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.

Initial development and psychometric properties of the Therapist Quality Scale

PURPOSE/OBJECTIVE

This study sought to develop and evaluate the psychometric properties of a brief measure of the quality of therapist treatment delivery that would be applicable for use across different types of psychosocial chronic pain treatments: the Therapist Quality Scale (TQS).

RESEARCH METHOD/DESIGN

An initial pool of 14 items was adapted from existing measures, with items selected that are relevant across interventions tested in a parent trial comparing an 8-week, group, Zoom-delivered mindfulness meditation, cognitive therapy, and behavioral activation for chronic back pain from which data for this study were obtained. A random selection of 25% of video-recorded sessions from each cohort was coded for therapist quality (two randomly selected sessions per group), with 66 sessions included in the final analyses (n = 33 completed pairs). Items were coded on a 7-point Likert-type scale. Exploratory factor analysis (EFA) and reliability estimates were generated.

RESULTS

EFA showed a single-factor solution that provided a parsimonious explanation of the correlational structure for both sessions. Eight items with factor loadings of ≥ .60 in both sessions were selected to form the TQS. Reliability analyses demonstrated all items contributed to scale reliability, and internal consistency reliabilities were good (αs ≥ .86). Scores for the eight-item TQS from the two sessions were significantly correlated (r = .59, p < .001).

CONCLUSIONS/IMPLICATIONS

The TQS provides a brief measure with preliminary psychometric support that is applicable for use across different types of treatments to rate the quality of the therapist's delivery. The items assess quality in delivering specific techniques, maintaining session structure, and in developing and maintaining therapeutic rapport. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Evaluating the benefits of a second pain treatment following a clinical trial

OBJECTIVE

To examine the value of including an open label phase after a clinical trial of pain treatments by examining participant characteristics and potential benefits.

METHOD

Secondary data analysis. Veterans with chronic pain who completed a randomized controlled trial (RCT) comparing hypnosis, mindfulness meditation, and pain education were invited to participate in an open label phase. Average and worst pain intensities, pain interference, and depression were assessed pre- and postopen label phase; global impressions of change and treatment satisfaction were assessed at postopen label phase only.

RESULTS

Of those who were offered the open label phase, 40% (n = 68) enrolled. Enrollees were likely to be older, to have attended more sessions in the RCT, to be satisfied with their first treatment, and to perceive improvement in their ability to manage pain after the RCT. In the open label phase, depression and worst pain decreased across all three treatment conditions. No other improvements were observed. However, most Veterans perceived improvements in pain intensity, ability to manage pain, and pain interference, and were satisfied with the second intervention.

CONCLUSIONS

There appears to be some value to adding an open label phase to the end of a trial of pain treatments. A substantial portion of study participants elected to participate and reported it to be beneficial. Exploring data from an open label phase can illuminate important aspects of patient experience, barriers to and facilitators of care, as well as treatment preferences. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Moderating Effects of Cognitive Processes on Pain-related Outcomes

Although evidence supports the importance of pain-related thoughts (ie, cognitive content, or what people think) as predictors of pain and pain-related function, evidence regarding the role of cognitive processes (ie, how people think about pain, eg, by accepting pain, not making judgments about pain, or being absorbed by the pain experience) in adjustment to chronic pain is in its early stages. Using baseline data from a clinical trial of individuals with chronic low back pain (N = 327), the study aimed to increase knowledge regarding the associations between cognitive processes, pain intensity, pain interference, and depression. The results indicate that a number of cognitive processes are significantly related to pain intensity when controlling for catastrophizing, although the pattern of associations found was opposite to those anticipated. One cognitive process (pain absorption) was found to be significantly associated with pain interference, and 9 of 10 cognitive processes were significantly associated with depression when controlling for catastrophizing. In each case, the processes thought to be adaptive were negatively associated with pain interference and depression, and processes thought to be maladaptive evidenced the opposite pattern. The findings are consistent with-but do not prove, given the cross-sectional nature of the data-the possibility that cognitive processes play an important role in adjustment to chronic pain. The potential role these variables play in depression was particularly noteworthy. Longitudinal and experimental studies to evaluate the causal nature of the associations identified are warranted. PERSPECTIVE: The study findings highlight the potential importance of cognitive process variables (ie, how people think) in adjustment to chronic pain. Research to evaluate cognitive processes as potential mechanism variables in pain treatment is warranted.

