Rumination-Focused Cognitive-Behavioral Therapy for Chronic Low Back Pain: A Randomized Controlled Trial

Emotion Regulation and Psychological Dependence on Pain Medication among Hospital Outpatients with Chronic Spinal Pain: The Influence of Rumination about Pain and Alexithymia

Objective: To examine the extent to which pain acceptance, pain catastrophising and alexithymia moderate associations between pain intensity and psychological pain medication dependence. Methods: Participants (106 hospital outpatients with chronic spinal pain) completed the Leeds Dependence Questionnaire (LDQ) to measure psychological dependence on pain medication, and the Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), the Pain Catastrophising Scale (PCS) and the Toronto Alexithymia Scale-20 (TAS-20), plus the Depression, Anxiety and Stress Scale-21 (DASS-21). Results: Multiple linear regression showed that degree of psychological dependence (measured dimensionally across the range of LDQ scores) was associated with TAS subscale difficulty identifying feelings (DIF) (β = 0.249, p = <0.002) and PCS subscale rumination (β = 0.193, p = 0.030), independently of pain intensity and risk behaviors for medication misuse. The effect of pain intensity was moderated by rumination, with pain intensity more strongly associated with dependence when rumination was high (interaction β = 0.192, p = 0.004). Logistic regression showed that the effect of pain intensity on severe dependence (measured categorically as LDQ score ≥ 20) was moderated by alexithymia, so that severe dependence was independently associated with the combination of intense pain and high alexithymia (interaction odds ratio = 7.26, 95% CIs = 1.63-32.42, p = 0.009). Conclusions: Rumination and alexithymia moderated the associations between pain intensity and psychological pain medication dependence, consistent with emotion regulation theory. This raises the possibility that specifically targeting rumination about pain and symptoms of alexithymia could potentially improve the effectiveness of psychological interventions for chronic pain and help people to avoid or reduce their psychological dependence on pain medication.

Comparative effectiveness of nonpharmacological interventions in reducing psychological symptoms among patients with chronic low back pain

OBJECTIVES

Chronic low back pain (CLBP) can seriously impair the quality of life of patients and has a remarkable comorbidity with psychological symptoms, which, in turn, can further exacerbate the symptoms of CLBP. Psychological treatments are critical and nonnegligent for the management of CLBP, and thus, should attract sufficient attention. However, current evidence does not suggest the superiority and effectiveness of nonpharmacological interventions in reducing psychological symptoms among patients with CLBP.Thus, this study was designed to compare the effectiveness of nonpharmacological interventions for depression, anxiety, and mental health among patients with CLBP and to recommend preferred strategies for attenuating psychological symptoms in clinical practice.

METHODS

In this systematic review and network meta-analysis (NMA), PubMed, Embase Database, Web of Science, and Cochrane Library were searched from database inception until March 2022. Randomized clinical trials (RCTs) that compare different nonpharmacological interventions for depression, anxiety, and mental health among patients with CLBP were eligible. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was used. Four reviewers in pairs and divided into two groups independently performed literature selection, data extraction, and risk of bias, and certainty of evidence assessments. This NMA was conducted with a random effects model under a frequentist framework. The major outcomes were depression, anxiety, and mental health presented as the standardized mean difference (SMD) with the corresponding 95% CI.

RESULTS

A total of 66 RCTs that randomized 4806 patients with CLBP met the inclusion criteria. The quality of evidence was typically low or some risks of bias (47 out of 66 trials, 71.3%), and the precision of summary estimates for effectiveness varied substantially. In addition, 7 categories of interventions with 26 specific treatments were evaluated. For depression, mind body therapy (pooled SMD = -1.20, 95% CI: -1.63 to -0.78), biopsychosocial approach (pooled SMD = -0.41, 95% CI: -0.70 to -0.12), and physical therapy (pooled SMD = -0.26, 95% CI: -0.50 to -0.02) exhibited remarkable effectiveness in reducing depression compared with the control group. For managing anxiety, mind body therapy (pooled SMD = -1.35, 95% CI: -1.90 to -0.80), multicomponent intervention (pooled SMD = -0.47, 95% CI: -0.88 to -0.06), and a biopsychosocial approach (pooled SMD = -0.46, 95% CI: -0.79 to -0.14) were substantially superior to the control group. For improving mental health, multicomponent intervention (pooled SMD = 0.77, 95% CI: 0.14 to 1.39), exercise (pooled SMD = 0.60, 95% CI: 0.08 to 1.11), and physical therapy (pooled SMD = 0.47, 95% CI: 0.02-0.92) demonstrated statistically substantial effectiveness compared with the control group. The rank probability indicated that mind body therapy achieved the highest effectiveness in reducing depression and anxiety among patients with CLBP. Besides, the combined results should be interpreted cautiously based on the results of analyses evaluating the inconsistency and certainty of the evidence.

