Consumer perspectives of the group itself in group-delivered programs for people with chronic pain: A systematic review and meta-synthesis

Group-delivered programs for chronic pain are evidence-based and frequently used. The contribution of group factors to outcomes is unclear and there are no integrated findings on consumer perceptions of the group itself in programs for people with chronic pain. The aim of this systematic review was to search and synthesise qualitative data specifically related to the group itself in studies investigating group-delivered programs for people with chronic pain (PROSPERO, CRD42023382447). MEDLINE, EMBASE, EmCare, PsycINFO, Scopus, and CINAHL databases were searched, and qualitative studies that explored the experiences of consumers who had attended any style of group-delivered program for people with chronic pain were included. Methodological quality was assessed using the Critical Appraisal Skills Programme checklist and meta-synthesis was guided by a thematic synthesis approach. Ninety-three studies were included, with 1806 participants. Programs were predominantly multi-component, with diverse interventions and facilitators. Three analytical themes were generated: (1) Peer interaction: a program component in and of itself; (2) Comparison: frequently used and mostly helpful; and (3) Beyond the program: when the group itself contributes to change. Findings highlighted that most consumers valued the group itself, finding interaction, and comparing themselves with peers useful. Future research related to group factors in programs for people with chronic pain should include consumer participation and co-design. PERSPECTIVE: This review demonstrates that many consumers valued peer interaction and used comparison-based cognitive processing within group-delivered programs for chronic pain. Dialogue-based interactions with similar others promoted cognitive, affect, and behaviour changes. Group factors may have been underestimated and outcomes could be influenced if peer interactions within programs were optimised.

Development and Initial Validation of Mindfulness-Based Pain Reduction (MBPR) in Patients With Chronic Low Back Pain

Purpose

Mindfulness-Based Stress Reduction (MBSR) has shown efficacy for alleviating chronic low back pain (cLBP) and is included in current treatment guidelines. However, benefits are moderate. We aimed to optimize MBSR for chronic pain by using recent research to develop Mindfulness-Based Pain Reduction (MBPR) and test it in patients with cLBP.

Patients and Methods

Phase 1: We modified the MBSR curriculum with theory-driven components and convened focus groups with local and international mindfulness and clinical pain management experts to refine an 8-week MBPR program. Phase 2: We recruited participants with cLBP from Northern California using outreach in newsletters, social media, and other methods to test and iteratively modify the curriculum. MBPR was delivered in a group format by videoconference. The first three groups received MBPR; a fourth group was randomized to MBSR or MBPR to assess randomization feasibility. We assessed feasibility and acceptability by attendance, practice logs, and exit interviews. We assessed changes in patient-reported outcome measures for low back pain trials using a single arm (treatment group only) approach at 2 and 6 months with linear mixed models (primary: pain intensity and interference (PEG) scores).

Results

Phase 1: The MBPR curriculum included: 1) mindful interoceptive exposure to pain, 2) pain neuroscience education, and 3) yoga postures specifically for cLBP. Phase 2: we enrolled 58 patients in 4 cohorts; 49 completed post-intervention and 41 completed 6-month follow-up assessments; 29 of the 41 received MBPR. Participants attended a mean of 80% of sessions and 23 of 24 participants accepted randomization in the 4th cohort. Mean PEG scores improved for 20 of 29 MBPR participants in a clinically meaningful way (PEG scores >30%).

Conclusion

MBPR was feasible and acceptable. Two-thirds of MBPR participants experienced clinically meaningful improvements in pain intensity and interference scores. MBPR warrants further investigation through a randomized, controlled trial.

Use of Intervention Mapping to Adapt a Psychologically Informed Physical Therapy Telerehabilitation Intervention for Latino Persons With Chronic Spine Pain

The need for culturally tailored pain care is well-recognized, yet few studies report how existing interventions can be adapted to the needs of culturally and linguistically diverse populations. This report describes a formative mixed-methods approach using intervention mapping-adapt and the expanded framework for reporting adaptations and modifications to evidence-based interventions to adapt and report modifications of an existing physical therapy intervention for Latino persons with chronic spine pain in Federally Qualified Health clinics in the southwestern United States. Mixed methods included literature reviews, patient surveys, an Adaptation Advisory Panel, and sequential case series with semistructured interviews. Six steps of intervention mapping-adapt guided the adaptation process and adaptations were prospectively documented with framework for reporting adaptations and modifications to evidence-based interventions. A needs assessment revealed an absence of culturally tailored physical therapy interventions for Latino persons with chronic spine pain in the United States. An intervention logic model and review of the sociocultural context guided the selection of essential interventions, determinants of behavior change, and outcomes. An existing cognitive behavioral-based physical therapy telerehabilitation intervention was selected for adaptation based on accessibility and strong congruency with the logic model. An Adaptation Advisory Panel planned and evaluated iterative adaptations of the cognitive behavioral-based physical therapy intervention content, activities, delivery, materials, and design. The adapted Goal-Oriented Activity for Latino persons with Spine pain intervention aimed to reduce pain intensity and disability through patient-centered goal setting in physical and cognitive treatment domains. Sequential case series supported feasibility and acceptability of the adapted intervention in the target population. PERSPECTIVE: We describe adaptation and reporting of an evidence-based physical therapy intervention for a culturally and linguistically diverse population. Greater rigor and transparency using tools such as intervention mapping-adapt and framework for reporting adaptations and modifications to evidence-based interventions will accelerate efforts to reduce ethnic and racial disparities in pain rehabilitation.

Psychologically Informed Physical Therapy Management of Chronic Musculoskeletal Pain in Culturally Diverse Populations: An Intervention Logic Model

Culturally and linguistically diverse (CALD) individuals are underrepresented in pain research, including studies of psychologically informed physical therapy (PIPT) for musculoskeletal pain. This perspective describes a conceptual framework for PIPT management of chronic musculoskeletal pain that identifies essential elements that can be culturally tailored to meet the needs of different CALD populations. Essential interventions, determinants of behavior change, and clinical outcomes were identified from studies of existing PIPT interventions for chronic pain. PIPT approaches shared the following essential interventions: 1) cognitive skill training, 2) general aerobic activity, 3) impairment-based therapeutic exercises, and 4) graded functional movement training. An intervention logic model was developed to conceptualize how these interventions might promote active coping behaviors and greater engagement in physical activity, therapeutic exercise, and functional mobility. The model included physical and cognitive-emotional processes that may contribute to behavioral changes that ultimately reduce pain-related disability. To illustrate the cultural tailoring of model constructs, we describe how intervention delivery and assessments were customized for Latino persons with chronic spine pain at a health center located near the United States-Mexico border. A literature review of sociocultural influences on the pain experience of Latino persons was conducted, and essential elements of the model were operationalized to ensure that therapeutic goals, language, content, and processes were compatible with Latino cultural beliefs, values, and behaviors. Future research using the proposed model to adapt and test PIPT interventions for other CALD populations may help identify shared and divergent mechanisms of treatment response for culturally tailored pain management programs. PERSPECTIVE: A novel conceptual framework may help inform the cultural tailoring of PIPT management approaches for chronic musculoskeletal pain by maintaining fidelity to essential treatment elements while also leveraging the unique sociocultural context of different CALD communities to improve health outcomes.

Mind over chronic pain: A meta-analysis of cognitive restructuring in chronically ill adults

OBJECTIVE

This meta-analysis synthesizes research on the impact of cognitive restructuring on chronic pain intensity, aiming to integrate diverse methodologies and findings while evaluating potential moderators.

METHODS

Following PRISMA guidelines, we systematically searched multiple databases (PubMed, Web of Science, JSTOR, Sage, Social Science Research Network, PsycArticles, ScienceDirect, and Education Resources Information Center) until July 2023. Studies involving adults (≥18 years) diagnosed with chronic conditions who underwent cognitive restructuring to reduce chronic pain intensity, were included. Eligible studies compared this intervention with a control group. We excluded studies incorporating cognitive restructuring within broader interventions, lacking statistical data, or not written in English. Study quality was assessed using the Cochrane Risk of Bias tool (RoB 2).

