacy of a brief, perioperative Acceptance and Commitment Therapy (ACT) intervention aimed at improving pain and reducing opioid use after spine surgery.

DESIGN

In this pilot randomized controlled trial, participants scheduled for spine surgery (anticipated N = 100) are assigned to the ACT intervention or a treatment-as-usual group.

INTERVENTION

The ACT intervention is a 5-h, single-session, virtual workshop with a booster call two weeks post-workshop or post-surgery, whichever is later.

OUTCOME MEASURES

The primary outcome is patient-reported treatment helpfulness immediately after the intervention. Secondary outcomes include patient-reported treatment credibility and expectancy post-intervention, treatment helpfulness at 1 month post-surgery, and pain interference, pain intensity and opioid use at 1, 3, and 6 months post-surgery.

CONCLUSION

This pilot trial examines a novel, brief ACT intervention aimed at preventing CPSP and reducing opioid dependence. If successful, feasibility and preliminary efficacy results will be utilized to inform a future, full-scale randomized trial of this intervention.

Improvements in pain interference among geographically diverse adults with neurofibromatosis: Results from a fully powered randomized controlled trial

Background

Pain is prevalent among adults with neurofibromatoses (NF) and hinders quality of life. Pain management for NF is predominantly pharmacological and often ineffective. Psychosocial treatments improve pain outcomes in other chronic illness populations but have not been developed and tested in fully powered efficacy trials among adults with NF. Using data from a fully powered randomized clinical trial of an 8-week mind-body program (Relaxation Response Resiliency Program for NF [3RP-NF]) versus a health education control (HEP-NF), we examined (1) improvements in pain intensity and pain interference, and (2) mechanisms underlying improvements.

Methods

Participants (N = 210, M age = 42.6, 73.4% female) were randomized to 3RP-NF versus HEP-NF. They completed measures of pain intensity, pain interference, and putative mechanisms (eg, mindfulness, coping, and social support) at baseline, post-intervention, 6-month, and 12-month follow-ups.

Results

There was a statistically significant change in pain interference over time F(3, 537.06) = 7.21, P < .001, but not pain intensity. Neither group (3RP-NF vs. HEP-NF) nor the group-by-time interaction predicted change in pain interference. While the group-by-time interaction was not statistically significant across all time points, planned post-hoc analyses probing the interaction at specific time points revealed a statistically significant decrease in pain interference from baseline to post-intervention (P < .001), which was sustained (ie, no subsequent change) from post-intervention through 6-month (P = 1.00) and 12-month follow-ups (P = 1.00) in the 3RP-NF group. The HEP-NF group had no significant changes in pain intensity or interference over time. The association between group (3RP-NF) and decreased pain interference from baseline to post-intervention was fully mediated by change in coping over the same period.

Conclusions

Participation in the 3RP-NF is associated with sustained improvement in pain interference. Improvement occurred through increased coping.

Trial Registration

ClinicalTrials.gov Identifier: NCT03406208.

Trial Registration URL

https://clinicaltrials.gov/study/NCT03406208.

Implementation Outcomes From a Pilot Study of Mindful Awareness in Body-Oriented Therapy (MABT) as a Chronic Pain Treatment Modality in an Integrative Health Clinic

Background

As regulation of opioid prescribing evolves, primary care and pain clinics are shifting to provide non-pharmacological and interdisciplinary chronic pain care. An under-utilized but growing area of health care for chronic pain is complementary and integrative health (CIH). However, there is limited availability of CIH approaches within the health care system. Mindful Awareness in Body-Oriented Therapy (MABT) is an evidence-based mind-body therapy, with a manualized protocol, that focuses on developing interoceptive sensibility for improved self-awareness and nervous system regulation. Prior MABT research shows MABT improves self-report and physiological indicators of interoception as well as mental and physical symptoms of distress.

Methods

This pilot single-group study used a hybrid implementation-effectiveness design and mixed methods to study implementation strategies and outcomes for bringing MABT into an integrative chronic pain clinic. Administrative data, staff surveys, and focus groups were used to understand the implementation process and outcomes (see Additional files 2, 3, and 4). Descriptive statistics were used to analyze survey and administrative data. A content analysis approach was used to analyze qualitative data from focus groups.

Results

7 staff surveys were administered over the 24-month study period and showed high acceptability and appropriateness that increased over time. Adoption, feasibility, and sustainability were also high. Clinicians made 70 referrals to MABT, 56 patients scheduled a session, 41 patients completed at least one session, and 71% of these completed the protocol. Focus groups identified MABT as a therapy that filled a gap in services, particularly for patients with a lack of body awareness and high emotion dysregulation.

Conclusion

Implementation of MABT was highly successful in an integrative health clinic focused on chronic pain treatment.

ClinicalTrialsgov registration

NCT05289024 Registered March 11, 2022 https://clinicaltrials.gov/study/NCT05289024?term=NCT05289024&rank=1.

Integrating psychiatry and family medicine in the management of somatic symptom disorders: Diagnosis, collaboration, and communication strategies

Somatic symptom disorders (SSDs) present a complex interplay of physical and psychological factors, necessitating an integrative approach to diagnosis and management. This article explores the collaborative efforts between family medicine and psychiatry in addressing SSDs, emphasizing the importance of a multidisciplinary strategy for comprehensive patient care. Effective diagnosis involves recognizing the significance of both somatic symptoms and the patient's psychological response, with tools like structured clinical interviews and self-report questionnaires playing crucial roles. Management strategies include psychotherapeutic interventions such as cognitive behavioral therapy (CBT), pharmacological treatments, and lifestyle modifications, all tailored to the patient's needs. Communication strategies are vital in validating patients' experiences while addressing underlying psychiatric issues. Techniques such as active listening, biopsychosocial framing, and the teach-back method foster trust and improve treatment adherence. Cultural considerations and the use of interpreters enhance communication with diverse patient populations. Training programs for healthcare providers further improve competency in managing SSDs. This integrative approach aims to enhance patient outcomes by addressing the multifaceted nature of SSDs through collaborative care, effective communication, and comprehensive treatment planning.

Development, implementation, and acceptability of a bedside mindfulness intervention for adults with sickle cell disease

Acute and chronic pain are the most frequent complications of sickle cell disease (SCD), often severely reducing quality of life and requiring management with long-term pharmacological interventions. A biopsychosocial approach conceptualizing pain in SCD as the result of complex biological, psychological, and social factors could facilitate targeted behavioral interventions. Mindfulness is one procedure for management of pain in individuals with chronic pain/illness. The goal of the current project was to design and implement a bedside mindfulness intervention to help patients with SCD enhance self-efficacy of pain management and reduce distress. As part of a quality improvement project in SCD clinics in a large health system, we developed a bedside mindfulness intervention to be provided during infusion sessions for patients presenting for acute vaso-occlusive episodes (VOE). The approach to development and implementation involved engagement of professionals working directly with patients. Concept planning meetings with these professionals along with qualitative patient and provider feedback informed feasibility, design, and intervention application. During a quantitative phase, patients completed validated surveys items on acceptability. Interview data (N = 11) supported patient interest in mindfulness skills and highlighted a need for tailored, person-centered interventions and non-pharmacological treatment strategies. On quantitative items, participants (N = 14) liked the intervention and agreed mindfulness skills would help manage disease-related distress. Following the interventions, participants reported increased mindfulness (p = .005). While preliminary, these results provide support for the continued development of evidence-based, mindfulness-oriented services to help individuals with SCD manage pain and other psychological difficulties.

