Guided Imagery for Musculoskeletal Pain.: A Systematic Review

Effectiveness of psychological intervention following anterior cruciate ligament reconstruction: A systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of psychological interventions in postoperative anterior cruciate ligament reconstruction (ACLR) compared to standard rehabilitation.

METHODS

The databases searched were PubMed, MEDLINE, Cochrane Central Register of Controlled Trials, PEDro, Cumulative Index to Nursing & Allied Health Literature, and EMBASE were searched from each database inception to May 2023 for published studies. The methodological quality was assessed with the Cochrane Risk of Bias Assessment (RoB 2.0) tool. The evidence quality was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Six papers were included in the meta-analysis. Psychological intervention significantly improved Tampa Scale for Kinesiophobia at 3 months (Standard Mean Difference [SMD], -0.51. 95% Confidence Interval [CI], -0.85 to -0.17) and pain (Knee Injury and Osteoarthritis Outcome Score for Pain, Numeric Rating Scale, Visual Analog Scale) at 3 months (SMD, -0.92. 95%CI, -1.69 to -0.15) and at 6 months following ACLR (MD, -1.25. 95%CI, -1.82 to -0.68) when compared with the standard rehabilitation, according to very low-quality data. Self-efficacy and knee strength did not show significant differences.

CONCLUSION

Very low-quality evidence suggests that psychological intervention following ACLR yields better short-term outcomes compared to standard rehabilitation, with uncertainty about its clinically significant benefits over standard rehabilitation.

The Effects of Motor Imagery on Pain in Lower Limb Sports Injuries: A Systematic Review and Meta-Analysis

This review evaluated the efficacy of Motor Imagery intervention in athletes with lower limb sports injuries that could affect their pain levels during rehabilitation. We carried out a thorough research of the scientific literature for RCT studies in athletes with lower limb musculoskeletal sports injuries including search terms Motor Imagery AND pain, Motor Imagery AND sport injuries, Motor Imagery AND lower limb. We searched 3 major databases, PubMed, Scopus, and ScienceDirect, with the search period ranging from their inception until May 2022. We assessed the quality of the studies using the PEDro Scale and the data was recorded and extracted with the use of Mendeley software. The search criteria resulted in a pool of 10.107 possible articles. Upon completion of the selection procedure, only 3 RCT studies met the inclusion criteria with a total of 60 injured athletes (n = 18 with ankle sprain and n = 42 with ACL injuries). The meta-analysis showed no statistically significant positive effects of MI intervention on pain intensity after lower limb sports injuries (n = 60; MD = -1.57; 95% CI: -3.60 to 0.46; I² = 50%; p = 0.13). The limited number of studies could justify the statistically insignificant effect of MI, but although the methodological quality of the studies was moderate to high, the heterogeneity of them was also relatively high. More RCT's are required to explore the effect of MI on pain in athletes with lower limb injuries in order to address psychophysiological processes during rehabilitation.

Use of a Guided Imagery Mobile App (See Me Serene) to Reduce COVID-19-Related Stress: Pilot Feasibility Study

Background

The SARS-CoV-2 pandemic has led to concerns about mental health resulting from regional and national lockdowns, social isolation, job loss, and concern about disease exposure.

Objective

We describe results of the pilot feasibility study of the See Me Serene mHealth app. The app provides users with immersive, vivid, nature experiences to reduce stress and anxiety related to COVID-19 and other isolation. The goals of the study were to develop the See Me Serene app and test the feasibility and acceptability of study procedures, and explore the potential impact of the app on stress and anxiety.

Methods

We developed and tested the See Me Serene app and our study procedures for feasibility, and gathered preliminary data with a goal of 100 participants. The research was conducted in 2 phases: (1) development and internal testing of the app; and (2) feasibility and pilot testing with participants recruited online through earned media (eg, news stories), presentations at a university campus, and social media (eg, online sharing of earned media and presentations). The feasibility study employed a mixed methods, within-subjects, pre-/posttest design. At baseline and 30-day follow-up, we assessed stress-related variables via validated self-report measures and saliva samples for determination of cortisol concentrations.