Who Benefits the Most From Different Psychological Chronic Pain Treatments? An Exploratory Analysis of Treatment Moderators

Different psychological chronic pain treatments benefit some individuals more than others. Understanding the factors that are associated with treatment response-especially when those factors differ between treatments-may inform more effective patient-treatment matching. This study aimed to identify variables that moderate treatment response to 4 psychological pain interventions in a sample of adults with low back pain or chronic pain associated with multiple sclerosis, spinal cord injury, acquired amputation, or muscular dystrophy (N = 173). The current study presents the results from secondary exploratory analyses using data from a randomized controlled clinical trial which compared the effects of 4 sessions of cognitive therapy (CT), hypnosis focused on pain reduction (HYP), hypnosis focused on changing pain-related cognitions and beliefs (HYP-CT), and a pain education control condition (ED). The analyses tested the effects of 7 potential treatment moderators. Measures of primary (pain intensity) and secondary (pain interference, depression severity) outcome domains were administered before and after the pain treatments, and potential moderators (catastrophizing, hypnotizability, and electroencephalogram (EEG)-assessed oscillation power across five bandwidths) were assessed at pre-treatment. Moderator effects were tested fitting regression analyses to pre- to post-treatment changes in the three outcome variables. The study findings, while preliminary, support the premise that pre-treatment measures of hypnotizability and EEG brain activity predict who is more (or less) likely to respond to different psychological pain treatments. If additional research replicates the findings, it may be possible to better match patients to their more individually suitable treatment, ultimately improving pain treatment outcomes. PERSPECTIVE: Pre-treatment measures of hypnotizability and EEG-assessed brain activity predicted who was more (or less) likely to respond to different psychological pain treatments. If these findings are replicated in future studies, they could inform the development of patient-treatment matching algorithms.

Placebo effects contribute to brief online mindfulness interventions for chronic pain: results from an online randomized sham-controlled trial

ABSTRACT

Mindfulness apps are becoming popular treatments for chronic pain and mental health, despite mixed evidence supporting their efficacy. Furthermore, it is unclear whether improvements in pain are due to mindfulness-specific effects or placebo effects because no trials have compared mindfulness against a sham control. The objective of this study was to compare mindfulness against 2 sham conditions with differing proximity to mindfulness to characterize the relative contributions of mindfulness-specific and nonspecific processes on chronic pain. We assessed changes in pain intensity and unpleasantness and mindfulness-specific and nonspecific pain-related processes in 169 adults with chronic or recurrent pain randomized to receive a single 20-minute online session of mindfulness, specific sham mindfulness, general sham mindfulness, or audiobook control. Mindfulness was not superior to shams for reducing pain intensity or unpleasantness, and no differential engagement of theorized mindfulness-specific processes was observed. However, mindfulness and both shams reduced pain unpleasantness relative to audiobook control, with expectancy most strongly associated with this effect. Sham specificity had no influence on expectancy or credibility ratings, pain catastrophizing, or pain effects. These findings suggest that improvements in chronic pain unpleasantness following a single session of online-delivered mindfulness meditation may be driven by placebo effects. Nonspecific treatment effects including placebo expectancy and pain catastrophizing may drive immediate pain attenuation rather than theorized mindfulness-specific processes themselves. Further research is needed to understand whether mindfulness-specific effects emerge after longer durations of online training.

Effects of hypnosis, mindfulness meditation, and education for chronic pain on substance use in veterans: A supplementary analysis of a randomized clinical trial

PURPOSE/OBJECTIVE

To examine the impact of three behavioral interventions for chronic pain on substance use.