The Association Between Chronic Pain Acceptance and Pain-Related Disability: A Meta-Analysis

Chronic pain acceptance has been identified as a crucial determinant of functioning among individuals living with chronic pain. However, research examining the relationship between chronic pain acceptance and pain-related disability has revealed variability across studies. The aims of this meta-analysis were to synthesize associations between chronic pain acceptance and pain-related disability, and test the moderating influence of pain characteristics, demographic factors, and methodological variables. Searches of PubMed and PsycINFO electronic databases located 24 studies (N = 6072) reporting correlations between chronic pain acceptance and pain-related disability. Meta-analytic calculations were performed using random effects models. Results indicated a negative association between chronic pain acceptance and pain-related disability that can be characterized as moderate in magnitude (r = -.45) and was stable across pain characteristics and demographic factors. Moderator analyses suggested the association between chronic pain acceptance and pain-related disability may be sensitive to the measures used to assess these constructs. These findings underscore the role of chronic pain acceptance in pain-related disability and reinforce the clinical significance of acceptance-based approaches in enhancing functional outcomes among chronic pain patients.

Biopsychosocial rehabilitation therapy in small fiber neuropathy: research protocol to study the effect of rehabilitation treatment

Background

Small fiber neuropathy (SFN) is a chronic neuropathic pain condition that can lead to a decreased quality of life (QOL) and disability. Current pain treatment is mainly symptomatic, consisting of analgesics, with often disappointing results. There is a need for new, more effective treatment modality. Treatment based on a biopsychosocial approach on SFN-related pain may be a promising alternative. A rehabilitation treatment study protocol is presented with the following main objective: to test the effect of a tailored interdisciplinary rehabilitation treatment targeting both cognitive and psychological factors related to pain, in decreasing disability, and improving QOL in SFN.

Methods

Single-case experimental design. Ten participants with SFN will be included. Every patient will be offered a personalized program based on one of three rehabilitation treatment modules (graded activity, exposure in vivo or acceptance and commitment therapy) depending on the most prominent factor maintaining disability. Treatment will be provided for at least 8 weeks with 2 sessions a week.

Discussion/conclusion

This is the first study investigating personalized rehabilitation treatment in patients with idiopathic SFN. The findings are expected to result in an effective treatment for SFN with an increase in QOL and a decrease in disability.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05798949.

About Distress in Chronic Pain Conditions: A Pre-Post Study on the Effectiveness of a Mindfulness-Based Intervention for Fibromyalgia and Low Back Pain Patients

Chronic pain (CP) affects about 30% of the global population and poses significant challenges to individuals and healthcare systems worldwide. The interactions between physiological, psychological, and social factors are crucial in the onset and development of CP conditions. This study aimed to evaluate the effectiveness of mindfulness-based intervention, examining its impact on perceived stress (PSS), depression and anxiety (BDI-II, PGWBI/DEP, SAS, STAI Y), sleep quality (PSQI), and mindfulness abilities (MAAS) in individuals with CP. Participants (N = 89, 84.3% female) underwent one of two diagnoses [fibromyalgia (FM) or low back pain (LBP)] and took part in an MBSR intervention. The mindfulness program proved effective in reducing PSQI scores (F = 11.97; p < 0.01) over time, independently of the type of diagnosis. There was also a marginal increase in trait mindfulness as measured by MAAS (F = 3.25; p = 0.07) in both groups. A significant difference between the two groups was found for the effect on PSS: F (1,87) = 6.46; p < 0.05. Mindfulness practice also reduced anxiety in FM and depressive symptoms in LBP, indicating a reduction in psychological distress among participants. Our findings suggest that mindfulness-based interventions may offer promising avenues for personalized pain management in clinical settings.

Pain Neuroscience Education: Teaching People About Pain

Chronic pain is an ever-increasing global challenge, and few strategies have been shown to significantly alter this trajectory, and a pure pharmaceutical approach, especially opioids, is not the answer. To truly impact a person with chronic pain's life, current best-evidence supports changing their cognitions (how they think about their pain), moving more, and calming the peripheral and central nervous system, including non-pharmacological strategies. All healthcare providers, however, must use a unified strategy regardless of their professional designation, skillset, and clinical setting. One variable that spans all patient interactions is communication. All healthcare providers talk to patients, be it during informal, casual conversation or during specific medical education tied to diagnosis, prognosis, treatment, reassurance, and more. Current evidence supports teaching patients more about their pain experience, called pain neuroscience education (PNE), which has significant clinical benefits. Any provider may offer PNE, from physicians, pharmacists, therapists, psychologists, nurses, etc. Pain neuroscience education is shown to positively influence self-reported pain, disability, fear-avoidance, pain catastrophizing, movement, and healthcare utilization in patients with chronic pain. This commentary aims to introduce all healthcare providers to PNE, and how, along with non-pharmacological treatments (PNE+) have the ability to positively impact people's lives living with chronic pain.

Serious Games for Serious Pain: Development and Initial Testing of a Cognitive Behavioral Therapy Game for Patients With Advanced Cancer Pain

PURPOSE

Cancer-related pain is prevalent among people with advanced cancer. To improve accessibility and engagement with pain-cognitive behavioral therapy (pain-CBT), we developed and tested a serious game hosted within a mobile health intervention that delivers pain-CBT and pharmacologic support. The game focuses on teaching and practicing cognitive restructuring (CR), a central pain-CBT intervention component.

METHODS

The pain-CBT game was developed through partnerships with commercial and academic game developers, graphic designers, clinical experts, and patients. Patients with metastatic cancer and pain participated in iterative, semistructured interviews. They described their experience playing each level and reflected on relevance, clarity, usability, and potential changes. Content codes captured patients' suggestions and informed game refinements.

RESULTS

The final game includes five levels that prompt players to distinguish between adaptive and maladaptive thoughts that are pain- and cancer-specific. The levels vary in objective (eg, hiking and sledding), interaction type (eg, dragging and tapping), and mode of feedback (eg, audio and animation). Fourteen participants reviewed the game. Patients appreciated the pain- and cancer-specific thought examples, with a few noting that the thoughts made them feel less alone. Many stated that the game was fun, relatable, and an engaging distraction. Others noted that the game provided helpful CR practice and prompted reflection. For example, one 40-year-old woman said the game "brings [a thought] to the forefront so you can acknowledge it, and then maybe you could let it go or… do something about it."