Results

We met or surpassed all our feasibility benchmarks for recruitment (101 participants recruited), retention (91% [90/99] of 30-day assessment completed), and data collection (99 participants completed all baseline data; 85% [84/99] of salivary cortisol samples returned). Participants adhered to the intervention. On average, participants listened to 48.2 audio files over 30 days or approximately 1.6 audio files per day. Participants were satisfied with the app, with 87% (78/90) rating the app as helpful in dealing with stress and anxiety. The app showed the potential to reduce stress, anxiety, loneliness, and worry. We did not find significant differences (P=.41) in cortisol levels over time. Our findings suggest that future research is warranted to test the efficacy of the See Me Serene app with a representative, diverse sample.

Conclusions

There is a need for evidence-based and easily disseminable stress-reduction interventions. See Me Serene is a feasible intervention and has the potential to reduce stress related to COVID-19 and other forms of social isolation. More research on See Me Serene is warranted.

The Influence of Verbal Suggestion on Post-Needling Soreness and Pain Processing after Dry Needling Treatment: An Experimental Study

BACKGROUND

It remains unclear as to whether verbal suggestions and expectancies can influence the perception of post-needling soreness. The aim of this study was to analyze the effects of verbal suggestions on post-needling soreness after dry needling of the trapezius muscle.

METHODS

This study is a randomized controlled trial including healthy subjects randomly assigned to one of three groups receiving different verbal suggestions about the effects of dry needling and the occurrence of post needling soreness (positive, negative, or neutral). Then, dry needling on a latent trigger point of the upper trapezius muscle was performed and the following outcomes were measured immediately after, 24, 48, and 72 h, and one week after the intervention: post-needling soreness intensity, pressure pain threshold (PPT), temporal summation (TS) and conditioned pain modulation (CPM).

RESULTS

Seventy-three consecutive participants were screened and 42 participants (12 men and 30 women, aged: 24 ± 8 years old) were eligible and finished the study protocol. The results showed that verbal suggestion did not influence the perception of post-needling soreness, since there were no differences between groups (p < 0.05) on the intensity of post-needling soreness or tenderness over a one-week follow-up. Moreover, verbal suggestion did not associate with changes in sensorimotor variables of TS and CPM.

CONCLUSIONS

The induction of different types of expectations through verbal suggestion does not influence the perception of acute pain perceived during the performance of a deep dry needling technique and post-needling pain or soreness after deep dry needling on a latent upper trapezius myofascial trigger point (MTrP).

Mind-Body Interventions for Rehabilitation Medicine: Promoting Wellness, Healing, and Coping with Adversity

Physical medicine providers work to cure organic aspects of disease while simultaneously enhancing quality of life and well-being. Mind-body interventions are evidence-based, cost-effective approaches to serve these aims. This article enhances provider knowledge and acceptance of the most effective and prevalent mind-body modalities: meditation, guided imagery, clinical hypnosis, and biofeedback. The scientific evidence is strongest for mind-body applications for chronic pain, primary headache, cardiac rehabilitation, and cancer rehabilitation, with preliminary evidence for traumatic brain injury and cerebrovascular events. Mind-body interventions are well-tolerated by patients and should be considered part of standard care in physical medicine and rehabilitation settings.

Complementary Therapies for Patients with Cancer: Reflexology and Relaxation in Integrative Palliative Care. A Randomized Controlled Comparative Study