RESULTS

After reviewing 18,312 studies, we selected 11 studies published between 1991 and 2022, involving 693 participants with chronic conditions. A significant large overall effect size was found (d = 0.94, 95% CI 0.48 to 1.40). Moderation analyses revealed significant differences based on sex and study quality, with effects less pronounced among females and more substantial in higher-quality studies.

CONCLUSION

Despite limitations such as statistical instability due to a small number of studies in certain moderator categories and methodological variability, this meta-analysis highlights the robust effects of cognitive restructuring on chronic pain intensity. The findings are valuable for guiding power calculations and future research expectations. Clinically, these results support the significant effect of cognitive restructuring in both individual and group settings, regardless of age, particularly when facilitated by teams that include psychologists.

The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review

Despite the lack of evidence, opioids are still routinely used as a solution to long-term management for chronic noncancer pain (CNCP). Given the significant risks associated with long-term opioid use, including the increased number of unregulated opioid pills at large in the opioid ecosystem, opioid cessation or reduction may be the desired goal of the patient and clinician. Viable nonpharmacological interventions (NPIs) to complement and/or replace opioids for CNCP are needed. Comprehensive reviews that address the impact of NPIs to help adults with CNCP reduce opioid use safely are lacking. We conducted a literature search in PubMed, CINAHL, Embase, PsycINFO, and Scopus for studies published in English. The initial search was conducted in April 2021, and updated in January 2024. The literature search yielded 19,190 relevant articles. Thirty-nine studies met the eligibility criteria and underwent data extraction. Of these, nineteen (49%) were randomized controlled trials, eighteen (46%) were observational studies, and two (5%) were secondary analyses. Among adults with CNCP who use opioids for pain management, studies on mindfulness, yoga, educational programs, certain devices or digital technology, chiropractic, and combination NPIs suggest that they might be an effective approach for reducing both pain intensity and opioid use, but other NPIs did not show a significant effect (e.g., hypnosis, virtual reality). This review revealed there is a small to moderate body of literature demonstrating that some NPIs might be an effective and safe approach for reducing pain and opioid use, concurrently.

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.

Enhancing Chronic Non-Cancer Pain Management: A Systematic Review of Mindfulness Therapies and Guided Imagery Interventions

Background and Objectives: There has been an increasing interest in the use of non-pharmacological approaches for the multidimensional treatment of chronic pain. The aim of this systematic review was to assess the effectiveness of mindfulness-based therapies and Guided Imagery (GI) interventions in managing chronic non-cancer pain and related outcomes. Materials and Methods: Searching three electronic databases (Web of Science, PubMed, and Scopus) and following the PRISMA guidelines, a systematic review was performed on Randomized Controlled Trials (RCTs) and pilot RCTs investigating mindfulness or GI interventions in adult patients with chronic non-cancer pain. The Cochrane Risk of Bias Tool was utilized to assess the quality of the evidence, with outcomes encompassing pain intensity, opioid consumption, and non-sensorial dimensions of pain. Results: Twenty-six trials met the inclusion criteria, with most of them exhibiting a moderate to high risk of bias. A wide diversity of chronic pain types were under analysis. Amongst the mindfulness interventions, and besides the classical programs, Mindfulness-Oriented Recovery Enhancement (MORE) emerges as an approach that improves interoception. Six trials demonstrated that mindfulness techniques resulted in a significant reduction in pain intensity, and three trials also reported significant outcomes with GI. Evidence supports a significant improvement in non-sensory dimensions of pain in ten trials using mindfulness and in two trials involving GI. Significant effects on opioid consumption were reported in four mindfulness-based trials, whereas one study involving GI found a small effect with that variable. Conclusions: This study supports the evidence of benefits of both mindfulness techniques and GI interventions in the management of chronic non-cancer pain. Regarding the various mindfulness interventions, a specific emphasis on the positive results of MORE should be highlighted. Future studies should focus on specific pain types, explore different durations of the mindfulness and GI interventions, and evaluate emotion-related outcomes.

The effects of telehealth-delivered mindfulness meditation, cognitive therapy, and behavioral activation for chronic low back pain: a randomized clinical trial

BACKGROUND

Chronic low back pain (CLBP) is a significant problem affecting millions of people worldwide. Three widely implemented psychological techniques used for CLBP management are cognitive therapy (CT), mindfulness meditation (MM), and behavioral activation (BA). This study aimed to evaluate the relative immediate (pre- to post-treatment) and longer term (pre-treatment to 3- and 6-month follow-ups) effects of group, videoconference-delivered CT, BA, and MM for CLBP.

METHODS

This is a secondary analysis of a three-arm, randomized clinical trial comparing the effects of three active treatments-CT, BA, and MM-with no inert control condition. Participants were N = 302 adults with CLBP, who were randomized to condition. The primary outcome was pain interference, and other secondary outcomes were also examined. The primary study end-point was post-treatment. Intent-to-treat analyses were undertaken for each time point, with the means of the changes in outcomes compared among the three groups using an analysis of variance (ANOVA). Effect sizes and confidence intervals are also reported.

RESULTS

Medium-to-large effect size reductions in pain interference were found within BA, CT, and MM (ds from - .71 to - 1.00), with gains maintained at both follow-up time points. Effect sizes were generally small to medium for secondary outcomes for all three conditions (ds from - .20 to - .71). No significant between-group differences in means or changes in outcomes were found at any time point, except for change in sleep disturbance from pre- to post-treatment, improving more in BA than MM (d =  - .49).

CONCLUSIONS

The findings from this trial, one of the largest telehealth trials of psychological treatments to date, critically determined that group, videoconference-delivered CT, BA, and MM are effective for CLBP and can be implemented in clinical practice to improve treatment access. The pattern of results demonstrated similar improvements across treatments and outcome domains, with effect sizes consistent with those observed in prior research testing in-person delivered and multi-modal psychological pain treatments. Thus, internet treatment delivery represents a tool to scale up access to evidence-based chronic pain treatments and to overcome widespread disparities in healthcare.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03687762.

Understanding the Role of Therapist Quality in Accounting for Heterogeneity of Patient Outcomes in Psychosocial Chronic Pain Treatments

A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.

[Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach : German version]

INTRODUCTION

Chronic low back pain (cLBP) is highly prevalent in the United States and globally, resulting in functional impairment and lowered quality of life. While many treatments are available for cLBP, clinicians have little information about which specific treatment(s) will work best for individual patients or subgroups of patients. The Back Pain Research Consortium, part of the National Institutes of Health Helping to End Addiction Long-termSM (HEAL) Initiative, will conduct a collaborative clinical trial, which seeks to develop a personalized medicine algorithm to optimize patient and provider treatment selection for patients with cLBP.

OBJECTIVE

The primary objective of this article is to provide an update on evidence-based cLBP interventions and describe the process of reviewing and selecting interventions for inclusion in the clinical trial.

METHODS

A working group of cLBP experts reviewed and selected interventions for inclusion in the clinical trial. The primary evaluation measures were strength of evidence and magnitude of treatment effect. When available in the literature, duration of effect, onset time, carryover effect, multimodal efficacy, responder subgroups, and evidence for the mechanism of treatment effect or biomarkers were considered.

CONCLUSION

The working group selected 4 leading, evidence-based treatments for cLBP to be tested in the clinical trial and for use in routine clinical treatment. These treatments include (1) duloxetine, (2) acceptance and commitment therapy, (3) a classification-based exercise and manual therapy intervention, and (4) a self-management approach. These interventions each had a moderate to high level of evidence to support a therapeutic effect and were from different therapeutic classes.

Effectiveness of integrated approach of yoga therapy versus usual care in management on chronic low back pain patients: A randomized controlled pilot study

BACKGROUND

Chronic low back pain is associated with both psychological and functional limitation. Yoga therapy has been shown to improve both the aspects. The present study was planned to evaluate integrated approach of yoga therapy with usaul care.

AIMS

This controlled randomized trial was done to evaluate the clinical and molecular changes resulting from integrated approach of yoga therapy (IAYT) as an adjunct regimen and compared it with usual care for the management of chronic low back pain patients.