CONCLUSION

Patients coping with cancer pain found the CR game helpful, enjoyable, and satisfactory. Serious games have the potential to increase engagement while facilitating learning and rehearsal of psychological skills for pain. Future testing will evaluate the efficacy of this serious game.

Effectiveness of psychological interventions to decrease cognitive fusion in patients with chronic pain: A systematic review and meta-analysis

OBJECTIVE

While there is sufficient evidence of Acceptance and Commitment Therapy's effectiveness in allowing patients to deal with chronic pain, the effectiveness in cognitive fusion, one of the six core components of the Psychology Flexibility Model, has yet to be established. The aim of this article is to assess whether psychological interventions decrease cognitive fusion.

METHODS

The Web of Science, SCOPUS, Medline, and PsycINFO databases were searched for primary studies up to June 2024. Studies with a cognitive fusion measure in which chronic pain patients received a psychological intervention were included. A methodological quality scale was applied to the selected studies and the average effect sizes (Hedges g) were calculated.

RESULTS

This review included 18 articles with 24 studies (19 pre-post/follow-up studies and five randomized control trials). Cognitive fusion decreased significantly after the intervention. The effect sizes were small/medium at post-test, g = -0.39, p < .001, 95% CI [-0.52, -0.26]; and medium at long-term follow-up, g = -0.55, p < .001, 95% CI [-0.74, -0.36]. A similar tendency was found for studies with RCTs at post-test, g = -0.61, p = .006, 95% CI [-1.05, -0.17], short-term follow-up, g = -0.79, p < .001, 95% CI [-1.18, -0.40] and long-term follow-up, g = -0.58, p = .003, 95% CI [-0.95, -0.20]). Moderator variables such as unemployment, gender, pain intensity, level of depression before the intervention, and duration and intervention modality were identified.

CONCLUSION

Psychological interventions tended to decrease cognitive fusion in chronic pain patients. Nonetheless, more clinical trials are needed to establish the role of cognitive fusion in psychological flexibility.

Is development and persistence of multiple physical symptoms associated with coping? A longitudinal study over a decade

OBJECTIVE

To examine the development and persistence of multiple physical symptoms (MPS) over a decade including the associations with sociodemographics and coping strategies.

METHOD

A longitudinal study of 16,405 individuals aged 20-64 years participating in the Danish Symptom Cohort (DaSC) was conducted in 2012 with follow-up data in 2022 (DaSC II). MPS were assessed according to the unifying diagnostic construct of bodily distress syndrome, and coping was measured with the Brief Approach/Avoidance Coping Questionnaire. Descriptive statistics and multivariable logistic regression analyses were performed.

RESULTS

Among individuals not having MPS in 2012, 17 % had developed MPS in 2022. Among individuals having MPS in 2012, 57 % had persistence of MPS in 2022. Individuals who developed or had persistence of MPS at follow-up were more likely to be female, have lower educational level, be immigrant, redeem antidepressants, have lower approach scores as well as higher diversion and resignation scores.

CONCLUSIONS

Individuals responding to stressful situations with low approach, high diversion, and high resignation may be at higher risk of developing MPS and have persistence of MPS. As coping can be targeted through psychotherapy, it is important to focus on maladaptive strategies, especially in high-risk groups for developing and maintaining MPS.

Outcomes of a Remotely Delivered Complementary and Integrative Health Partnered Intervention to Improve Chronic Pain and Posttraumatic Stress Disorder Symptoms: Randomized Controlled Trial

BACKGROUND

Nonpharmacological interventions for veterans are needed to help them manage chronic pain and posttraumatic stress disorder (PTSD) symptoms. Complementary and integrative health (CIH) interventions such as Mission Reconnect (MR) seek to provide veterans with the option of a partnered, self-directed intervention that teaches CIH skills remotely to support symptom management.

OBJECTIVE

The purpose of this study was to describe the physical, psychological, and social outcomes of a self-directed mobile- and web-based CIH intervention for veterans with comorbid chronic pain and PTSD and their partners and qualitatively examine their MR user experience.

METHODS

A sample of veteran-partner dyads (n=364) were recruited to participate in a mixed methods multisite waitlist control randomized controlled trial to measure physical, psychological, and social outcomes, with pain as the primary outcome and PTSD, depression, stress, sleep, quality of life, and relationships as secondary outcomes. Linear mixed models were constructed for primary and secondary patient-reported outcomes. The quantitative analysis was triangulated using qualitative interviews from a subsample of dyads (n=35) to examine participants' perceptions of their program experience.

RESULTS

Dyads were randomized to 2 groups: intervention (MR; 140/364, 38.5%) and waitlist control (136/364, 37.4%). No significant change was observed in overall pain, sleep, PTSD, quality of life, relationship satisfaction, overall self-compassion, or compassion for others. A significant reduction in pain interference in mood (P=.008) and sleep (P=.008) was observed among the veteran MR group that was not observed in the waitlist control group. We also observed a positive effect of the MR intervention on a reduction in negative affect associated with pain (P=.049), but this effect did not exceed the adjusted significance threshold (P=.01). Significant improvements were also observed for partners in the affection (P=.007) and conflict (P=.001) subdomains of the consensus and satisfaction domains. In contrast to quantitative results, qualitative data indicated that intervention impacts included improved sleep and reduced pain, anxiety, and stress and, in contrast to the survey data, overall improvement in PTSD symptoms and social relationships. Participants' overall impressions of MR highlight usability and navigation, perceptions on packaging and content, and barriers to and facilitators of MR use.

CONCLUSIONS

Adjunctive CIH-based modalities can be delivered using web and mobile apps but should be developed and tailored using established best practices. MR may be beneficial for veterans with pain and PTSD and their partners. Further pragmatic trials and implementation efforts are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/study/NCT03593772.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/13666.

Chronic Pain Psychology in Neurology Practice

OBJECTIVE

This article reviews the latest literature regarding chronic pain epidemiology and describes pain-specific psychological factors associated with the development and maintenance of chronic pain, mental health conditions that co-occur with chronic pain, and advances in the psychobehavioral treatment of chronic pain, including established treatments (ie, cognitive behavioral therapy [CBT], acceptance and commitment therapy, and mindfulness-based stress reduction) and emerging treatments (ie, pain reprocessing therapy).

LATEST DEVELOPMENTS

In addition to CBT and acceptance and commitment therapy for pain, numerous other psychological treatment modalities have been integrated into chronic pain management, including mindfulness-based stress reduction, mindfulness meditation, chronic pain self-management, relaxation response, pain neuroscience education, biofeedback, hypnosis, and, more recently, integrative psychological treatment for centralized pain. This article gives an overview of these methods and contextualizes their use within the standard psychological treatment of chronic pain.

ESSENTIAL POINTS

Guided by the biopsychosocial treatment model, pain psychologists use numerous evidence-based psychological methods to treat patients with chronic pain conditions. Familiarity with the psychological tools available for pain management will aid neurologists and their patients in navigating the psychological aspects of living with chronic pain.