Objectives: Comparison of the effects of reflexology and relaxation on pain, anxiety, and depression, and quality of life (QoL) of patients with cancer. Design: A stratified random sample was selected, using an experimental design. Location: An outpatient Palliative Care Unit in Attica, Greece. Subjects: 88 patients suffering with cancer. Interventions: The sample was randomly divided into two equal groups, a reflexology and a relaxation group. The number of interventions for both groups was six 30-min weekly sessions. Outcome measures: The Greek Brief Pain Inventory (G-BPI) was used to measure pain, the Greek Hospital Anxiety and Depression Scale for screening anxiety and depression, and finally the Short Form Health Survey was used to measure QoL. Measurements of the above tools were taken three times in both groups as follows: preintervention, at fourth and at sixth week of intervention. Results: Anxiety and depression for both groups exhibited a statistically significant decrease during the observation period (p < 0.001, η² > 0.25) but at the sixth week, there was a more significant decrease in the reflexology group compared with the relaxation group (p = 0.062, η² = 0.044 vs. p = 0.005, η² = 0.096 for anxiety), (p = 0.006, η² = 0.094 vs. p = 0.001, η² = 0.138 for depression). QoL physical and mental component measurements were significantly greater for the reflexology group (p < 0.001, η² = 0.168 and p = 0.017, η² = 0.071, respectively). The baseline-to-sixth week G-BPI measurements were markedly decreased for the reflexology group (p = 0.207, η² = 0.020). Conclusions: Both interventions, relaxation and reflexology, seemed to be effective in decreasing anxiety and depression in patients with cancer. However, reflexology was found to be more effective in improving QoL (physical component) and to have a greater effect on pain management than relaxation.

Pain and Evil: From Local Nociception to Misery Following Social Harm

Experiencing pain, especially when chronic, is an excruciating condition that should be regarded as a syndrome, if not a disease. People suffering from chronic pain tend to develop psychological discomfort mostly due to lack of acceptance, disbelief, blame. The complexity of pain pathophysiology, plus a wide range of negative psychosocial factors, leads to a more complex suffering that deserves attention and multidisciplinary treatments. The possibility that chronic pain may occur following physical aggression, torture, or persecution raises the issue of evil as a major contributor to pain in its worst representation - when individuals or groups are attacked based on racial, social, gender, religious, political, or other grounds. To explore the complex issue of chronic pain following physical or psychological harm, and to underscore the need for a multidisciplinary approach to reduce the burden of chronic pain, we discuss the biological mechanisms underlying pain state. We seek to clarify those factors leading to pain chronification, as well as personal and social attitudes that confound patients with chronic pain. The importance of family and social environment is also investigated, as well as personality traits of chronic pain patients that may further hamper successful treatment. The presence of chronic pain, modulated by, for example, acceptance of being a victim of premeditated physical and social violence, makes the issue more difficult to comprehend.

Try-It-On: Preparing family nurse practitioners to use holistic integrative interventions to reduce opioid prescriptions in chronic pain management

In the United States, more than 130 people die each day from an opioid overdose. Nonopioid chronic pain management options are necessary in primary care. This educational innovation describes a new curriculum to teach future family nurse practitioner (FNP) prescribers holistic integrative interventions to decrease overprescribing of opioids for chronic pain management. The Modeling and Role Modeling theory and Kirkpatrick Evaluation Model guided the development and implementation of the curriculum innovation using a Try-It-On teaching-learning strategy, which focuses on immersion experience. The focus was to teach students to communicate effectively with patients in an effort to increase patient awareness of the pathophysiology of pain, risks of opioid use, and holistic integrative pain management options. Students learned to manage chronic pain within a holistic focus through immersion within integrative modalities, such as yoga, meditation, mindfulness, and guided imagery. Pre and post participation evaluations documented students' increased comfort level managing patients with chronic pain. Students reported they were much more likely to prescribe holistic integrative modalities after completing the Try-It-On learning modules. Holistic integrative interventions are a viable treatment option and/or adjunct treatment for chronic pain management. In conclusion, using the Try-It-On, teaching-learning strategy provided FNP students with the tools needed to prescribe nonopioid holistic integrative interventions to manage chronic pain.

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

Importance

Mind-body therapies (MBTs) are emerging as potential tools for addressing the opioid crisis. Knowing whether mind-body therapies may benefit patients treated with opioids for acute, procedural, and chronic pain conditions may be useful for prescribers, payers, policy makers, and patients.

Objective

To evaluate the association of MBTs with pain and opioid dose reduction in a diverse adult population with clinical pain.

Data Sources

For this systematic review and meta-analysis, the MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Cochrane Library databases were searched for English-language randomized clinical trials and systematic reviews from date of inception to March 2018. Search logic included (pain OR analgesia OR opioids) AND mind-body therapies. The gray literature, ClinicalTrials.gov, and relevant bibliographies were also searched.