RESEARCH METHOD/DESIGN

Participants were 328 Veterans with chronic pain receiving care at one of two Veterans Affairs Medical Centers in the northwest United States. Participants were randomly assigned to one of three 8-week manualized in-person group treatments: (a) hypnosis (HYP), (b) mindfulness meditation (MM), or (c) active education control (ED). Substance use frequency was assessed using 10 individual items from the WHO-ASSIST, administered at baseline prior to randomization and at 3- and 6-month posttreatment.

RESULTS

Baseline substance use (i.e., any use) in the past 3 months was reported by 22% (tobacco), 27% (cannabis), and 61% (alcohol) of participants. Use of all other substances assessed was reported by < 7% of participants. Results showed that MM, as compared to ED, significantly reduced risk of daily cannabis use by 85% and 81% at the 3- and 6-month posttreatment follow-ups, respectively, after adjusting for baseline use. HYP, as compared to ED, significantly reduced risk of daily cannabis use by 82% at the 6-month posttreatment follow-up after adjusting for baseline use. There was no intervention effect on tobacco or alcohol use at either posttreatment follow-up.

CONCLUSIONS/IMPLICATIONS

HYP and MM for chronic pain may facilitate reductions in cannabis use, even when reducing such use is not a focus of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Are Prayer-Based Interventions Effective Pain Management Options? A Systematic Review and Meta-analysis of Randomized Controlled Trials

This review examined the effects of private and communal participatory prayer on pain. Nine databases were searched. Six randomized controlled trials were included. For private prayer, medium to large effects emerged for 67% to 69% of between-group comparisons; participants in the prayer condition reported lower pain intensity (0.59 < d < 26.17; 4 studies) and higher pain tolerance (0.70 < d < 1.05; 1 study). Pre- to post-intervention comparisons yielded medium to large effects (0.76 < d < 1.67; 2 studies); pain intensity decreased. Although firm conclusions cannot be made because meta-analysis was based on only two studies, the analysis suggested prayer might reduce pain intensity (SMD = - 2.63, 95% CI [- 3.11, - 2.14], I = 0%). (PROSPERO: CRD42020221733).

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

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

Immediate Effects of Hypnosis, Mindfulness Meditation, and Prayer on Cold Pressor Outcomes: A Four-Arm Parallel Experimental Study

Purpose

Previous research supports the usefulness of hypnosis (HYP), mindfulness meditation (MM), and prayer as pain self-management strategies in adults with chronic pain. However, their effects on acute pain have been less researched, and no previous head-to-head study compared the immediate effects of these three approaches on pain-related outcomes. This study compared the immediate effects of HYP, MM, and Christian prayer (CP) on pain intensity, pain tolerance, and stress as assessed by heart rate variability (HRV).

Participants and Methods

A total of 232 healthy adults were randomly assigned to, and completed, a single 20-minute session of MM, SH, CP, or an attention control (CN), and underwent two cycles (one pre- and one post-intervention) of Cold Pressor Arm Wrap (CPAW). Sessions were audio-delivered. Participants responded to pre- and post-intervention pain intensity measurements. Pain tolerance (sec) was assessed during the CPAW cycles. HRV was assessed at baseline, and at pre- and post-intervention CPAW cycles. The study protocol was pre-registered at the ClinicalTrials.gov registry (NCT04491630).

Results

Small within-group decreases in pain intensity and small increases in pain tolerance were found for HYP and MM from the pre- to the post-intervention. Small within-group improvements in the LH/HF ratio were also found for HYP. The exploratory between-group pairwise comparisons revealed a medium effect size effects of HYP on pain tolerance relative to the control condition. The effects of CP were positive, but small and not statistically significant. Only small to medium, though non-significant, Time × Group interaction effects were found.

Conclusion

Study results suggest that single short-term HYP and MM sessions, but not biblical-based CP, may be useful for acute pain self-management, with HYP being the slightly superior option. Future research should compare the effects of different types of prayer and examine the predictors and moderators of these pain approaches' effects on pain-related outcomes.

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.