MATERIAL AND METHODS

We enrolled 29 adult patients with non-specific chronic low back pain (CLBP). Patients were randomly divided into two groups. The control group received the usual care of treatment as per institutional protocol. The yoga group received IAYT as an adjunct to usual care. Primary outcomes were pain intensity assessed by verbal numerical rating scale (VNRS) and functional ability assessed by Modified Oswestry Disability Index (MODI). Secondary outcomes were pain catastrophizing, quality of life, fear of movement related to CLBP, type of pain, levels of β-endorphin and TNF-α, and salivary CGRP. All parameters were measured at baseline, 1 and 3 months.

RESULTS

A Significant decrease in VNRS score at 1 and 3 months was observed in both the groups with the yoga group showing a more significant reduction in pain over time than the control group (p = 0.036). MODI improved significantly only in the yoga group at 1 and 3 months. Intergroup comparison revealed significantly better MODI over time in the yoga group (p < 0.001). DN4, PDQ, PCS, HADS (anxiety), and Euro QOL had a statistically significant improvement at 1 and 3 months in the yoga group compared with the control group. The HADS (depression) had a statistically significant reduction scores in the yoga group at 3 months compared with the control group (p = 0.012). There was a significant reduction in TNF-α values in the yoga group compared with baseline (p = 0.004).

CONCLUSION

IAYT therapy helped in addressing the psychological components of pain and improved quality of life patients with chronic low back pain compared with usual care.

A Content Analysis of African Americans' Experience of Engaging in Qigong Exercise Intervention in a Community Setting

Introduction: Although an increasing number of African Americans 50 years of age and older practice qigong, a mind-body exercise, to manage their health conditions, little is known about their perceptions and experiences of engaging in and learning qigong exercise. This study aimed to explore the subjective perceptions of the health benefits, engagement, adherence, and learning of qigong exercise in African Americans 45-85 years of age as a foundation for promoting this approach for African Americans' physical and psychological health. Methods: Fifteen African Americans were enrolled in a 1-h qigong exercise program twice a week for 8 weeks (a total of 16 sessions) in the activity center of a local church. Participants were interviewed after the intervention to explore their perceptions of learning and practicing qigong exercise. Interviews were conducted in person, audio recorded, transcribed verbatim, and analyzed using content analysis. Results: Five themes emerged: (1) Perceived benefits of practicing qigong, (2) helpful strategies for qigong learning, (3) facilitators for home qigong practice, (4) motivators for qigong exercise adherence, and (5) recommending qigong to others. qigong exercise was perceived to be effective for balance, flexibility, muscle strength, sleep quality, emotion regulation, and stress management. Nearly 75% of participants reported home qigong practice at least twice a week. Conclusions: Middle-age and older African Americans' responses provide insights on health benefits associated with practicing qigong exercise, adherence, home practice, and learning, which may serve as the first step to promoting the use of qigong exercise in this population and may be adopted to similar exercise interventions with minority older adults in the future.

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.

Home-Use and Portable Biofeedback Lowers Anxiety and Pain in Chronic Pain Subjects

In this study, we investigated the use of novel, home-use and portable biofeedback devices in a remote program for managing chronic pain. In three separate 4-week pilot studies, participants engaged in twice-daily, 10-minute biofeedback sessions, with self-assessed reductions in anxiety and pain levels using the 6-item State-Trait Anxiety Inventory (STAI-6) and Visual Analogue Scale (VAS), respectively, in Studies 2 and 3. Among these 113 (Study 2) and 237 (Study 3) biofeedback sessions, 81 (∼72%) and 130 (∼55%) showed reductions in pain, while 93 (∼82%) and 184 (∼78%) experienced reductions in anxiety. A positive relationship was found between anxiety and pain reduction, indicating that larger reductions in anxiety correspond to larger reductions in pain. In Study 1, only anxiety reductions were measured: across 143 biofeedback sessions, 127 experienced reductions in anxiety (∼89%). Participants in all studies demonstrated reductions in baseline to final results in pain, anxiety, and showed increases in satisfaction and recovery. Our results provide strong evidence that portable biofeedback devices can enhance pain management programs by helping to alleviate anxiety and pain in individuals living with chronic conditions. This study can provide a basis for the integration of biofeedback devices into the expanding research of lifestyle and integrative medicine.

[Efectividad de una intervención multimodal para la mejora de la atención al dolor crónico.]

OBJECTIVE

The prevalence of chronic pain in Spain is 17%, which causes suffering and significant loss of quality of life. Therapies should not focus only on pain reduction, to improve function and quality of life are necessary. Currently, it is committed to combining drugs and other therapies such as relaxation, meditation, cognitive behavioral therapy, targeted exercises, healthy lifestyles and techniques to increase self-esteem and motivation for change. These therapies can be used as part of a multimodal approach, forming part of multicomponent programs or workshops. In this paper we proposed to evaluate the effectiveness of a workshop developed from the Hospital San Juan de Dios del Ajarafe, that integrated different non-pharmacological therapies in the control of chronic non-oncologic pain and to analyze patients' perceptions of the techniques applied and how they affected pain and lifestyles.

METHODS

An intragroup before-after study (beginning-end of the workshop) was carried out, comparing pain, well-being, drug use, quality of life, and self-esteem. Surveys were conducted to deepen more qualitative aspects and identify improvements. The workshop consisted of psychoeducational action and training for the mental control of pain and emotions, based on the active participation of the patient in the management of his disease, promoting self-care and self-esteem, and aiming to improve well-being and quality of life. It consisted of 5 sessions of 3 hours (1 per week); of a group, interactive and practical nature. Statistical analysis was performed with SPSS vs.27.0. To compare related measures (before-after) we used Student's T tests for paired samples and Wilcoxon's test and to compare independent groups, Student's T and Mann Whitney's U; for the qualitative variables, we used Chi-Square and Fisher's test.

RESULTS

Four workshops were evaluated in which 63 patients participated, with a mean age of 57.6 (SD:11.37) years, 60 (95.2%) of them were women. At the end of the workshop pain decreased 1.5 median (-2.0-0) and well-being increased 2.0 (0-2.0); quality of life increased a median of 0.121 (SD: 0.209), health status 16.8 (23.78) and self-esteem 2.74 (4.73); [p<0.001]. The best valued techniques were meditations, mainly mental analgesia, affirmations in the mirror and self-esteem techniques.

CONCLUSIONS

Overall satisfaction with the workshop is 9.8 out of 10. There is a pain control and improvement in quality of life, self-perception of health status, well-being and self-esteem.

Pain-Related Beliefs, Coping, and Function: An Observational Study on the Moderating Influence of Country of Origin

Chronic pain is a multidimensional experience and pain treatments targeting psychosocial factors reduce pain and improve function. These treatments often overlook the sociocultural factors that influence pain and the psychological factors associated with function in people with chronic pain. Although preliminary findings suggest that cultural background may influence pain and function via their effects on beliefs and coping, no previous study has directly tested if the country of origin moderates the associations between these psychological factors and pain and function. This study sought to address this knowledge gap. Five hundred sixty-one adults with chronic pain, born and living in the USA (n = 273) or Portugal (n = 288), completed measures of pain, function, pain-related beliefs, and coping. Between-country similarities were found in the endorsement of beliefs related to disability, pain control, and emotion, and in asking for assistance, task persistence, and coping self-statement responses. Portuguese participants reported greater endorsement of harm, medication, solicitude, and medical cure beliefs, more frequent use of relaxation and support seeking, and less frequent use of guarding, resting, and exercising/stretching. In both countries, disability and harm beliefs and guarding responses were associated with worse outcomes; pain control and task persistence were associated with better outcomes. Six country-related small effect-size moderation effects emerged, such that task persistence and guarding are stronger predictors of pain and function in adults from the USA, but pain control, disability, emotion, and medication beliefs are more important in adults from Portugal. Some modifications may be needed when adapting multidisciplinary treatments from one country to another. PERSPECTIVE: This article examines the similarities and differences in beliefs and coping endorsed by adults with chronic pain from 2 countries, and the potential moderation effects of country on the associations between these variables and pain and function. The findings suggest that some modifications may be needed when culturally customizing psychological pain treatments.