Study Selection

Randomized clinical trials that evaluated the use of MBTs for symptom management in adults also prescribed opioids for clinical pain.

Data Extraction and Synthesis

Independent reviewers screened citations, extracted data, and assessed risk of bias. Meta-analyses were conducted using standardized mean differences in pain and opioid dose to obtain aggregate estimates of effect size with 95% CIs.

Main Outcomes and Measures

The primary outcome was pain intensity. The secondary outcomes were opioid dose, opioid misuse, opioid craving, disability, or function.

Results

Of 4212 citations reviewed, 60 reports with 6404 participants were included in the meta-analysis. Overall, MBTs were associated with pain reduction (Cohen d = -0.51; 95% CI, -0.76 to -0.26) and reduced opioid dose (Cohen d = -0.26; 95% CI, -0.44 to -0.08). Studies tested meditation (n = 5), hypnosis (n = 25), relaxation (n = 14), guided imagery (n = 7), therapeutic suggestion (n = 6), and cognitive behavioral therapy (n = 7) interventions. Moderate to large effect size improvements in pain outcomes were found for meditation (Cohen d = -0.70), hypnosis (Cohen d = -0.54), suggestion (Cohen d = -0.68), and cognitive behavioral therapy (Cohen d = -0.43) but not for other MBTs. Although most meditation (n = 4 [80%]), cognitive-behavioral therapy (n = 4 [57%]), and hypnosis (n = 12 [63%]) studies found improved opioid-related outcomes, fewer studies of suggestion, guided imagery, and relaxation reported such improvements. Most MBT studies used active or placebo controls and were judged to be at low risk of bias.

Conclusions and Relevance

The findings suggest that MBTs are associated with moderate improvements in pain and small reductions in opioid dose and may be associated with therapeutic benefits for opioid-related problems, such as opioid craving and misuse. Future studies should carefully quantify opioid dosing variables to determine the association of mind-body therapies with opioid-related outcomes.

Effectiveness of the graded motor imagery to improve hand function in patients with distal radius fracture: A randomized controlled trial

STUDY DESIGN

Single-blinded randomized controlled trial.

INTRODUCTION

Pain management is essential in the early stages of the rehabilitation of distal radius fractures (DRFx). Pain intensity at the acute stage is considered important for determining the individual recovery process, given that higher pain intensity and persistent pain duration negatively affect the function and cortical activity of pain response. Graded motor imagery (GMI) and its components are recent pain management strategies, established on a neuroscience basis.

PURPOSE OF THE STUDY

To investigate the effectiveness of GMI in hand function in patients with DRFx.

METHODS

Thirty-six participants were randomly allocated to either GMI (n = 17; 52.59 [9.8] years) or control (n = 19; 47.16 [10.5] years) groups. The GMI group received imagery treatment in addition to traditional rehabilitation, and the control group received traditional rehabilitation for 8 weeks. The assessments included pain at rest and during activity using the visual analog scale, wrist and forearm active range of motion (ROM) with universal goniometer, grip strength with the hydraulic dynamometer (Jamar; Bolingbrook, IL), and upper extremity functional status using the Disability of the Arm, Shoulder and Hand Questionnaire, and the Michigan Hand Questionnaire. Assessments were performed twice at baseline and at the end of the eighth week.

RESULTS

The GMI group showed greater improvement in pain intensity (during rest, 2.24; activity, 6.18 points), wrist ROM (flexion, -40.59; extension, -45.59; radial deviation, -25.59; and ulnar deviation, -26.77 points) and forearm ROM (supination, -43.82 points), and functional status (Disability of the Arm, Shoulder and Hand Questionnaire, 38.00; Michigan Hand Questionnaire, -32.53 points) when compared with the control group (for all, P < .05).

CONCLUSION

The cortical model of pathological pain suggests new strategies established on a neuroscience basis. These strategies aim to normalize the cortical proprioceptive representation and reduce pain. One of these recent strategies, GMI appears to provide beneficial effects to control pain, improve grip strength, and increase upper extremity functions in patients with DRFx.