The Flares of Low back pain with Activity Research Study (FLAReS): study protocol for a case-crossover study nested within a cohort study

BACKGROUND

Although it is generally accepted that physical activity and flares of low back pain (LBP) are related, evidence for the directionality of this association is mixed. The Flares of Low back pain with Activity Research Study (FLAReS) takes a novel approach to distinguish the short-term effects of specific physical activities on LBP flares from the cumulative effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. The first aim is to estimate the short-term effects (≤ 24 h) of specific physical activities on LBP flares among Veterans in primary care in the Veterans Affairs healthcare system. The second aim is to estimate the cumulative effects of specific activities on LBP-related functional limitations at 1-year follow-up.

METHODS

Up to 550 adults of working age (18-65 years) seen for LBP in primary care complete up to 36 "Scheduled" surveys over 1-year follow-up, and also complete unscheduled "Flare Window" surveys after the onset of new flares. Each survey asks about current flares and other factors associated with LBP. Surveys also inquire about activity exposures over the 24 h, and 2 h, prior to the time of survey completion (during non-flare periods) or prior to the time of flare onset (during flares). Other questions evaluate the number, intensity, duration, and/or other characteristics of activity exposures. Other exposures include factors related to mood, lifestyle, exercise, concurrent treatments, and injuries. Some participants wear actigraphy devices for weeks 1-4 of the study. The first aim will examine associations between 10 specific activity categories and participant-reported flares over 1-year follow-up. The second aim will examine associations between the frequency of exposure to 10 activity categories over weeks 1-4 of follow-up and long-term functional limitations at 12 months. All analyses will use a biopsychosocial framework accounting for potential confounders and effect modifiers.

DISCUSSION

FLAReS will provide empirically derived estimates of both the short-term and cumulative effects of specific physical activities for Veterans with LBP, helping to better understand the role of physical activities in those with LBP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04828330 , registered April 2, 2021.

Development of the Pain Responses Scale: A measure informed by the BIS-BAS model of pain

BACKGROUND

The behavioural inhibition system and activation system (BIS-BAS) model of pain focusses on two clusters of responses to pain-escape/avoidance (BIS) and approach (BAS) behaviours. While the BIS-BAS model emphasizes active responses to pain, deactivation responses such as despondence and relaxation are also common. This study sought to develop self-report scales assessing cognitive, behavioural intentions and affective responses to pain consistent with this extended BIS-BAS framework. We also sought to develop short-forms of the emerging scales.

METHODS

Confirmatory factor analysis was performed to derive scales from a large item pool administered to a community sample with heterogeneous chronic pain (N = 476).

RESULTS

The items resulted in 16 scales assessing Thoughts, Affective responses, Behavioural Intentions and Valence-Associated Thoughts, which loaded on to the four theorized types of pain responses-Escape, Approach, Despondence and Relaxation-with the four emerging short-form scales assessing these overarching factors. The internal consistency reliabilities of the long-forms generally ranged from good to excellent (αs ≥ 0.83), with the exception of the Relaxation-Behavioural Intentions scale (α = 0.64). The four short-forms demonstrated at least adequate internal consistency reliability (αs ≥ 0.79). An initial test of the construct validity of the scales in relation to pain-related outcomes is also reported.

CONCLUSIONS

We anticipate that the Pain Responses Scale (PRS) developed from this research will be useful for assessing mechanisms targeted by many psychosocial pain treatments and will provide a nuanced understanding of the shared versus specific nature of these mechanisms.

SIGNIFICANCE

The Pain Responses Scale emerging from this research assesses four theorized, overarching responses to pain: Escape, Approach, Giving Up and Relaxation. This measure will afford the capacity to test a reconceptualized BIS-BAS model of pain and inform treatments that are adapted based on this framework.