Protocol for a Parallel Group Randomized Clinical Trial Comparing a Culturally Adapted Cognitive Behavioral Telerehabilitation Intervention to Usual Physical Therapy for Latino Patients With Chronic Spine Pain

OBJECTIVE

Disparities exist in health care access, diagnosis, and treatment of chronic pain in Latino populations and other minority populations. Cognitive behavioral-based physical therapy (CBPT) interventions have been shown to be effective in predominantly non-Hispanic white populations with chronic spine pain. However, there is a need for culturally adapted CBPT interventions that focus on the conservative management of chronic spine pain. The primary purpose of the study described in this protocol is to test the efficacy of an adapted cognitive behavioral-based hybrid telerehabilitation intervention for Latino patients with chronic spine pain.

METHODS

A single-blind, 2-arm parallel group, superiority randomized clinical trial is planned to compare an adapted CBPT intervention to Usual Care physical therapy. Goal Oriented Activity for Latinos with chronic Spine pain (GOALS/Metas) is an 8-week hybrid telerehabilitation intervention that integrates guideline-based physical therapy and pain management interventions using cognitive behavioral approaches and has been adapted for Latino patients with chronic spine pain. Usual Care physical therapy will be administered based on institutional standards at the referring health center. Outcome measures will be evaluated preintervention and at 1-week, 3-months, and 6-months postintervention. The primary outcome is pain-related disability 1-week postintervention using the Brief Pain Inventory Pain Interference subscale. Secondary outcome measures include behavioral measures of functional activity, social participation, physical activity, and sleep. Determinants of treatment effect, including pain-related psychological measures, posture and movement, self-efficacy, treatment expectancy, and therapeutic alliance, will be included in the secondary moderation and mediation analyses.

IMPACT

This clinical trial will provide information on the extent to which an adapted CBPT hybrid telerehabilitation intervention is effective in reducing pain-related disability for Latino patients with chronic spine pain. This information will be useful for clinicians to integrate in their practice, given the growing population of Latino patients who experience disparities in health care management of chronic pain.

Brief Mindfulness-Based Cognitive Behavioral Therapy is Associated with Faster Recovery in Patients Undergoing Total Knee Arthroplasty: A Pilot Clinical Trial

OBJECTIVE

To assess whether brief mindfulness-based cognitive behavioral therapy (MBCBT) could enhance the benefits of total knee arthroplasty (TKA) in improving pain and pain-related disability. Specifically, to determine 1) whether patients who received MBCBT differed from matched controls who received treatment-as-usual with regard to postsurgical pain outcomes and 2) whether changes in pain catastrophizing, depression, or anxiety explained the potential effects of MBCBT on pain outcomes.

DESIGN

Pilot clinical trial.

SETTING

An academic teaching hospital serving a large urban and suburban catchment area surrounding the Boston, Massachusetts metropolitan region.

SUBJECTS

Sample of 44 patients undergoing TKA. Patients who completed a brief MBCBT intervention (n = 22) were compared with age-, race-, and sex-matched controls who received treatment-as-usual (n = 22).

METHODS

The MBCBT intervention included four 60-minute sessions delivered by a pain psychologist in person and via telephone during the perioperative period. Participants were assessed at baseline and at 6 weeks, 3 months, and 6 months after surgery.

RESULTS

Compared with matched controls, patients who received MBCBT had lower pain severity and pain interference at 6 weeks after surgery. Group differences in outcomes were mediated by changes in pain catastrophizing but not by changes in depression or anxiety. The MBCBT group had similar reductions in pain severity and interference as the control group did at 3 and 6 months after surgery.

CONCLUSIONS

This work offers evidence for a safe and flexibly delivered nonpharmacological treatment (MBCBT) to promote faster recovery from TKA and identifies change in pain catastrophizing as a mechanism by which this intervention could lead to enhanced pain-related outcomes.

Internet-Based Cognitive Behavioural Therapy for Individuals With Depression and Chronic Health Conditions: A Systematic Review

Cognitive behavioural therapy (CBT) has heightened the need for internet-delivered intervention for depression with chronic diseases than a traditionally-based treatment procedure, and the need for CBT as an internet-delivered intervention has increased because it scales down the stigma of proceeding to a therapist, saves travel time from different geographical areas, and increases access to the service. This study aimed to evaluate the contemporary evidence for the effectiveness of internet-delivered cognitive behavioural therapy (CBT) as a treatment option for depression with chronic illness (CVD, diabetes, chronic pain, cancer, and chronic obstructive pulmonary disease (COPD)) among adult populations in high-income countries. A systematic search strategy was devised based on selecting search terms, inclusion and exclusion criteria, and refinement processes. Electronic searches were conducted using databases related to healthcare and containing peer-reviewed literature: the Cumulated Index to Nursing and Allied Health Literature (CINAHL), the Excerpta Medica Database (Embase), the Medical Literature Analysis and Retrieval System Online (Medline), and PsycINFO. Key search terms were applied to all databases and combined using Boolean operators to maximise the efficiency of the search. This review included randomised controlled trials (RCTs) evaluating the adult population aged ≥18 years published from 2006-2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was employed to guide the review process. The initial search yielded 134 studies across all databases, which were refined, leading to 18 studies in the final review data set. This review suggests that internet-based CBT is an effective strategy for reducing depressive symptoms in patients with comorbid depression and chronic diseases.

Effects of meditation on pain intensity, physical function, quality of life and depression in adults with low back pain - A systematic review with meta-analysis

BACKGROUND

Low back pain (LBP) is a common biopsychosocial health problem. Meditation may provide a complementary treatment option for LBP patients.

OBJECTIVES

The aim of this systematic review with meta-analysis was to examine the effects of meditation on pain intensity, functional disability, quality of life, and depression in LBP populations.

METHODS

This systematic review was conducted according to the PRISMA Guidelines. PubMed, Web of Science, CENTRAL, CamQuest and PubPsych were searched up to a publication date of June 2020. Inclusion criteria were RCTs or non-RCTs with LBP patients, aged at least 18 years, the application of a specific meditation technique, and pain intensity and/or functional disability as outcomes. Pooled SMDs were calculated at post-treatment and follow up. The Cochrane risk-of-bias tool was used to estimate risk of bias. The overall quality of evidence was assessed using the GRADE approach.

RESULTS

12 studies with a total of 1005 participants were included in this review. Compared to controls, meditation solely showed a significant positive effect on pain intensity (SMD = -0.27 [CI -0.43; -0.11]; p = 0.001; based on 10 studies with 934 participants) and physical quality of life (SMD = 0.21 [CI 0.07; 0.36]; p = 0.005; based on 5 studies with 756 participants) at post-treatment. At follow up (mean 20 weeks, range 4-52) there were no significant effects anymore. The quality of the evidence was moderate due to study limitations and imprecision.

CONCLUSIONS

Meditation seems to be promising with regard to reducing short-term pain intensity in patients with LBP. However, additional well-designed and large trials are required in order to draw more reliable conclusions.

Preliminary study: quantification of chronic pain from physiological data

Supplemental Digital Content is Available in the Text.

Preliminary evidence suggests that physiological variables collected with our low-cost pain meter are correlated with chronic pain, both for individuals and populations.

Introduction:

It is unknown if physiological changes associated with chronic pain could be measured with inexpensive physiological sensors. Recently, acute pain and laboratory-induced pain have been quantified with physiological sensors.

Objectives:

To investigate the extent to which chronic pain can be quantified with physiological sensors.

Methods:

Data were collected from chronic pain sufferers who subjectively rated their pain on a 0 to 10 visual analogue scale, using our recently developed pain meter. Physiological variables, including pulse, temperature, and motion signals, were measured at head, neck, wrist, and finger with multiple sensors. To quantify pain, features were first extracted from 10-second windows. Linear models with recursive feature elimination were fit for each subject. A random forest regression model was used for pain score prediction for the population-level model.