Opioid-Independent and Opioid-Mediated Modes of Pain Modulation

Pain is regulated endogenously through both opioid and non-opioid mechanisms. We hypothesized that two novel pain modulation tasks, one drawing on context/expectations and one using voluntary reappraisal, would show differing levels of opioid dependence. Specifically, we expected that naloxone would block context-related analgesia, whereas mental imagery-based pain reappraisal would be opioid-independent.A double-blind, placebo-controlled intravenous naloxone versus saline crossover design was used. Twenty healthy volunteers completed the two modulation tasks with acute heat stimuli calibrated to induce moderate pain. In the mental imagery task, participants imagined either a "pleasant" or a "comparison" scenario during painful heat. In the relative relief task, moderate heat stimuli coincided with visual cues eliciting relief from the expectation of intense pain, and were compared with moderate heat stimuli delivered under the expectation of non-painful warmth. Both "pleasant imagery" and "relative relief" conditions significantly improved ratings of pain intensity and pleasantness during saline treatment. Indeed, the target stimuli in both tasks, which had been calibrated to induce moderate pain, were rated as mildly pleasant. Furthermore, consistently with the main hypothesis, blocking endogenous opioid signaling with naloxone did not significantly affect imagery-induced regulation of pain intensity or pleasantness. In contrast, the relative relief-induced pain regulation (i.e., context/expectation) was blocked by naloxone. We conclude that endogenous opioid signaling is necessary for expectation-related relative relief analgesia, but not for pain reappraisal through mental imagery. These results support mental imagery as a powerful and clinically relevant strategy for regulating pain affect also in patients where endogenous opioid mechanisms might be compromised.SIGNIFICANCE STATEMENT Neurotransmitter systems in the human brain can be probed through antagonist drugs. Studies using the opioid antagonist naloxone have demonstrated that the brain relies on both opioid and non-opioid mechanisms to downregulate pain. This holds clinical relevance given altered endogenous opioid processes in many chronic pain conditions. The present study used a double-blinded, placebo-controlled naloxone blockage of endogenous opioids in healthy humans to show differential opioid involvement in two pain modulation tasks. Context/expectation-driven (relative relief-related) analgesia was blocked by naloxone. In contrast, pain reappraisal through mental imagery was intact despite opioid receptor blockade, suggesting opioid independence. These results support mental imagery as a powerful, clinically relevant strategy for regulating pain as it does not rely on a functioning opioidergic system.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Integrative Medicine as an Adjunct to Orthopaedic Surgery

Patients often seek nontraditional forms of treatment, including alternative/complementary medical options, such as chiropractic care and acupuncture, to meet their personal needs. In the United States, interest has grown in methods to reduce pain and improve function through Ayurvedic medicine, which uses plant-based supplements, such as turmeric. Traditional allopathic medicine attempts to provide patients with evidence-based therapeutic regimens for their musculoskeletal conditions. Integrative medicine often is used to prevent and manage the sequelae associated with injuries and illnesses; however, competitive athletes and military personnel use complementary medicine for performance enhancement. Thus, physicians should be aware of the evolving field of integrative medicine, including the reported benefits as well as any potential drawbacks, to facilitate an educated discussion with their patients.

EULAR revised recommendations for the management of fibromyalgia

OBJECTIVE

The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'.

METHODS

A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations.

RESULTS

2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability).

CONCLUSIONS

These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

A Systematic Review of Relaxation, Meditation, and Guided Imagery Strategies for Symptom Management in Heart Failure

BACKGROUND

Pain, dyspnea, fatigue, and sleep disturbance are prevalent and distressing symptoms in persons with advanced heart failure. Although many lifestyle and self-care interventions have been developed to control heart failure progression, very few studies have explored treatments exclusively for symptom palliation. Cognitive-behavioral strategies may be effective treatment for these symptoms in advanced heart failure.

OBJECTIVE

A systemic review was conducted to describe the effect of cognitive-behavioral strategies on pain, dyspnea, fatigue, and sleep disturbance in patients with heart failure.

METHODS

CINAHL, Medline, and PsychINFO were searched from inception through December 2014. Articles were selected for inclusion if they tested a cognitive-behavioral strategy using a quasi-experimental or experimental design, involved a sample of adults with heart failure, and measured pain, dyspnea, fatigue, sleep disturbance, or symptom-related quality of life. The 2 authors evaluated study quality, abstracted data elements from each study, and synthesized findings.