Experiences of patients with chronic low back pain plus comorbid depressive symptoms in a videoconference group acceptance and commitment therapy or behavioral activation treatment for depression: a qualitative study

PURPOSE

To explore the experiences of patients with chronic low back pain (CLBP) plus comorbid depressive symptoms who received a remote synchronous videoconference group form of Acceptance and Commitment Therapy (ACT) or Behavioral Activation Treatment for Depression (BATD).

METHODS

A qualitative study (IMPACT-Q) was nested within a randomized controlled trial (RCT) designed to assess the efficacy and the cost-utility/cost-effectiveness of two therapies in the management of CLBP and depression. Fifty-five patients with CLBP plus depression were selected from the RCT. Twelve focus group sessions, each approximately 60-90 min long, were audio-recorded, transcribed verbatim, and analyzed by six coders through a thematic analysis (deductive and inductive) based on a descriptive phenomenological approach.

RESULTS

Patients perceived behavioral, affective, and cognitive improvements after completing group sessions. Overall, psychotherapy was perceived as a safe and non-judgmental place to express emotions and feel understood. The main barriers reported were lack of human contact and loss of social interaction. In contrast, ease of access, flexibility in the ability to connect from anywhere, avoidance of the need to travel, and savings in time and money were key facilitators to increase attendance and adherence to therapy.

CONCLUSION

This study provided support for the acceptability of videoconference-delivered ACT or BATD in patients with CLBP plus comorbid depressive symptoms.

Outcome Expectancies, Effects, and Mechanisms of Brief Training in Mindfulness Meditation vs. Loving-Kindness Meditation vs a Control Condition for Pain Management: A Randomized Pilot Study

This study investigated the analgesic effects of a single session of mindfulness meditation (MM) and loving-kindness meditation (LKM) relative to a control. A total of 100 adults with chronic or current problematic pain completed a survey and were randomized to a 20-minute MM, LKM, or audiobook control. Co-primary outcomes of pain intensity and unpleasantness and mediators of mindfulness and self-compassion were assessed pre- and posttraining. Expectancies were assessed pretraining. Pain type (chronic vs current problematic) was a covariate. Relative to the control, higher expectancies were reported for MM and LKM (P < .001). MM (d = 0.41, P = .032) and LKM (d = 0.38, P = .027) had medium effects on pain intensity, with greater decreases than control (d = 0.05, P = .768). All conditions had small effects on unpleasantness. Mindful observing increased more within MM (d = 0.52, P = .022) and the control (d = 0.50, P = .011) than LKM (d = 0.12, P = .50); self-compassion increased more in LKM (d = 0.36, P = .042) than MM (d = 0.27, P = .201) and the control (d = 0.22, P = .249). The mediation models were nonsignificant. Pain type was a nonsignificant covariate. Overall, MM and LKM were associated with positive expectancies and small-medium pain intensity reductions, which did not differ by pain type. Although MM and LKM were associated with changes in theorized mediators, these changes did not underlie improvement.

Mindfulness-based stress reduction (MBSR) for fibromyalgia patients: The role of pain cognitions as mechanisms of change

BACKGROUND

Fibromyalgia (FM) is a pain condition characterized by physical and psychological difficulties. This randomized controlled trial aimed to evaluate the effects of a mindfulness-based stress reduction (MBSR) on FM patients and identify the role of two pain cognitions: psychological inflexibility in pain (PIPS) and pain catastrophizing (PCS), as mechanisms of change.

METHODS

95 FM patients (Mean ± SD: 49.18 ± 13.26 years) were randomly assigned to MBSR group therapy (n = 49) or a waitlist (WL) control group (n = 46). An adapted MBSR protocol for FM was employed. A series of measures were taken, covering FM symptoms, depression, perceived stress (PSS), PIPS and PCS. Three measurements were conducted: pre-intervention, post-intervention and 6-months follow up.

RESULTS

Compared to WL controls, the MBSR group showed greater improvements in FM symptoms (F(1,78) = 2.81, p < 0.05), PSS (F(1,78) = 4.38, p < 0.05) and Depression (F(1,78) = 21.12, p < 0.001), with mostly medium effect sizes. Improvements in PSS (F(2,68) = 7.75, p < 0.05) and depression (F(2,68) = 15.68, p < 0.05) remained stable over six months. The effect of MBSR on FM and PSS was mediated by one's reported change in PIPS. The effect of MBSR on depression was mediated by one's reported change in PCS.

CONCLUSIONS

These results reveal the significant therapeutic potential of MBSR for FM patients, due to the emphasis on non-judging and acceptance of negative inner states. Furthermore, this research identified two important pain-related cognitions as mechanisms of change, suggesting that MBSR contributes to cognitive change, which enables the reduction of physical and psychological distress.

TRIAL REGISTRATION NUMBER

NCT04304664.

Meditation-Based Therapies for Chronic Neuropathy: A Systematic Review and Meta-Analysis

Mind-body therapies have been found to be effective in a variety of pathologies. The purpose of this study was to evaluate the efficacy of meditation-based therapies in relieving the symptoms severity, quality of life, stress and other associated mood conditions, in individuals with chronic neuropathy of various etiologies. A systematic review of randomized controlled trials, involving adult patients with persistent peripheral neuropathy, was performed. Seven article databases were searched. A meta-analysis was conducted to assess the benefits of meditation-based therapy on symptomatology, quality of life, anxiety, depression, perceived stress, sleep quality and mindfulness score. Ten of the 1133 reviewed papers were selected for quantitative review. The meditation group had a lower standardized mean difference (SMD) score (-0.47 (95% CI: -0.97 to 0.02), p=0.062) for neuropathic pain severity score; lower anxiety scores (-2.5 (95% CI: -3.68 to -1.32), p=<0.001); lower depression scores (-1.53 (95% CI: -2.12 to -0.93), p=<0.001); lower perceived stress (-1.06 (95% CI: -3.15 to 1.04), p=0.323); higher quality of life scores (2.19 (95% CI: -0.65 to 5.03), p=0.13); lower sleep quality scores (-1.27 (95% CI: -4.22 to 1.67), p=0.397); higher mindfulness scores (6.71 (95% CI: 4.09 to 9.33), p=<0.001); and lower pain severity at 1 to 1.5 follow up (-1.75 (95% CI: -2.98 to -0.51), p=0.006). Some of the results were characterized by a substantial, statistically significant heterogeneity. Nevertheless, a major part of the results pointed in the same direction, improving symptomatology with meditation-based therapy. The studies had a risk of bias mostly regarding the measurement of the outcome, randomization process and selection of the reported result. The current study discovered that the meditation group had significantly lower pain (at 1 to 1.5 months follow-up) anxiety, and depression scores and higher mindfulness scores at the end of the interventions.