Results:

Predictive performance was assessed using leave-one-recording-out cross-validation and nonparametric permutation testing. For individual-level models, 5 of 12 subjects yielded intraclass correlation coefficients between actual and predicted pain scores of 0.46 to 0.75. For the population-level model, the random forest method yielded an intraclass correlation coefficient of 0.58. Bland–Altman analysis shows that our model tends to overestimate the lower end of the pain scores and underestimate the higher end.

Conclusion:

This is the first demonstration that physiological data can be correlated with chronic pain, both for individuals and populations. Further research and more extensive data will be required to assess whether this approach could be used as a “chronic pain meter” to assess the level of chronic pain in patients.

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

ABSTRACT

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

Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach

Literature on current treatments for chronic low back pain (cLBP) were reviewed and 4 interventions were recommended for inclusion in a multisite cLBP clinical trial.

Introduction:

Objective:

Methods:

Conclusion:

The Effect of M-Health-Based Core Stability Exercise Combined with Self-Compassion Training for Patients with Nonspecific Chronic Low Back Pain: A Randomized Controlled Pilot Study

INTRODUCTION

Nonspecific chronic low back pain (NCLBP) is a leading contributor to disease burden worldwide, and the management of NCLBP has always been a problem. This study is designed to explore the feasibility and efficacy of m-health-based core stability exercise (CSE) combined with self-compassion training (SCT) and compare it with m-health-based CSE alone for the management of NCLBP.

METHODS

This study is a pilot, patient-blinded randomized controlled trial. Participants with NCLBP were randomized into an intervention group and a control group. All the participants received m-health-based CSE, but those in the intervention group also received SCT before CSE. The intervention took place weekly on Saturday or Sunday for 4 weeks in total. Patients self-assessed their outcomes by filling out electronic questionnaires at 4 and 16 weeks after the start of the study. The primary outcome metrics for these questionnaires were back pain disability (based on the Roland-Morris Disability Questionnaire, RMDQ) and Pain intensity (Numeric Rating Scale, NRS; current pain, worst pain, average pain). The secondary outcome metrics were anxiety (GAD-7,7-item Generalized Anxiety Disorder scale), Depression Symptoms (PHQ-9,Patient Health Questionnaire-9), pain catastrophizing (PCS, Pain Catastrophizing Scale) and Self-efficiency (PSEQ, Pain Self-Efficiency Questionnaire).

RESULTS

A total of 37 patients comprising 28 (75.7%) females completed the study, with 19 patients in the intervention group and 18 in the control group. The mean (SD) patient age was 35.2 (11.1) years. For all primary outcomes, although there were no significant differences between groups, we found that participants in the intervention group improved function and pain earlier. The RMDQ score changed by - 1.771 points (95% CI - 3.768 to 0.227) from baseline to 4 weeks in the control group and by - 4.822 points (95% CI - 6.752 to - 2.892) in the intervention group (difference between groups, - 3.052 [95% CI - 5.836 to - 0.267]). Also, the RMDQ score changed by - 3.328 points (95% CI - 5.252 to - 1.403) from baseline to 16 weeks in the control group and by - 5.124 points (95% CI - 7.014 to - 3.233) in the intervention group (difference between groups - 1.796 [95% CI - 4.501 to 0.909]). A similar pattern was found in the NRS scores. For secondary outcomes, the intervention group was superior to the control group in for GAD-7 (intervention difference from CSE along at week 16, - 2.156 [95% CI - 4.434 to - 0.122; P value for group effect was 0.030]). At the end of treatment, the improvement in PCS in the intervention group was significant (difference in PCS score at week 4, - 6.718 [95% CI - 11.872 to - 1.564]). We also found significant changes in PCS in the control group (- 6.326 [95% CI, - 11.250 to - 1.401]) at the 16-week follow-up. As for PSEQ, there were no apparent differences between the two groups. There were no adverse events relented to study participation.

CONCLUSIONS

The pilot study is feasible to deliver, and our results indicate that participants in the group of m-health-based CSE combined with SCT may experience faster relief from pain intensity and back disability than those in the group of m-health-based CSE alone.

TRIAL REGISTRATION

ChiCTR2100042810.

How do psychologically based interventions for chronic musculoskeletal pain work? A systematic review and meta-analysis of specific moderators and mediators of treatment

Psychologically based interventions aim to improve pain-related functioning by targeting pain-related fears, cognitions and behaviors. Mediation and moderation analyses permit further examination of the effect of treatment on an outcome. This systematic review and meta-analysis aims to synthetize the evidence of specific mediators and moderators (i.e., treatment targets) of psychologically based treatment effects on pain and disability. A total of 28 mediation and 11 moderation analyses were included. Thirteen mediation studies were included in a meta-analysis, and the rest was narratively synthetized. Reductions in pain-related fear (indirect effect [IE]: -0.07; 95% confidence interval [CI]: -0.11, -0.04) and catastrophizing (IE: -0.07; 95%CI: -0.14, -0.00), as well as increases in self-efficacy (IE: -0.07; 95%CI: -0.11, -0.04), mediated effects of cognitive behavioral therapy on disability but not on pain intensity, when compared to control treatments. Enhancing pain acceptance (IE: -0.17; 95%CI: -0.31, -0.03) and psychological flexibility (IE: -0.30; 95%CI: -0.41, -0.18) mediated acceptance and commitment therapy effects on disability. The narrative synthesis showed conflicting evidence, which did not support a robust moderated effect for any of the examined constructs. Overall, the methodological quality regarding mediation was low, and some key pitfalls are highlighted alongside recommendations to provide a platform for future research.

A Single-blind, randomized, pilot study of a brief Mindfulness-Based Intervention for the endometriosis-related pain management

BACKGROUND

Women with endometriosis suffer from frequent symptoms despite multiple treatments in tertiary care. Although there is a need for a biopsychosocial perspective on endometriosis treatment, few conservative treatments have been investigated. We aimed to investigate the effects of a brief Mindfulness-Based Intervention (bMBI) in women with deep endometriosis who remain symptomatic despite undergoing conventional medical treatment.

METHODS

A randomized controlled trial was performed with 2 groups: a standard medical treatment plus bMBI program and only standard medical treatment as a control. A total of 63 eligible participants were randomized to bMBI and control group. The primary outcome was endometriosis-related pain, and secondary outcomes were quality of life and stress perception posttreatment. Analyses were carried out using multiple regression models.

RESULTS

The results show that bMBI significantly improved pain unpleasantness (Cohen's f2 = 0.67, NNT = 3.2), pelvic pain (Cohen's f2 = 0.16, NNT = 5.3), and dyschezia (Cohen's f2 = 0.23, NNT = 2.9) immediately posttreatment and decreased all endometriosis-related pain (Cohen's f2 ranging from 0.20 to 0.60 and NNT ranging from 5 to -9) after the follow-up. We found an extensive positive effect of bMBI on the mental health dimension in the two time-point measures (Cohen's f2 = 0.34 and 0.25, NNT = 3.5 and 2.3) and vitality (Cohen's f2 = 0.22, NNT = 2.1) after the follow-up.

CONCLUSIONS

Our study suggests that bMBI is useful for managing endometriosis-related pain and restoring women's psychological well-being.

Meditation-Based Therapy for Chronic Low Back Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Chronic low back pain (CLBP) is among the most common types of pain in adults. Currently, injections and analgesic and nonsteroidal anti-inflammatory drugs are often provided for patients with CLBP. However, their effectiveness remains questionable, and the safest approach to CLBP remains debated. Meditation-based therapies constitute an alternative treatment with high potential for widespread availability. We evaluated the applicability of meditation-based therapies for CLBP management.

Materials and Methods

We performed a systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy of meditation-based therapies for CLBP management. The primary outcomes were pain intensity, quality of life, and pain-related disability; the secondary outcomes were the experienced distress or anxiety and pain bothersomeness in the patients. The PubMed, Embase, and Cochrane databases were searched for studies published from their inception until July 2021, without language restrictions.