RESULTS

Thirteen articles describing 9 unique studies met criteria and were included in the review. Five studies tested relaxation strategies, 3 tested meditation strategies, and 1 tested a guided imagery strategy. Of the 9 studies, 7 demonstrated some improvement in symptom outcomes. Relaxation, meditation, guided imagery, or combinations of these strategies resulted in less dyspnea and better sleep compared with attention control or usual care conditions and reduced pain, dyspnea, fatigue, and sleep disturbance within treatment groups (pretreatment to posttreatment). Symptom-related quality of life was improved with meditation compared with attention control and usual care conditions and improved pre- to post-guided imagery.

CONCLUSIONS

Studies exploring cognitive-behavioral symptom management strategies in heart failure vary in quality and report mixed findings but indicate potential beneficial effects of relaxation, meditation, and guided imagery on heart failure-related symptoms. Future research should test cognitive-behavioral strategies in rigorously designed efficacy trials, using samples selected for their symptom experience, and measure pain, dyspnea, fatigue, and sleep disturbance outcomes with targeted symptom measures.

The Effects of Guided Imagery on Patients Being Weaned from Mechanical Ventilation

The study purpose was to assess the effects of guided imagery on sedation levels, sedative and analgesic volume consumption, and physiological responses of patients being weaned from mechanical ventilation. Forty-two patients were selected from two community acute care hospitals. One hospital served as the comparison group and provided routine care (no intervention) while the other hospital provided the guided imagery intervention. The intervention included two sessions, each lasting 60 minutes, offered during morning weaning trials from mechanical ventilation. Measurements were recorded in groups at baseline and 30- and 60-minute intervals and included vital signs and Richmond Agitation-Sedation Scale (RASS) score. Sedative and analgesic medication volume consumption were recorded 24 hours prior to and after the intervention. The guided imagery group had significantly improved RASS scores and reduced sedative and analgesic volume consumption. During the second session, oxygen saturation levels significantly improved compared to the comparison group. Guided imagery group had 4.88 less days requiring mechanical ventilation and 1.4 reduction in hospital length of stay compared to the comparison group. Guided imagery may be complementary and alternative medicine (CAM) intervention to provide during mechanical ventilation weaning trials.

Effectiveness of app-based relaxation for patients with chronic low back pain (Relaxback) and chronic neck pain (Relaxneck): study protocol for two randomized pragmatic trials

BACKGROUND

Chronic low back pain (LBP) and neck pain (NP) are highly prevalent conditions resulting in high economic costs. Treatment guidelines recommend relaxation techniques, such as progressive muscle relaxation, as adjuvant therapies. Self-care interventions could have the potential to reduce costs in the health care system, but their effectiveness, especially in a usual care setting, is unclear. The aim of these two pragmatic randomized studies is to evaluate whether an additional app-delivered relaxation is more effective in the reduction of chronic LBP or NP than usual care alone.

METHODS/DESIGN

Each pragmatic randomized two-armed study aims to include a total of 220 patients aged 18 to 65 years with chronic (>12 weeks) LBP or NP and an average pain intensity of ≥ 4 on a numeric rating scale (NRS) in the 7 days before recruitment. The participants will be randomized into an intervention and a usual care group. The intervention group will be instructed to practice one of these 3 relaxation techniques on at least 5 days/week for 15 minutes/day over a period of 6 months starting on the day of randomization: autogenic training, mindfulness meditation, or guided imagery. Instructions and exercises will be provided using a smartphone app, baseline information will be collected using paper and pencil. Follow-up information (daily, weekly, and after 3 and 6 months) will be collected using electronic diaries and questionnaires included in the app. The primary outcome measure will be the mean LBP or NP intensity during the first 3 months of intervention based on daily pain intensity measurements on a NRS (0 = no pain, 10 = worst possible pain). The secondary outcome parameters will include the mean pain intensity during the first 6 months after randomization based on daily measurements, the mean pain intensity measured weekly as the average pain intensity of the previous 7 days over 3 and 6 months, pain acceptance, 'LBP- and NP-related' stress, sick leave days, pain medication intake, adherence, suspected adverse reaction, and serious adverse events.