CONCLUSION

This systemic review and NMA suggested that nonpharmacological interventions show promise for reducing psychological symptoms among patients with CLBP. In particular, mind body therapy and a biopsychosocial approach show considerable promise, and mind body therapy can be considered a priority choice in reducing depression and anxiety. These findings can aid clinicians in assessing the potential risks and benefits of available treatments for CLBP comorbidity with psychological symptoms and provide evidence for selecting interventions in clinical practice. More RCTs involving different interventions with rigorous methodology and an adequate sample size should be conducted in future research.

The impact of rumination on fibromyalgia pain after physical activity: an experimental study

Some fibromyalgia (FM) patients engage in rumination (i.e. a chain of repetitive, passive and relatively uncontrollable thoughts focused on negative content) to cope with the pain and discomfort of daily activities. The partial model of rumination in chronic pain suggests that rumination processes may play a causal role in maintaining pain. Rumination might also be one of the key factors interfering with the reestablishment of adapted physical activity. The objective of this study was to test how rumination vs. distraction induction influence FM patients' pain intensity, discomfort linked to pain, and affect after physical activity. Forty-seven participants with a diagnosis of FM were randomly assigned to undergo distraction induction vs. rumination induction after performing a physical activity in ecological setting. Their pain intensity, pain-related discomfort, and affect were measured at the baseline, after physical activity, and after rumination versus distraction induction. A series of mixed-design ANOVAs showed that rumination induction after physical activity impairs patients' recovery in terms of pain intensity and discomfort, but not affect, as compared to the distraction condition. In conclusion, participants with fibromyalgia who engage in rumination following a physical activity recover less from their pain experience as compared to distraction induction. These results are consistent with the partial model of rumination in chronic pain and support the idea that rumination may play a causal role in the development and maintenance of pain.

Evaluating the effectiveness of a comprehensive education on low back pain treatment outcomes: A controlled clinical study

OBJECTIVES

To investigate the effect of integrating an individualized, evidence-based low back pain comprehensive education package on low back pain treatment outcomes.

DESIGN

Single-blind, controlled clinical study using the alternate allocation of patients.

SETTING

Outpatient clinic.

SUBJECTS

In total, 54 participants with chronic low back pain (46.75 ± 11.11 years, 80% females) were randomized to intervention (n = 27) or a control group (n = 27).

INTERVENTION

The intervention group received additional four one-hour low back pain-related education sessions to eight 45 minutesstandard physical therapy sessions over 4 weeks.

OUTCOME MEASURES

Assessed at baseline, post-intervention, and 3 months. Outcome measures included pain intensity (Visual Analogue Scale), knowledge (Low Back Pain Knowledge Questionnaire), attitude (the Back Pain Attitudes Questionnaire), disability (the Oswestry Disability Index), mental health symptoms (Depression Anxiety Stress Scale, DASS-21 scale), and fear-avoidance (Fear-Avoidance Beliefs Questionnaire).

RESULTS

The intervention group showed significantly lower pain intensity ((4 weeks (3.58 ± 1.50 vs. 5.54 ± 1.92), 3 months (3.21 ± 1.74 vs. 5.69 ± 2.51)), higher knowledge ((4 weeks (21.67 ± 2.12 vs. 11.62 ± 3.47), three months (22.08 ± 3.40 vs. 12.23 ± 3.24)), lower negative attitudes ((4 weeks (99.29 ± 11.02 vs. 134.31 ± 12.97), 3 months (102.92 ± 15.58 vs. 132.42 ± 17.79)), lower disability ((4 weeks (26.30 ± 11.37 vs. 45.14 ± 18.67), 3 months (22.83 ± 16.06 vs. 44.13 ± 15.02)), lower stress score ((4 weeks (3.54 ± 3.01 vs. 8.81 ± 5.19), 3 months (3.21 ± 3.22 vs. 7.21 ± 4.36)), lower anxiety ((4 weeks (2.63 ± 3.16 vs. 6.42 ± 4.75), three months (2.63 ± 3.80 vs. 5.73 ± 4.44)), lower depression ((4 weeks (2.42 ± 2.15 vs. 6.42 ± 3.68), three months (2.63 ± 4.18 vs. 7.08 ± 4.41)), and lower fear-avoidance ((4 weeks (13.88 ± 12.32 vs. 50.88 ± 23.25), three months (15.50 ± 16.75 vs. 54.65 ± 31.81)).

CONCLUSION

Integrating low back pain comprehensive education into standard physical therapy might optimize the treatment outcomes of low back pain.