Results

We reviewed 12 randomized controlled trials with 1153 patients. In 10 trials, meditation-based therapies significantly reduced the CLBP pain intensity compared with nonmeditation therapies (standardized mean difference [SMD] −0.27, 95% CI = −0.43 to − 0.12, P = 0.0006). In 7 trials, meditation-based therapies also significantly reduced CLBP bothersomeness compared with nonmeditation therapies (SMD −0.21, 95% CI = −0.34 to − 0.08, P = 0.002). In 3 trials, meditation-based therapies significantly improved patient quality of life compared with nonmeditation therapies (SMD 0.27, 95% CI = 0.17 to 0.37, P &lt; 0.00001)

Conclusions

In conclusion, meditation-based therapies constitute a safe and effective alternative approach for CLBP management.

Psychological Approaches for the Integrative Care of Chronic Low Back Pain: A Systematic Review and Metanalysis

Chronic low back pain (CLBP) is the most common cause of disability worldwide, affecting about 12% to 30% of the adult population. Psychological factors play an important role in the experience of pain, and may be predictive of pain persistence, disability, and long-term sick leave. The aim of this meta-analysis was to identify and to describe the most common psychological approaches used to treat patients who suffer from CLBP. A systematic search was performed on PubMed/MEDLINE and Cochrane Central. Overall, 16 studies with a total of 1058 patients were included in the analysis. Our results suggest that cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) interventions are both associated with an improvement in terms of pain intensity and quality of life when singularly compared to usual care. Disability also improved in both groups when compared to usual care. Significant differences in fear-avoidance beliefs were noted in the CBT group compared to usual care. Therefore, psychological factors are related to and influence CLBP. It is crucial to develop curative approaches that take these variables into account. Our findings suggest that CBT and MBSR modify pain-related outcomes and that they could be implemented in clinical practice.

The Use of Behavioral Modalities for Headache During Pregnancy and Breastfeeding

Purpose of Review

Migraine is primary headache which commonly affects women of childbearing age. Migraine and other primary headache disorders are also common during pregnancy. Understanding which treatments are effective and can be safely given to patients with primary headache during pregnancy and lactation is essential in supporting these patients before, during, and after childbirth. Behavioral modalities have the potential to improve the health of both mother and baby, while empowering patients to make informed decisions in family planning and creating future treatment plans.

Recent Findings

Research shows that behavioral therapies can be powerful tools to treat pain conditions with minimal side effects. Recent literature prioritizes behavioral therapies in preparation for pregnancy, during pregnancy, and during lactation due to the superior safety profile of such therapies. Digital resources for behavioral therapy are another well-received recent direction supported by growing evidence of both efficacy and safety. Popular with patients and headache specialists, digital behavioral therapy has taken various forms during the pandemic, such as telemedicine, online psychology support groups, and smartphone applications that patients can interact with on their own time.

Summary

In summary, the purpose of this review is to equip providers with important information and updates on the use of behavioral modalities for the treatment of primary headache during pregnancy and lactation.

Response to Mindfulness-Based Cognitive Therapy Differs Between Chronic and Episodic Migraine

Objective

Evaluate whether the benefits of Mindfulness-Based Cognitive Therapy for Migraine (MBCT-M) on headache disability differs among people with episodic and chronic migraine (CM).

Methods

This is a planned secondary analysis of a randomized clinical trial. After a 30-day baseline, participants were stratified by episodic (6-14 d/mo) and CM (15-30 d/mo) and randomized to 8 weekly individual sessions of MBCT-M or wait list/treatment as usual (WL/TAU). Primary outcomes (Headache Disability Inventory; Severe Migraine Disability Assessment Scale [scores ≥ 21]) were assessed at months 0, 1, 2, and 4. Mixed models for repeated measures tested moderation with fixed effects of treatment, time, CM, and all interactions. Planned subgroup analyses evaluated treatment*time in episodic and CM.

Results

Of 60 participants (MBCT-M N = 31, WL/TAU N = 29), 52% had CM. CM moderated the effect of MBCT-M on Severe Migraine Disability Assessment Scale, F(3, 205) = 3.68, p = 0.013; MBCT-M vs WL/TAU reduced the proportion of people reporting severe disability to a greater extent among people with episodic migraine (-40.0% vs -14.3%) than CM (-16.4% vs +8.7%). Subgroup analysis revealed MBCT-M (vs WL/TAU) significantly reduced Headache Disability Inventory for episodic (p = 0.011) but not CM (p = 0.268).

Conclusions

MBCT-M is a promising treatment for reducing headache-related disability, with greater benefits in episodic than CM.

Trial Registration Information

ClinicalTrials.gov Identifier: NCT02443519.

Classification of Evidence

This study provides Class III evidence that MBCT-M reduces headache disability to a greater extent in people with episodic than CM.

Web- and Mindfulness-Based Intervention to Prevent Chronic Pain After Cardiac Surgery: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Cardiac surgery is a frequently performed procedure. However, pain after cardiac surgery may become chronic (lasting >3 months) in adults. Once discharged from the hospital, patients are at greater risk of developing chronic postsurgical pain (CPSP) and of prolonged opioid use, as they need to self-manage their pain. Psychological risk and protective factors such as pain-related catastrophic thoughts and pain acceptance determine their ability to cope and their use of opioids, which is crucial for self-management of pain. Studies on mindfulness-based cognitive therapy (MBCT) have multiplied their potential effects on pain acceptance and catastrophic thoughts. However, web-based MBCT for the prevention of CPSP has not yet been examined.

OBJECTIVE

The aim of this study is to pilot test a 4-week-long web-based MBCT intervention for adults following discharge from the hospital by assessing the acceptability or feasibility of the intervention and examining preliminary effects on pain intensity, pain interference with activities and opioid use, and pain acceptance and catastrophic thoughts in the 6 months following surgery.

METHODS

A double-blinded pilot randomized controlled trial will be used to assess a web-based MBCT intervention. Patients will be selected according to the following criteria: age ≥18 years; first-time elective cardiac surgery via a median sternotomy; worst pain in the past week score ≥4/10; ability to understand and complete questionnaires in English; and ability to use an electronic device such as a smartphone, computer, or tablet. After baseline measures, 32 participants will be randomized into two groups: one receiving both the brief, 4-week-long web-based MBCT intervention and usual care (experimental group) and the other receiving only one standardized, web-based educational session with weekly reminders and usual care (attention control group). Peer-reviewed competitive funding was received from Florida State University's Council on Research & Creativity in January 2021, as well as research ethics approval from Florida State University's institutional review board.

RESULTS

Recruitment began in June 2021. Unfortunately, because of the current COVID-19 pandemic, recruitment is not progressing as expected. Recruitment strategies are constantly monitored and updated according to latest data and restrictions surrounding the pandemic.

CONCLUSIONS

This research is significant because it targets the trajectory of CPSP, a leading cause of disability and opioid misuse. This is the first study to assess MBCT for the prevention of CPSP after cardiac surgery in the recovery phase. This approach is innovative because it promotes self-management of pain through the modulation of individual factors. If successful, the intervention could be expanded to numerous populations at risk of chronic pain.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30951.

Psychological Therapy in Chronic Pain: Differential Efficacy between Mindfulness-Based Cognitive Therapy and Cognitive Behavioral Therapy

The objective of this study is to evaluate the differential efficacy between Mindfulness-Based Cognitive Therapy (MBCT) and Cognitive Behavioral Therapy (CBT). A quasi-experimental design of repeated measures before and after the test (n = 57) was used with a non-equivalent control group from a previous cohort treated with CBT (n = 105). The t-test revealed significant differences in subjective quality of life for the MBCT group, and in quantity, optimum, and adequate sleep for the CBT group. The pre-post effect size comparison mostly showed slightly larger effect sizes in the MBCT group. CBT and MBCT had comparable efficacies, although a slight trend towards larger effect sizes in MBCT was found. Likewise, CBT seemed to improve sleep-related variables, while MBCT was associated with improvements in pain and quality of life.

Mechanisms of Mindfulness Meditation, Cognitive Therapy, and Mindfulness-based Cognitive Therapy for Chronic Low Back Pain

OBJECTIVES

This study evaluated theoretically derived mechanisms and common therapeutic factors to test their role in accounting for pain-related outcome change during group-delivered cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain.