DISCUSSION

The designed studies reflect a usual self-care setting and will provide evidence on a pragmatic self-care intervention that is easy to combine with care provided by medical professionals.

TRIAL REGISTRATION

ClinicalTrials.gov identifier Relaxback NCT02019498, Relaxneck NCT02019134 registered on 18 December 2013.

Contextual and time dependent pain in fibromyalgia: an explorative study

Background

Little is known about contextual effects on chronic pain, and how vulnerability factors influence pain in different contexts. We wanted to examine if fibromyalgia (FM) pain varied between two social contexts, i.e. at home versus in a doctor office, when it was measured the same day, and if pain was stable for 14 years when measured in similar contexts (doctor office). Our secondary aim was to explore if pain vulnerability factors varied in the two different contexts.

Findings

Fifty-five female FM patients were included in the study and scored pain in both contexts at baseline. Their age ranged between 21–68 years (mean 45.7), mean education level was 11 years and mean FM-duration was 15.6 years. Their mean pain was perceived significantly lower at home than in a doctor context the same day. However, pain was much more stable when measured in two similar contexts 14 year apart where 30 subjects (54.5%) completed. Predictor analyses revealed that pain vulnerability factors apparently varied by home and doctor contexts.

Conclusion

Pain and pain predictors seem to vary by contexts and time, with less pain at home than to a doctor the same day, but with unchanged pain in the same context after 14 years. Thus, contextual pain cues should be accounted for when pain is measured and treated, e.g. by focusing more on home-measured pain and by optimizing the doctor office context. This explorative study should be followed up by a larger full-scale study.

Does acupuncture activate endogenous analgesia in chronic whiplash-associated disorders? A randomized crossover trial

BACKGROUND

Many patients with chronic pain, including those with chronic whiplash-associated disorders (WAD), show features of central sensitization. Randomized trials examining whether treatments are able to influence the process of central sensitization in patients with chronic WAD are emerging. Therefore, the present study aimed at examining whether acupuncture results in activation of endogenous analgesia and relief in symptoms in patients with chronic WAD.

METHODS

In this randomized crossover pilot trial with blinded assessors, each patient (n = 39) received two treatment sessions of identical duration, with acupuncture and relaxation therapy randomly crossed over in visit 2. Primary outcome measurement included immediate activation of endogenous analgesia i.e., pressure pain sensitivity and conditioned pain modulation. Secondary outcome measurements included pain relief and reduced disability level.

RESULTS

Local pressure pain sensitivity at baseline and during conditioned pain modulation decreased significantly more following acupuncture compared with relaxation (time × group interactions: p < 0.001), both in the neck and at a site distinct from the painful region. When comparing the effects of acupuncture versus relaxation, no differences were observed on conditioned pain modulation, temporal summation of pressure pain, neck disability or symptom severity (all p-values >0.05).

CONCLUSION

It was shown that one session of acupuncture treatment results in acute improvements in pressure pain sensitivity in the neck and calf of patients with chronic WAD. Acupuncture had no effect on conditioned pain modulation or temporal summation of pressure pain. Both acupuncture and relaxation appear to be well-tolerated treatments for people with chronic WAD. These findings suggest that acupuncture treatment activates endogenous analgesia in patients with chronic WAD.

Mind-body CAM interventions: current status and considerations for integration into clinical health psychology

OBJECTIVE

Complementary and alternative medicine (CAM) is increasingly used for treating myriad health conditions and for maintaining general health. The present article provides an overview of current CAM use with a specific focus on mind-body CAM and its efficacy in treating health conditions.

METHOD

Characteristics of CAM users are presented, and then evidence regarding the efficacy of mind-body treatments (biofeedback, meditation, guided imagery, progressive muscle relaxation, deep breathing, hypnosis, yoga, tai chi, and qi gong) is reviewed.