A Qualitative Analysis of the Impact of Preoperative Mindfulness-Based Stress Reduction on Total Knee Arthroplasty Surgical Experiences

We qualitatively explored the impact of preoperative mindfulness-based stress reduction (MBSR) on total knee arthroplasty (TKA) experiences. Participants (n = 10) who received MBSR prior to TKA participated in semi-structured interviews concerning their experiences with MBSR and its perceived impact on surgery. We analyzed interviews according to reflexive thematic analysis, and coded data into three main themes: 1) Impact of MBSR on surgery experiences; 2) Contributors to change; and 3) Motivations for participation. Participants noted they were able to relax, feel more confident, and cope more effectively during the preoperative period, and that others in their lives noticed positive changes following their participation in MBSR. Participants' openness to mindfulness and health-related beliefs and may have contributed to the positive impacts they experienced from MBSR. Participants described being motivated to participate in MBSR to help them prepare for their surgery and to learn new coping strategies. Participants described a strong level of commitment to the intervention. With further research, integration of MBSR into prehabilitation for TKA may be appropriate.

Effects of Savoring Meditation on Positive Emotions and Pain-Related Brain Function: A Mechanistic Randomized Controlled Trial in People With Rheumatoid Arthritis

Positive emotions are a promising target for intervention in chronic pain, but mixed findings across trials to date suggest that existing interventions may not be optimized to efficiently engage the target. The aim of the current pilot mechanistic randomized controlled trial was to test the effects of a positive emotion-enhancing intervention called Savoring Meditation on pain-related neural and behavioral targets in patients with rheumatoid arthritis. Participants included 44 patients with a physician-confirmed diagnosis of rheumatoid arthritis (n = 29 included in functional magnetic resonance imaging (fMRI) analyses), who were randomized to either Savoring Meditation or a Slow Breathing control. Both meditation interventions were brief (four 20-minute sessions). Self-report measures were collected pre-and post-intervention. An fMRI task was conducted at post-intervention, during which participants practiced the meditation technique on which they had been trained while exposed to non-painful and painful thermal stimuli. Savoring significantly reduced experimental pain intensity ratings relative to rest (P < .001). Savoring also increased cerebral blood flow in the ventromedial prefrontal cortex and increased connectivity between the ventromedial prefrontal cortex and caudate during noxious thermal stimulation relative to Slow Breathing (z = 2.3 voxelwise, false discovery rate cluster corrected P = .05). Participants in the Savoring condition also reported significantly increased positive emotions (ps < .05) and reduced anhedonic symptoms (P < .01) from pre- to post-intervention. These findings suggest that Savoring recruits reward-enhancing corticostriatal circuits in the face of pain, and future work should extend these findings to evaluate if these mechanisms of Savoring are associated with improved clinical pain outcomes in diverse patient populations. PERSPECTIVE: Savoring Meditation is a novel positive emotion-enhancing intervention designed for patients with chronic pain. The present findings provide preliminary evidence that Savoring Meditation is acutely analgesic, and engages neural and subjective emotional targets that are relevant to pain self-management. Future work should evaluate the clinical translation of these findings.

Economic Evaluation of Videoconference Group Acceptance and Commitment Therapy and Behavioral Activation Therapy for Depression Versus Usual Care Among Adults With Chronic Low Back Pain Plus Comorbid Depressive Symptoms

Chronic pain and depression are frequently comorbid conditions associated with significant health care and social costs. This study examined the cost-utility and cost-effectiveness of videoconference-based group forms of Acceptance and Commitment Therapy (ACT) and Behavioral Activation Therapy for Depression (BATD), as a complement to treatment-as-usual (TAU), for patients with chronic low back pain (CLBP) plus depressive symptoms, compared to TAU alone. A trial-based economic evaluation (n = 234) was conducted from a governmental and health care perspective with a time horizon of 12 months. Primary outcomes were the Brief Pain Inventory-Interference Scale (BPI-IS) and Quality Adjusted Life Year. Compared to TAU, ACT achieved a significant reduction in total costs (d = .47), and BATD achieved significant reductions in indirect (d = .61) and total costs (d = .63). Significant improvements in BPI-IS (d = .73 and d = .66, respectively) and Quality Adjusted Life Year scores (d = .46 and d = .28, respectively) were found in ACT and BATD compared to TAU. No significant differences in costs and outcomes were found between ACT and BATD. In the intention-to-treat analyses, from the governmental and health care perspective, no significant differences in cost reduction and incremental effects were identified in the comparison between ACT, BATD, and TAU. However, in the complete case analysis, significant incremental effects of ACT (∆BPI-IS = -1.57 and -1.39, respectively) and BATD (∆BPI-IS = -1.08 and -1.04, respectively) compared with TAU were observed. In the per-protocol analysis, only the significant incremental effects of ACT (∆BPI-IS = -1.68 and -1.43, respectively) compared to TAU were detected. In conclusion, ACT and BATD might be efficient options in the management of CLBP plus comorbid depression symptoms as compared to usual care. However, no clear difference was found in the comparison between the 2 active therapies regarding cost-effectiveness or cost-utility. PERSPECTIVE: The economic evaluation of psychological therapies for the management of complex conditions can be used in decision-making and resource allocation. This study provides evidence that ACT and BATD are more effective and involve a greater reduction in costs than usual care in the management of CLBP plus comorbid depressive symptoms. TRIAL NUMBER: NCT04140838.

Feasibility of Web-Based Single-Session Empowered Relief in Patients With Chronic Pain Taking Methadone or Buprenorphine: Protocol for a Single-Arm Trial

BACKGROUND

Chronic pain affects tens of millions of US adults and continues to rise in prevalence. Nonpharmacologic behavioral pain treatments are greatly needed and yet are often inaccessible, particularly in settings where medication prescribing is prioritized.

OBJECTIVE

This study aims to test the feasibility of a live-instructor, web-based 1-session pain relief skills class in an underserved and potentially at-risk population: people with chronic pain prescribed methadone or buprenorphine either solely for pain or for comorbid opioid use disorder (OUD).

METHODS

This is a national, prospective, single-arm, uncontrolled feasibility trial. The trial is untethered from medical care; to enhance participants' willingness to join the study, no medical records or drug-monitoring records are accessed. At least 45 participants will be recruited from outpatient pain clinics and from an existing research database of individuals who have chronic pain and are taking methadone or buprenorphine. Patient-reported measures will be collected at 6 time points (baseline, immediately post treatment, 2 weeks, and months 1-3) via a web-based platform, paper, or phone formats to include individuals with limited internet or computer access and low literacy skills. At baseline, participants complete demographic questions and 13 study measures (Treatment Expectations, Body Pain Map, Medication Use, Pain Catastrophizing Scale [PCS], Patient-Reported Outcomes Measurement Information System [PROMIS] Measures, and Opioid Craving Scale). Immediately post treatment, a treatment satisfaction and acceptability measure is administered on a 0 (very dissatisfied) to 10 (completely satisfied) scale, with 3 of these items being the primary outcome (perceived usefulness, participant satisfaction, and likelihood of using the skills). At each remaining time point, the participants complete all study measures minus treatment expectations and satisfaction. Participants who do not have current OUD will be assessed for historical OUD, with presence of OUD (yes or no), and history of OUD (yes or no) reported separately. Feasibility threshold is set as an overall group treatment satisfaction rating of 8 of 10. In-depth qualitative interviews will be conducted with about 10 participants to obtain additional data on patient perceptions, satisfactions, needs, and wants. To assess preliminary efficacy, we will examine changes in pain catastrophizing, pain intensity, pain bothersomeness, sleep disturbance, pain interference, depression, anxiety, physical function, global impression of change, and opioid craving at 1 month post treatment.