Pain Medication Beliefs Mediate the Relationship Between Pain Catastrophizing and Opioid Prescription Use in Patients With Chronic Non-Cancer Pain

Little is known about the mechanisms by which pain catastrophizing may be associated with opioid use outcomes. This study aimed to investigate the potential mediating role of beliefs about the appropriateness of pain medicines for pain treatment on the association between pain catastrophizing and prescription opioid use in a community chronic non-cancer pain (CNCP) sample. Individuals (N = 420) diagnosed with CNCP participated in a cross-sectional online self-report study with validated measures of pain medication beliefs, pain catastrophizing, and current prescription opioid use. Two parallel multiple mediator analyses with percentile-based bootstrapping examined pathways to both prescription opioid use and high-dose use (≥ 100mg oral morphine equivalents/day), while controlling for pain intensity and other relevant covariates. Pain medication beliefs significantly mediated the association between pain catastrophizing and prescription opioid use (CI = 0.011, 0.033). A similar pattern of findings was found for high-dose opioid use, with pain medication beliefs significantly mediating the pain catastrophizing-high-dose use association (CI = 0.006, 0.050). Pain medication beliefs are a potentially modifiable psychological mechanism by which pain catastrophizing is associated with opioid use, including high-dose use. These findings have important implications for personalizing prevention and treatment programs.

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.

A qualitative comparison of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain

PURPOSE/OBJECTIVE

This study reports a qualitative analysis of patient experiences following cognitive therapy (CT), mindfulness meditation (MM), or mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP). It aimed to investigate the procedural elements reported by participants as important across these approaches, as well as the role of treatment-related change processes and common factors. Research Method/Design: A qualitative analysis of posttreatment semistructured interviews was conducted with participants who enrolled in a randomized controlled trial comparing MM, CT, and MBCT (N = 57 adults with CLBP). A thematic analysis of transcribed interviews was undertaken by two independent coders; emerging themes, subthemes, and direct quotes were collated, and thematic maps were created.

RESULTS

Procedural elements that were both unique (e.g., "cognitive restructuring" in CT) and shared among the three treatments (e.g., "knowledge gained" on pain-related topics) were reported as important. Each treatment was associated with a small number of unique therapeutic processes that were consistent with theoretical tenets underlying the interventions (e.g., "staying in the present moment" in MM). A large number of shared processes and common factors also emerged as important across all three treatments.

CONCLUSIONS/IMPLICATIONS

These first-person accounts provide insight into those participant-identified therapeutic procedures and change processes that were most valued by individuals completing cognitive and mindfulness-based interventions for CLBP. Early identification of treatment barriers and strategies to overcome these barriers is necessary. Further, therapeutic rapport and training participants in coping skills they themselves can use were critical, as was engendering changes in cognitive, emotional, and behavioral mechanisms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Prayer as a pain intervention: protocol of a systematic review of randomised controlled trials

BACKGROUND

Pain is a universal experience and the most common reason for seeking healthcare. Inadequate pain management negatively impacts numerous aspects of patient health. Multidisciplinary treatment programmes, including psychosocial interventions, are more useful for pain management than purely biomedical treatment alone. Recently, researchers showed increasing interest in understanding the role of spirituality/religiosity and spiritual/religious practices on pain experience, with engagement in religious practices, such as prayer, showing to positively impact pain experience in religious individuals. This systematic review will seek to summarise and integrate the existing findings from randomised controlled trials assessing the effects of prayer and prayer-based interventions on pain experience.

METHODS

The systematic review procedures and its report will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Electronic searches in nine databases (Web of Science Core Collection, MEDLINE, SCIELO Citation Index, PubMed, Cochrane Central Register of Controlled Clinical Trial, PsycINFO, Scopus, LILACS and Open-SIGLE) will be performed to identify randomised controlled trials of prayer-based interventions. Two independent researchers will assess studies for inclusion and extract data from each paper. Risk of bias assessment will be assessed independently by two reviewers based on the Consolidated Standards of Reporting Trials statement. Qualitative synthesis of the body of research will be conducted using a narrative summary synthesis method. Meta-analysis will be limited to studies reporting on the same primary outcome. Formal searches are planned to start in June 2021. The final report is anticipated to be completed by September 2021.