METHODS

A secondary analysis of a pilot randomized controlled trial was used to explore the primary mechanisms of pretreatment to posttreatment changes in pain control beliefs, mindful observing, and pain catastrophizing, and the secondary common factor mechanisms of therapeutic alliance, group cohesion, and amount of at-home skill practice during treatment. The primary outcome was pain interference; pain intensity was a secondary outcome.

RESULTS

Large effect size changes in the 3 primary mechanisms and the outcome variables were found across the conditions. Across all 3 treatment conditions, change in pain control beliefs and pain catastrophizing were significantly associated with improved pain interference, but not pain intensity. Therapeutic alliance was significantly associated with pain intensity improvement and change in the therapy-specific mechanisms across the 3 conditions. Mindful observing, group cohesion, and amount of at-home practice were not significantly associated with changes in the outcomes.

DISCUSSION

Cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain were all associated with significant changes in the primary mechanisms to a similar degree. Change in perceived pain control and pain catastrophizing emerged as potential "meta-mechanisms" that might be a shared pathway that contributes to improved pain-related outcomes across treatments. Further, strong working alliance may represent a critical therapeutic process that both promotes and interacts with therapeutic techniques to influence outcome.

Change in Brain Oscillations as a Mechanism of Mindfulness-Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain

OBJECTIVE

Psychological treatments for chronic low back pain (CLBP) are effective. However, limited research has investigated their neurophysiological mechanisms. This study examined electroencephalography- (EEG-) assessed brain oscillation changes as potential mechanisms of cognitive therapy (CT), mindfulness-meditation (MM), and mindfulness-based cognitive therapy (MBCT) for CLBP. The a priori bandwidths of interest were changes in theta, alpha and beta power, measured at pre- and post-treatment.

DESIGN

A secondary analysis of a clinical trial.

SETTING

University of Queensland Psychology Clinic.

SUBJECTS

Adults (N = 57) with CLBP who completed pre- and post-treatment EEG and pain outcome assessments.

METHODS

EEG data were examined for five regions of interest (ROIs); the primary outcome was pain intensity.

RESULTS

A significant reduction in theta (P=.015) and alpha (P=.006) power in the left frontal ROI across all treatments was found, although change in theta and alpha power in this region was not differentially associated with outcome across treatments. There were significant reductions in beta power in all five ROIs across all treatments (P≤.013). Beta power reduction in the central ROI showed a significant association with reduced pain intensity in MBCT only (P=.028). Changes in other regions were not statistically significant.

CONCLUSIONS

These findings provide support for the capacity of psychological CLBP treatments to induce changes in brain activity. The reduced beta power in all five ROIs indicated that all three treatments engendered a state of lowered cortical arousal. The growing body of research in this area could potentially inform novel directions towards remedying central nervous system abnormalities associated with CLBP.

Effects of Mindfulness-Based Cognitive Therapy for Chronic Pain: A Multicenter Study

The prevalence of chronic pain in Spain is 15%. The objective of this study was to evaluate the efficacy of mindfulness-based cognitive therapy on patients with chronic pain. A quasi-experimental design of repeated measures pre- and post-test (N = 57) was carried out at three hospitals from the province of Alicante. Self-reported assessment measurements of pain intensity, anxiety-depression symptoms, perception of health status, interference of pain on sleep, self-efficacy in pain, acceptance, and mindfulness attitude were included. The T-test indicates significant differences in intensity of present pain, mental quality of life, and depression (medium effect sizes), as well as in self-efficacy: total score, symptom management and pain control (medium effect sizes), sleep disturbances and quantity of sleep (large effect sizes). MBCT is effective in reducing many symptoms in patients with chronic pain, although its maintenance needs to be further investigated.

Dialectical Pain Management: Feasibility of a Hybrid Third-Wave Cognitive Behavioral Therapy Approach for Adults Receiving Opioids for Chronic Pain

OBJECTIVES

This study evaluated the feasibility, acceptability, and potential effectiveness of a hybrid skills-based group intervention, dialectical pain management (DPM), for adults with chronic pain who are receiving long-term opioid therapy. DPM adapts dialectical behavior therapy, a rigorous psychotherapeutic approach to emotion dysregulation, to treat disorders of physiological dysregulation.

METHODS

Individuals with chronic pain (N = 17) participated in one of two 8-week DPM intervention cohorts. At pre-test and post-test, participants completed quantitative self-report assessments measuring pain intensity and interference, depressive symptoms, pain acceptance, beliefs about pain medications, and global rating of change. Within 2 weeks after the intervention, participants completed qualitative interviews to assess participant satisfaction and obtain feedback about specific intervention components.

RESULTS

Of the 17 enrolled, 15 participants completed the group with 12 (70%) attending six or more sessions. Participants reported high satisfaction with the intervention. Preliminary findings suggested a significant increase in pain acceptance and a significant reduction in depressive symptoms. Participants also reported an improved relationship with their pain conditions and increased flexibility in responding to pain and applying coping skills. Several participants showed a reduction in opioid dosage over the course of the intervention.

DISCUSSION

Findings support that DPM is a feasible and well-received intervention for individuals with chronic pain. Additional research with a control group is needed to further determine the intervention's efficacy and impact.

Cognition and Pain: A Review

Cognition is defined as the brain's ability to acquire, process, store, and retrieve information. Pain has been described as an unpleasant sensory or emotional experience, and for experiencing pain consciously, cognitive processing becomes imperative. Moreover, evaluation of pain strongly depends on cognition as it requires learning and recall of previous experiences. There could be a possible close link between neural systems involved in cognition and pain processing, and studies have reported an association between pain and cognitive impairment. In this narrative review, we explore the available evidence that has investigated cognitive changes associated with pain. We also examine the anatomical, biochemical, and molecular association of pain and neuro-cognition. Additionally, we focus on the cognitive impairment caused by analgesic medications. There is a need to improve our understanding of pathophysiology and cognitive impairment mechanisms associated with chronic pain and its treatment. This area provides a diverse opportunity for grounding future research, aiding institution of timely interventions to prevent chronic pain and associated cognitive decline, ultimately improving patient care.

Group Differences Between Countries and Between Languages in Pain-Related Beliefs, Coping, and Catastrophizing in Chronic Pain: A Systematic Review

Objective

To evaluate the extent to which pain-related beliefs, appraisals, coping, and catastrophizing differ between countries, language groups, and country economy.

Design

Systematic review.

Methods

Two independent reviewers searched 15 databases without restriction for date or language of publication. Studies comparing pain beliefs/appraisals, coping, or catastrophizing across two or more countries or language groups in adults with chronic pain (pain for longer than three months) were included. Two independent reviewers extracted data and performed the quality appraisal. Study quality was rated as low, moderate, or high using a 10-item modified STROBE checklist. Effect sizes were reported as small (0.20–0.49), medium (0.50–0.79), or large (≥0.80).

Results

We retrieved 1,365 articles, read 42 potential full texts, and included 10 (four moderate-quality, six low-quality) studies. A total of 6,797 adults with chronic pain (33% with chronic low back pain) were included from 16 countries. Meta-analysis was not performed because of heterogeneity in the studies. A total of 103 effect sizes were computed for individual studies, some of which indicated between-country differences in pain beliefs, coping, and catastrophizing. Of these, the majority of effect sizes for pain beliefs/appraisal (60%; eight large, eight medium, and eight small), for coping (60%; seven large, 11 medium, and 16 small), and for catastrophizing (50%; two medium, one small) evidenced statistically significant between-country differences, although study quality was low to moderate.

Conclusions

In 50% or more of the studies, mean scores in the measures of pain beliefs and appraisals, coping responses, and catastrophizing were significantly different between people from different countries.