RESULTS

This project opened to enrollment in September 2021 and completed the recruitment in October 2023. The data collection was completed in February 2024. Results are expected to be published in late 2024.

CONCLUSIONS

Results from this trial will inform the feasibility and preliminary efficacy of Empowered Relief in this population and will inform the design of a future randomized controlled trial testing web-based Empowered Relief in chronic pain and comorbid OUD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05057988; https://clinicaltrials.gov/study/NCT05057988.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53784.

Explaining the Components of Resilience in Patients with Chronic Pain: A Qualitative Content Analysis

Background

Resilience is a psychological trait and a protective factor that plays a vital role in coping with Chronic Pain (CP). Despite its importance, research has yet to fully clarify the concept and components of resilience in patients with CP. Accordingly, the present study aims to explain the components of resilience in patients with CP.

Materials and Methods

The current qualitative study used a conventional content analysis methodology. The research population included all patients with CP who were referred to clinics affiliated with Shiraz University of Medical Sciences (south of Iran) from August 2021 to August 2022. Participants were selected using the purposive sampling method. In-depth semi-structured interviews were conducted with 20 participants to collect information. Data analysis was conducted using MAXQDA 2020 software in conjunction with data collection efforts.

Results

Generally, in the current study, 30 sub-sub-categories, 11 sub-categories, and five main categories were extracted as components of resilience in patients with CP. The main categories of resilience against CP included the following: 1. emotional self-regulation, 2. psychological flexibility, 3. self-care, 4. appeal to religion-spirituality, and 5. internal resources and individual competencies.

Conclusions

The present study highlights the different physical, mental, and religious-spiritual strategies that may contribute to resilience against pain. The resilience components identified in this study provide a foundation for healthcare professionals, particularly nurses, to design and implement diverse pain management strategies that enhance adjustment to CP conditions.

Mind-body practices in chronic inflammatory arthritis

Mind-body practices are complementary approaches recognized by the World Health Organization (WHO). While these practices are very diverse, they all focus on the interaction between mind and body. These include mindful meditation, yoga, Tai Chi, sophrology, hypnosis and various relaxation techniques. There is growing interest in incorporating these strategies in the management of chronic rheumatic diseases including rheumatoid arthritis. The aim of this review is to describe the main mind-body practices and analyze the existing evidence in chronic rheumatic diseases. In rheumatoid arthritis, the Mindfulness-Based Stress Reduction program, yoga, Tai Chi and relaxation may improve patient-reported outcomes, but the benefit on inflammation and structural progression is unclear. In spondyloarthritis, very few studies are available but similar evidence exist. Further evaluations of these practices in chronic rheumatic diseases are needed since their risk/benefit ratio appears excellent.

The Role of Attentional Control in Mindfulness Intervention for Emotional Distress: A Randomized Controlled Trial With Longitudinal Mediation Analyses

OBJECTIVE

This study aimed to investigate whether attentional control serves as a mediator for mindfulness-based interventions for emotional distress, utilizing a randomized waitlist (WL)-controlled design.

METHODS

A total of 498 participants with high emotional distress was recruited online and randomly assigned to a 49-day online Mindfulness Intervention for Emotional Distress (MIED) group (N = 249) or a WL control group (N = 249). Levels of attentional control, anxiety and depression were assessed at baseline (T0), Week 3 (T3), Week 5 (T5) and Week 7 (postintervention, T7).

RESULTS

Linear mixed models revealed significant Group-by-Time interaction effects for attentional control (p < 0.001), anxiety (p < 0.001) and depression (p < 0.05). Latent growth curve analyses demonstrated a significant increase in attentional control and a decrease in anxiety and depression levels during the MIED programme. These changes becoming evident starting Week 3. Longitudinal mediation analyses revealed that the slope of attentional control significantly mediated the effects of the MIED programme on the slope of anxiety and depression levels. Further, attentional control level at Week 3 significantly mediates the effect of MIED programme on anxiety and depression levels at Weeks 5 and 7. Similarly, attentional control level at Week 5 significantly mediates the MIED programme's effects on anxiety and depression levels at Week 7.

CONCLUSIONS

The present trial provides evidence suggesting that mindfulness interventions may alleviate emotional distress through the enhancement of attentional control.

TRIAL REGISTRATION

Chinese Clinical Trial Registry number: ChiCTR2200064140.

Effects of a Brief Mindfulness-based Intervention in Patients with Psoriasis: A Randomized Controlled Trial

Mindfulness is a special type of attention, namely focusing on the current moment in a non-judgmental manner. Extensive mindfulness-based interventions have been shown to have positive effects in patients with psoriasis. However, it is unclear whether brief (2-week) interventions are also beneficial. Therefore, the aim of this study was to investigate the effects of a 2-week mindfulness-based intervention in patients with psoriasis. Patients were randomly assigned to an experimental (treatment-as-usual + mindfulness-based intervention) or control group (treatment-as-usual) during their clinic stay. All variables were measured by self-report using validated questionnaires: primary outcomes were mindfulness and self-compassion, secondary outcomes were itch catastrophizing, social anxiety, stress and skin status. Variables were assessed prior to, immediately and 3 months after the intervention. Effects were tested by repeated-measures analysis of variance (ANOVA). Analyses of pre-post-measurements (n = 39) revealed a significant interaction effect on self-reported mindfulness [F(1,35) = 7.46, p = 0.010, η2p = 0.18] and a tendency to a significant effect on self-reported self-compassion [F(1,36) = 3.03, p = 0.090, η2p = 0.08]. There were no other significant effects, but most descriptive data were in favour of the experimental group. However, the control group showed a greater improvement in skin status. Further studies are needed to replicate these findings and investigate which subgroups especially profit from such an intervention.

Activating values intervention: an integrative pathway to well-being

Introduction

The present study expands the existing knowledge base regarding positive psychology interventions (PPIs), by employing an integrative approach to explore the potential benefits of translating values into action.

Methods

Participants (n = 476) were randomly assigned to the Activating Values intervention, the affirmation-only, or the control (no treatment) group. The intervention involved participants choosing a life area they valued, affirming its importance, identifying a specific action related to that valued area, and then planning and carrying out that chosen action within the following week. Data was collected at baseline and three follow-up points: one, two, and three weeks after the intervention.