DISCUSSION

Findings will be useful to (1) understand the condition of our knowledge in this field and (2) provide evidence for prayer effectiveness in reducing pain intensity and pain-related stress and increasing pain tolerance in adults experiencing acute or chronic pain.

PROSPERO REGISTRATION NUMBER

CRD42020221733.

Pain-related beliefs, cognitive processes, and electroencephalography band power as predictors and mediators of the effects of psychological chronic pain interventions

ABSTRACT

The current study used data from a clinical trial to identify variables that are associated with and/or mediate the beneficial effects of 4 psychological chronic pain treatments: one teaching patients self-hypnosis to reduce pain intensity (HYP), one teaching self-hypnosis to change thoughts about pain (hypnotic cognitive therapy [HYP-CT]), one teaching cognitive restructuring skills to change thoughts about pain (cognitive therapy [CT]), and one providing education about pain (ED; included as an active control condition). Of 17 possible mechanism variables examined, and with alpha not corrected for multiple comparisons, significant between-group differences were observed for 3. Two of these (changes in beliefs about control over pain and number of days of skill practice) were supported as mediators of the beneficial effects of HYP, CT, or HYP-CT, relative to ED. Six mechanism variables evidenced significant pretreatment to post-treatment changes in the sample as a whole, without showing significant between-group differences. Pretreatment to post-treatment changes in all 6 were associated with improvements in pain interference, pain intensity, or both. In addition, participant ratings of therapeutic alliance at post-treatment were associated significantly with improvements in both pain intensity and pain interference in the sample as a whole. Thus, of the 17 possible mediators examined, there were relatively few that served as mediators for the beneficial effects of specific treatments; a larger number of variables predicted treatment outcome overall. The extent to which these variables are treatment mediators (ie, are responsible for, rather than merely associated with, treatment-related improvements) will require further research.

Transdiagnostic Cognitive Processes in Chronic Pain and Comorbid PTSD and Depression in Veterans

BACKGROUND

Chronic pain in Veterans is a major problem compounded by comorbid posttraumatic stress disorder (PTSD) and depression. Adopting a transdiagnostic framework to understanding "shared territory" among these diagnoses has the potential to inform our understanding of the underlying cognitive processes and mechanisms that transverse diagnostic boundaries.

PURPOSE

To examine the associations between pain-related cognitive processes (diversion, distancing, absorption, and openness), pain intensity, PTSD and depressive symptoms, and the extent to which Veterans with chronic pain with and without comorbid PTSD and depression engage in different/similar pain-related cognitive processes.

METHODS

Secondary analysis of pretreatment data with a subsample (n = 147) of Veterans with chronic pain from a larger clinical trial. Pretreatment PCL-5 and PROMIS Depression scales were used to categorize participants into three groups: (a) Pain-only; (b) Pain-PTSD; and (c) Pain-PTSD-DEP.

RESULTS

Compared to the Pain-only group, the Pain-PTSD and Pain-PTSD-DEP groups reported significantly greater pain intensity, PTSD and depressive symptoms, and ruminative pain absorption. The Pain-PTSD-DEP group had significantly lower pain diversion and pain openness scores. When diversion and openness were used within the Pain-PTSD-DEP group, however, they were both associated with lower pain intensity and openness was additionally associated with lower PTSD scores. However, in the Pain-PTSD group, pain openness was associated with higher depression scores.

CONCLUSIONS

Across increasing complexity of comorbidity profiles (i.e., one vs. two comorbid conditions), ruminative absorption with pain emerged as a cognitive process that transverses diagnoses and contributes to worse outcomes. Nonjudgmental acceptance may not be universally beneficial, potentially depending upon the nature of comorbidity profiles.