RESULTS

Demographics associated with CAM use are fairly well-established, but less is known about their psychological characteristics. Although the efficacy of mind-body CAM modalities for health conditions is receiving a great deal of research attention, studies have thus far produced a weak base of evidence. Methodological limitations of current research are reviewed. Suggestions are made for future research that will provide more conclusive knowledge regarding efficacy and, ultimately, effectiveness of mind-body CAM. Considerations for clinical applications, including training and competence, ethics, treatment tailoring, prevention efforts, and diversity, conclude the article.

CONCLUSIONS

Integration of CAM modalities into clinical health psychology can be useful for researchers taking a broader perspective on stress and coping processes, illness behaviors, and culture; for practitioners seeking to incorporate CAM perspectives into their work; and for policy makers in directing healthcare resources wisely.

Guided imagery for non-musculoskeletal pain: a systematic review of randomized clinical trials

CONTEXT

Our previous review of the literature concluded that there is encouraging evidence that guided imagery alleviates musculoskeletal pain, but the value of guided imagery in the management of non-musculoskeletal pain remains uncertain.

OBJECTIVES

The objective of this systematic review was to assess the effectiveness of guided imagery as a treatment option for non-musculoskeletal pain.

METHODS

Six databases were searched from their inception to February 2011. Randomized clinical trials were considered if they investigated guided imagery in human patients with any type of non-musculoskeletal pain in any anatomical location and assessed pain as a primary outcome measure. Trials of motor imagery and hypnosis were excluded. The selection of studies, data extraction, and validation were performed independently by two reviewers.

RESULTS

Fifteen randomized clinical trials met the inclusion criteria. Their methodological quality was generally poor. Eleven trials found that guided imagery led to a significant reduction of non-musculoskeletal pain. Four studies found no change in non-musculoskeletal pain with guided imagery in comparison with progressive relaxation, standard care, or no treatment.

CONCLUSION

The evidence that guided imagery alleviates non-musculoskeletal pain is encouraging but remains inconclusive.

The use of functional neuroimaging to evaluate psychological and other non-pharmacological treatments for clinical pain

A large number of studies have provided evidence for the efficacy of psychological and other non-pharmacological interventions in the treatment of chronic pain. While these methods are increasingly used to treat pain, remarkably few studies focused on the exploration of their neural correlates. The aim of this article was to review the findings from neuroimaging studies that evaluated the neural response to distraction-based techniques, cognitive behavioral therapy (CBT), clinical hypnosis, mental imagery, physical therapy/exercise, biofeedback, and mirror therapy. To date, the results from studies that used neuroimaging to evaluate these methods have not been conclusive and the experimental methods have been suboptimal for assessing clinical pain. Still, several different psychological and non-pharmacological treatment modalities were associated with increased pain-related activations of executive cognitive brain regions, such as the ventral- and dorsolateral prefrontal cortex. There was also evidence for decreased pain-related activations in afferent pain regions and limbic structures. If future studies will address the technical and methodological challenges of today's experiments, neuroimaging might have the potential of segregating the neural mechanisms of different treatment interventions and elucidate predictive and mediating factors for successful treatment outcomes. Evaluations of treatment-related brain changes (functional and structural) might also allow for sub-grouping of patients and help to develop individualized treatments.

How a Better Understanding of Spontaneous Mental Imagery Linked to Pain Could Enhance Imagery-Based Therapy in Chronic Pain

Therapy with mental images is prevalent in the field of chronic pain, and this has been the case for centuries. Yet few of the recent advances in the cognitive behavioural understanding of spontaneous (i.e. intrusive) mental imagery have been translated to this field. Such advances include imagery as a component of a psychopathological process, as an emotional amplifier and as a cognitive therapeutic target in its own right. Hence very little is known about the contents, prevalence and emotional impact of spontaneous mental imagery in the context of chronic pain. This article discusses the evidence in favour of spontaneous imagery being a potentially important part of patients' pain experience, and makes a case, based on neurophysiological findings, for imagery having an impact on pain perception. Furthermore, it presents how mental imagery has been used in the treatment of chronic pain. A case report illustrates further how spontaneous negative imagery linked to pain can be distressing, and how this might be addressed in therapy. Additionally, the case report demonstrates the spontaneous use of coping imagery, and raises a discussion of how this might be enhanced.