Results

Results suggest that the intervention contributes to the participants' well-being, including increased self-insight, sense of coherence, and prioritizing meaning, and decreased symptoms of psychopathology. Exploratory content analyses provide a deeper understanding of the content and frequency of activities chosen and the enabling conditions.

Discussion

The discussion explores the findings within this intersection as well as ramifications for brief, scalable interventions to support and promote well-being.

Through the extended evolutionary meta-model, and what ACT found there: ACT as a process-based therapy

This article is part of a special issue in the Journal of Contextual Behavioral Science devoted to process-based therapy (PBT) or a process-based approach to therapy and the role it plays in harmonizing existing evidence-based treatments. In the present discussion, we focus on acceptance and commitment therapy (ACT) and how it fits into the PBT framework. We describe how viewing ACT through a PBT framework and its organizing rubric-the extended evolutionary meta-model (EEMM)-provides fertile ground to expand the ACT and psychological flexibility models, transforming ACT into a more inclusive and flexible version of itself and giving clinicians wider berth with respect to delivering ACT. The PBT approach allows ACT to incorporate therapeutic elements that are not traditionally part of the framework, including include cognitive reappraisal, interpersonal therapy dynamics, physiological downregulation, and the principle of nonattachment. Importantly, ACT maintains its foundational principles throughout this integration. We provide a case example of how to use PBT methods to conceptualize an ACT case, to illustrate PBT-infused ACT in practice. Finally, we outline possible future directions for ACT as it continues to evolve inside of PBT.

Considering the psychological experience of amputation and rehabilitation for military veterans: a systematic review and metasynthesis of qualitative research

PURPOSE

Research highlights the differences and unique experiences of military veterans experiencing amputation compared to civilians. This review aimed to synthesise qualitative research exploring the experience of amputation and rehabilitation among existing or previous members of the military.

METHODS

A systematic search of six databases (PsycINFO, AMED, MEDLINE, CINAHL, Web of Science and Scopus) was undertaken in March 2022. The results of 17 papers reporting 12 studies published between 2009 and 2022 were synthesised using a meta-ethnographic approach to generate new interpretations reflecting the experiences of members of the military who have experienced limb loss.

RESULTS

Three themes were developed from the data: (1) Making the physical and psychological transition to life after amputation; (2) The role of the military culture in rehabilitation; and (3) The impact of relationships and the gaze of others during rehabilitation and beyond.

CONCLUSIONS

Military veterans with limb loss experience difficulties in navigating civilian healthcare systems and gaining appropriate support away from the military. Rehabilitation professionals, with psychological training or mentoring, involved in the care of military veterans following amputation could offer psychological support during the transition to civilian life and targeted therapies to veterans experiencing high levels of pain, and facilitate peer support programmes.

Acceptance and Commitment Therapy for Chronic Pain: An Overview of Systematic Reviews with Meta-Analysis of Randomized Clinical Trials

This overview of reviews aimed to summarize the evidence from systematic reviews and meta-analyses of randomized clinical trials of the efficacy of acceptance and commitment therapy (ACT) for adults with chronic pain in relation to pain intensity, pain-related functioning, quality of life, and psychological factors. The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, PubMed, and the Cochrane Library databases were searched from inception to July 2, 2023. AMSTAR 2 was used to assess the methodological quality of systematic reviews. The overlap among reviews was calculated. Nine reviews comprising 84 meta-analyses of interest were included. At post-treatment, some meta-analyses mainly showed that ACT can reduce depression symptoms, anxiety symptoms, psychological inflexibility, and pain catastrophizing; and can improve mindfulness, pain acceptance, and psychological flexibility. At three-month follow-up, ACT can reduce depression symptoms and psychological inflexibility, as well as improve pain-related functioning and psychological flexibility. At six-month follow-up, ACT can improve mindfulness, pain-related functioning, pain acceptance, psychological flexibility, and quality of life. At six-twelve-month follow-up, ACT can reduce pain catastrophizing and can improve pain-related functioning. Some methodological and clinical issues are identified in the reviews, such as a very high overlap between systematic reviews, the fact that the certainty of the evidence is often not rated and specific details needed to replicate the interventions reviewed are often not reported. Overall, however, randomized clinical trials and systematic reviews show that ACT can improve outcomes related to chronic pain (eg, pain-related functioning). Future systematic reviews should address the methodological and clinical concerns identified here to produce higher-quality findings. PERSPECTIVE: Despite certain methodological and clinical issues, randomized clinical trials and systematic reviews of ACT appear to show that it can improve outcomes related to chronic pain (eg, psychological factors).

Oxytocin Modulation in Mindfulness-Based Pain Management for Chronic Pain

In the context of chronic pain management, opioid-based treatments have been heavily relied upon, raising concerns related to addiction and misuse. Non-pharmacological approaches, such as Mindfulness-Based Pain Management, offer alternative strategies. We conducted a mechanistic clinical study to investigate the impact of an 8-week Mindfulness-Based Pain Management intervention on chronic pain, the modulation of inflammatory markers, stress physiology, and oxytocin, and their interplay with clinical pain symptoms and perception, in comparison to a patient wait-list active control. A total of 65 participants, including 50 chronic pain patients and 15 healthy controls, underwent salivary assays to assess endocrine markers, oxytocin, interleukin (IL)-1b, IL-6, IL-8, tumor necrosis factor (TNF)-a, and dehydroepiandrosterone sulphate (DHEA-S). Psychological assessments were also conducted to evaluate aspects of pain perception, mindfulness, mood, and well-being. Findings revealed significant differences between chronic pain patients and healthy controls in various clinical metrics, highlighting the psychological distress experienced by patients. Following Mindfulness-Based Pain Management, oxytocin levels significantly increased in chronic pain patients, that was not observed in the patient wait-list control group. In contrast, cytokine and DHEA-S levels decreased (not to statistically significant margins) supporting anti-inflammatory effects of Mindfulness-Based Pain Management. The fact DHEA-S levels, a marker of stress, did attenuate but not to statistically meaningful levels, suggests that pain reduction was not solely related to stress reduction, and that oxytocin pathways may be more salient than previously considered. Psychological assessments demonstrated substantial improvements in pain perception and mood in the intervention group. These results contribute to the growing body of evidence regarding the effectiveness of mindfulness-based interventions in chronic pain management and underscore oxytocin's potential role as a therapeutic target.

Benefits, Recruitment, Dropout, and Acceptability of the Strength Back Digital Health Intervention for Patients Undergoing Spinal Surgery: Nonrandomized, Qualitative, and Quantitative Pilot Feasibility Study

BACKGROUND

Patients undergoing spinal surgery report high levels of insecurity, pain, stress, and anxiety before and after surgery. Unfortunately, there is no guarantee that surgery will resolve all issues; postsurgical recovery often entails moderate to severe postoperative pain, and some patients undergoing spinal surgery do not experience (long-term) pain relief after surgery. Therefore, focusing on sustainable coping skills and resilience is crucial for these patients. A digital health intervention based on acceptance and commitment therapy (ACT) and positive psychology (PP) was developed to enhance psychological flexibility and well-being and reduce postsurgical pain.