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

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

Psychosocial morbidity profile in a community based sample of low back pain patients

Low back pain (LBP) is a major health concern and is closely associated with psychosocial morbidity and diminished Health-related quality of life (HRQoL). This is minimally investigated in community-based samples of developing nations like India. This study is aimed to specifically investigate the exposure-outcome associations between LBP and burden of disability (Modified Oswestry questionnaire (MODQ)), psychological morbidities (Depression, Anxiety and Stress Scale (DASS-21)), and HRQoL (Short Form -12 version 2 (SF12V2). A Cross-sectional study using a community-based sample of LBP positive population was conducted. The range of treatment options sought was also collected. Chi-square tests and independent t-test were used to analyze the data. Of 1531 recruited participants, 871(57%) were identified as LBP positive of whom 60% were females. Mean (SD) of age and pain intensity of LBP patients was 33 (11) years and numeric rating scale4.2 (2.6) respectively. Two-third reported minimal/moderate disability. Mean (SD) scores of depression 11.87 (4.05), anxiety (8.32), stress 13.7 (5.98), physical and mental summary scores of SF-12v2 were 47.9 (7.4) and 42.2 (10.4). A multitude of remedial options was sought for the ailment. LBP causes significant disability and psychological morbidity among affected population. This may adversely affect their HRQoL and subsequently productivity. Acupuncture was a preferred treatment sought by Indian LBP patients.

Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease

Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.

Mindfulness-Based Cognitive Therapy for Treating Chronic Pain A Systematic Review and Meta-analysis

Chronic pain is a significant public health problem with emotional and disabling factors, which may not completely respond to current medical treatments such as opioids. The systematic review and meta-analysis aimed to examine the effectiveness and safety of MBCT for patients with chronic pain. Database searches of PubMed, Medline, EMBASE, the Cochrane Library, PsycINFO, Web of Science, Scopus and CINAHL up to 15 October 2019. Included studies assessed with the Cochrane risk-of-bias tool. Eight RCTs involved 433 patients, including chronic low back pain, fibromyalgia, migraine, rheumatoid arthritis and mix etiology. MBCT intervention demonstrated a short-term improvement on depression mood [standardized mean difference -0.72; 95% confidence interval = -1.22 to -0.22, p = 0.005] compared with usual care and was associated with short-term improvement in mindfulness compared with non-MBCT [SMD 0.51; 95% CI = 0.01 to 1.01, p = 0.04]. Between-group differences in pain intensity, pain inference and pain acceptance were not significant at short- or long-term follow-up. Compared to active treatments, MBCT intervention not found significant differences in either short- or long-term outcomes. MBCT showed short-term efficacious on depressed mood and mindfulness of chronic pain patients. Longer follow-ups, large sample and rigorous RCTs that can be best understand remaining uncertainties needed.

Differential efficacy between cognitive-behavioral therapy and mindfulness-based therapies for chronic pain: Systematic review

Background/Objective: To assess the differential efficacy between mindfulness-based interventions and cognitive-behavioral Therapy (CBT) on chronic pain across medical conditions involving pain. Method: ProQuest, Science Direct, Google Scholar, Pubmed, and Embase databases were searched to identify randomized clinical trials. Measurements of mindfulness, pain, mood, and further miscellaneous measurements were included. Results: 18 studies met the inclusion criteria (fibromyalgia, n = 5; low back pain, n = 5; headache/migraine, n = 4; non-specific chronic pain, n = 4). In fibromyalgia, mindfulness based stress reduction (MBSR) was superior to the usual care and Fibroqol, in impact and symptoms. In low back pain, MBSR was superior to the usual care, but not to CBT, in physical functionality and pain intensity. There were no studies on differential efficacy between mindfulness and CBT for headache and non-specific chronic pain, but Mindfulness interventions were superior to the usual care in these syndromes. Conclusions: Mindfulness interventions are superior to usual cares in all diagnoses, but it is not possible to conclude their superiority over CBT. Comparisons between mindfulness interventions are scarce, with MBSR being the most studied. In central sensitization syndromes, variables associated with pain tend to improve with treatment. More research is needed to differentiate diagnosis and intervention.

A randomized trial to examine the mechanisms of cognitive, behavioral and mindfulness-based psychosocial treatments for chronic pain: Study protocol

This randomized trial will evaluate the mechanisms of three chronic pain treatments: cognitive therapy (CT), mindfulness meditation (MM), and activation skills (AS). We will determine the extent to which late-treatment improvement in primary outcome (pain interference) is predicted by early-treatment changes in cognitive content, cognitive process, and/or activity level. The shared versus specific role of these mechanisms across the three treatments will be evaluated during treatment (Primary Aim), and immediately post-treatment to examine relapse mechanisms (Secondary Aim). We will enroll 300 individuals with chronic pain (with low back pain as a primary or secondary condition), with 240 projected to complete the study. Participants will be randomly assigned to eight, 1.5 h telehealth group sessions of CT, MM, or AS. Mechanisms and outcomes will be assessed twice daily during 2-week baseline, 4-week treatment period, and 4-week post-treatment epoch via random cue-elicited ecological momentary assessment (EMA); activity level will be monitored during these time epochs via daily monitoring with ActiGraph technology. The primary outcome will be measured by the PROMIS 5-item Pain Interference scale. Structural equation modeling (SEM) will be used to test the primary aims. This study is pre-registered on clinicaltrials.gov (Identifier: NCT03687762). This study will determine the temporal sequence of lagged mediation effects to evaluate rates of change in outcome as a function of change in mediators. The findings will provide an empirical basis for enhancing and streamlining psychosocial chronic pain interventions. Further, results will guide future efforts towards optimizing maintenance of gains to effectively reduce relapse risk.

Positive affect and chronic pain: a preregistered systematic review and meta-analysis

Chronic noncancer pain (CNCP) is a significant health burden among adults. Standard behavioral therapies typically focus on targeting negative affect (NA) and yield only modest treatment effects. The aims of this study were to systematically review and investigate the association between positive affect (PA) and pain severity among adults with CNCP. Databases that were searched included MEDLINE (PubMed), PsycINFO, CINAHL, ProQuest Dissertations and Theses, OLASTER, Open Grey, and PsyArXiv (inception to July 23, 2019). We analyzed studies that: (1) used observational, experimental, or intervention study designs; (2) enrolled individuals with CNCP (pain ≥ 12 weeks); and (3) reported full quantitative results on outcomes. Two researchers independently screened articles, extracted data, and assessed the risk of bias. The main meta-analysis was followed by subgroup analyses. All analyses were performed using random-effects models. Formal tests for heterogeneity (Q-statistic; I) and publication bias (p-curve and p-uniform*) were performed. We meta-analyzed 29 studies with 3521 participants. Results demonstrated that PA inversely impacts pain severity in people with CNCP (r = -0.23). Subgroup analyses showed a significant effect for gender and marginally significant effects for age in studies that adjusted for NA. On average, effect sizes for observational studies were larger in studies with a higher proportion of female respondents and in studies that did not adjust for NA. Finally, larger effect sizes were found in intervention studies with older compared with younger samples.

Use of Mindfulness-based Cognitive Therapy to Change Pain-related Cognitive Processing in Patients with Primary Headache: A Randomized Trial with Attention Placebo Control Group

Background

Mindfulness-based interventions have shown to be efficient in managing chronic pain. Cognitive factors play a prominent role in chronic pain complications and negative cognitive contents about pain are often the first issues targeted in cognitive-based therapies, which are known as first-line treatment of chronic pain over the past decades. Little, however, is known about the manner of thinking about pain or pain-related cognitive processing.

Objectives

Therefore, the purpose of this study was to investigate the effect of mindfulness-based cognitive therapy (MBCT) on pain-related cognitive processing and control of chronic pain in patients with primary headache.

Methods

A clinical trial was conducted in 2017 - 2018 on 85 Persian language patients with one type of primary headache selected through purposive sampling in Emam Hossein Hospital in Tehran province. To measure the variables of the study, we used the Brief Pain Inventory (BPI) and Pain-related Cognitive Processing Questionnaire (PCPQ). All data were analyzed by independent t-test and chi-square and longitudinal data were analyzed using linear mixed model analysis.

Results

Statistically significant time × group interactions were found in pain intensity (P < 0.001), pain interference (P < 0.001), as well as in three cognitive processing subscales including pain focus, pain distancing, and pain openness (P < 0.001). However, the results of pain diversion were not meaningful.

Conclusions

MBCT is a potentially efficacious approach for individuals with headache pain. Regulation and correction of cognitive processing are considered as effective cognitive coping strategies in MBCT treatment.