OBJECTIVE

The objective of this study was 3-fold: to explore the potential benefits for patients undergoing spinal surgery of the digital ACT and PP intervention Strength Back (research question [RQ] 1), explore the feasibility of a future randomized controlled trial in terms of recruitment and dropout (RQ 2), and assess the acceptability of Strength Back by patients undergoing spinal surgery (RQ 3).

METHODS

We used a nonrandomized experimental design with an intervention group (n=17) and a control group (n=20). To explore the potential benefits of the intervention, participants in both groups filled out questionnaires before and after surgery. These questionnaires included measurements of pain intensity (Numeric Pain Rating Scale), pain interference (Multidimensional Pain Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), valued living (Engaged Living Scale), psychological flexibility (Psychological Inflexibility in Pain Scale), and mental well-being (Mental Health Continuum-Short Form). Semistructured interviews combined with log data and scores on the Twente Engagement With eHealth Technologies Scale were used to assess the acceptability of the intervention.

RESULTS

A significant improvement over time in emotional (V=99; P=.03) and overall (V=55; P=.004) well-being (Mental Health Continuum-Short Form) was observed only in the intervention group. In addition, the intervention group showed a significantly larger decline in pain intensity (Numeric Pain Rating Scale) than did the control group (U=75; P=.003). Of the available weekly modules on average 80% (12/15) was completed by patients undergoing spinal fusion and 67% (6/9) was completed by patients undergoing decompression surgery. A total of 68% (17/25) of the participants used the intervention until the final interview. Most participants (15/17, 88%) in the intervention group would recommend the intervention to future patients.

CONCLUSIONS

This pilot feasibility study showed that combining ACT and PP in a digital health intervention is promising for patients undergoing spinal surgery as the content was accepted by most of the participants and (larger) improvements in pain intensity and well-being were observed in the intervention group. A digital intervention for patients undergoing (spinal) surgery can use teachable moments, when patients are open to learning more about the surgery and rehabilitation afterward. A larger randomized controlled trial is now warranted.

Factors Associated With Interest in Engaging in Psychological Interventions for Pain Management

OBJECTIVE

Engagement in evidence-based psychological interventions for pain management is low. Identifying characteristics associated with interest in interventions can inform approaches to increase uptake and engagement. The purpose of this study was to examine factors associated with interest in psychological interventions among persons with chronic noncancer pain receiving prescription opioids.

METHODS

Participants with chronic noncancer pain and a new 30 to 90 day opioid prescription were recruited from 2 health systems. Participants (N=845) completed measures regarding pain, opioid use, psychiatric symptoms, emotional support, and interest in psychological interventions for pain management.

RESULTS

There were 245 (29.0%) participants who reported a high interest in psychological interventions for pain management. In bivariate analyses, variables associated with interest included younger age, female sex, greater pain severity, greater pain interference, greater number of pain sites, lower emotional support, depression, anxiety, and post-traumatic stress disorder ( P <0.05). In a multivariate model, greater pain severity (odds ratio [OR]=1.17; CI: 1.04-1.32), depression (OR=2.10; CI: 1.39-3.16), post-traumatic stress disorder (OR=1.85; CI: 1.19-2.95), and lower emotional support (OR=0.69; CI: 0.5-0.97) remained statistically significant.

DISCUSSION

The rate of interest in psychological interventions for pain management was low, which may indicate that patients initiating opioid treatment of chronic noncancer pain have low interest in psychological interventions. Greater pain severity and psychiatric distress were related to interest, and patients with these characteristics may especially benefit from psychological interventions. Providers may want to refer to psychological interventions before or when opioids are initiated. Additional work is needed to determine whether this would reduce long-term opioid use.

Mindfulness-based Interventions for Chronic Low Back Pain: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to compile existing evidence examining the effects of mindfulness-based interventions (MBIs) for chronic low back pain (CLBP). CLBP leads to millions of disabled individuals in the United States each year. Current pharmacologic treatments are only modestly effective and may present long-term safety issues. MBIs, which have an excellent safety profile, have been shown in prior studies to be effective in treating CLBP yet remained underutilized.

DESIGN

Ovid/Medline, PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs), pilot RCTs, and single-arm studies that explored the effectiveness of MBIs in CLBP.

METHODS

Separate searches were conducted to identify trials that evaluated MBIs in reducing pain intensity in individuals with CLBP. A meta-analysis was then performed using R v3.2.2, Metafor package v 1.9-7.

RESULTS

Eighteen studies used validated patient-reported pain outcome measures and were therefore included in the meta-analysis. The MBIs included mindfulness meditation, mindfulness-based stress reduction, mindfulness-based cognitive therapy, mindfulness-oriented recovery enhancement, acceptance and commitment therapy, dialectical behavioral therapy, meditation-cognitive behavioral therapy, mindfulness-based care for chronic pain, self-compassion course, and loving-kindness course. Pain intensity scores were reported using a numerical rating scale (0 to 10) or an equivalent scale. The meta-analysis revealed that MBIs have a beneficial effect on pain intensity with a large-sized effect in adults with CLBP.

CONCLUSIONS

MBIs seem to be beneficial in reducing pain intensity. Although these results were informative, findings should be carefully interpreted due to the limited data the high variability in study methodologies, small sample sizes, inclusion of studies with high risk of bias, and reliance on pre-post treatment differences with no attention to maintenance of effects. More large-scale RCTs are needed to provide reliable effect size estimates for MBIs in persons with CLBP.

Treating a common comorbidity: Pain outcomes following a 3-week cognitive processing therapy-based intensive treatment for posttraumatic stress disorder address

Posttraumatic stress disorder (PTSD) commonly co-occurs with pain and has been implicated in the maintenance of chronic pain. However, limited research has examined whether intervening for PTSD can hinder or optimize treatment outcomes for co-occurring pain and PTSD. In the present study, we examined changes in pain, PTSD, and depressive symptoms among 125 veterans completing a 3-week cognitive processing therapy (CPT)-based intensive treatment program (ITP) for PTSD. We also explored whether pretreatment pain interference predicted changes in PTSD and depressive symptom severity and whether larger changes in pain interference over the course of treatment were associated with larger changes in PTSD and depressive symptom severity. Linear mixed models revealed that participants' pain interference decreased throughout treatment, d = 0.15, p = .039. Higher levels of pretreatment pain interference were associated with higher PTSD, p = .001, and depressive symptom severity, p = .014, over time. Larger reductions in pain interference corresponded to more improvement in PTSD symptoms, β = -.03; p < .001, but not depressive symptoms. These findings indicate that ITPs for PTSD can reduce pain interferences, albeit to a small degree, and that reductions in pain interference can contribute to reductions in PTSD symptom severity. Future studies should examine which treatment components contribute to larger changes in symptom severity for veterans with co-occurring pain and PTSD.