COPAHS Study: protocol of a randomised experimental study comparing the effects of hypnosis, mindfulness meditation, and spiritual practices on experimental pain in healthy adults

BACKGROUND

There has been an increasing interest in studying the potential benefits of so-called complementary and alternative approaches for pain management, such as hypnosis and mindfulness-based interventions. More recently, researchers have been interested in studying the effects of spiritual practices on pain experience as well. These practices may increase pain tolerance, result in a positive re-appraisal of pain and influence other psychological variables that are known to be associated with pain experience. The purpose of this study is to evaluate and compare the immediate effects of self-hypnosis, mindfulness meditation, and a spiritual intervention relative to a control condition for increasing pain tolerance and reducing pain intensity and pain-related stress, in response to experimental painful stimulation.

METHODS AND ANALYSIS

Recruitment is anticipated to start in November 2020. This is a randomised quantitative experimental mixed-design repeated-measures study with three assessment points: baseline (T0), pre-test (T1) and post-test (T2). Eligible healthy adults will be randomised to one of the four study conditions. Interventions will be a 20-minute audio-guided practice of either self-hypnosis, mindfulness meditation, or Christian prayer. Participants in the control group will not be instructed to use any specific strategy during the painful stimulation. Participants will be submitted to a first cycle of Cold Pressor Arm Wrap. They will then listen to a 20-minute audio recording inducing one of the three interventions, or, in the case of the control group, to a 20-minute audio recording of text from a natural history textbook. Primary outcomes are pain intensity and pain tolerance. Pain-related stress as measured by salivary cortisol level and heart rate variability are secondary outcomes.

ETHICS AND DISSEMINATION

This study was approved by ISPA-University Institute's internal Ethics Committee for Research on 3rd December 2018 (reference I/010/12/2018). Findings will be published in peer-reviewed indexed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov registry (NCT04491630). Stage: pre-results.

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.

Differentiating state versus trait pain catastrophizing

PURPOSE/OBJECTIVE

This study investigated the type and recency of the pain experience recalled (i.e., pain referent) by a healthy group and a chronic/recurrent pain group when they responded to the trait version of the Pain Catastrophizing Scale (PCS). We also aimed to disentangle the influence of trait personality factors and state oriented pain-related cognitive processes on PCS scores. Research Method/Design: A cross-sectional online survey was administered. Participants who reported chronic/recurrent pain comprised the pain group (N = 153) and those not reporting a pain condition comprised the healthy group (N = 120).

RESULTS

A sensory pain referent, as opposed to an emotional pain referent, was reported by 92% of the healthy group and 95% of the pain group; however, the PCS pain referent in the pain group was different from their self-reported type of chronic/recurrent pain in 55% of cases. In the healthy group, 86% of participants reported PCS pain referents that occurred > 24 hr ago; 51% of participants in the pain group reported using pain referents occurring < 24 hr ago. Neuroticism and conscientiousness significantly predicted PCS scores in the healthy group. Within the pain group, both neuroticism and the state-oriented measure of rumination/absorption significantly predicted PCS scores, with rumination/absorption evidencing the largest effect size.

CONCLUSIONS/IMPLICATIONS

These findings suggest individuals with and without chronic/recurrent pain focus on a sensory pain referent when answering the PCS. The results have implications for refining the PCS instructions and for improving the sensitivity of this measure in capturing variance in pain-related outcomes, particularly when administered in homogenous pain type (e.g., migraine) populations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Behavioral activation and behavioral inhibition: An examination of function in chronic pain

PURPOSE/OBJECTIVE

The objective of the study was to examine the BIS-BAS model of chronic pain. This model posits that 2 neurophysiological systems-the behavioral inhibition system (BIS) sensitized to and activated by punishment cues and the behavioral activation system (BAS) sensitized to and activated by reward cues-make independent and concurrent contributions to 2 domains of pain-related function: pain interference and positive function despite pain. The study additionally hypothesized that BIS and BAS sensitivity would have different associations with these 2 different aspects of pain-related function. BIS activation would be more strongly correlated with pain interference and BAS would be more strongly correlated with positive function despite pain. Research Method/Design: This was a cohort study consisting of the baseline assessments of 328 veterans enrolled in a large clinical trial examining 3 psychosocial interventions for chronic pain.

RESULTS

In multivariable regression adjusting for demographic factors and pain intensity, BIS was associated with greater pain interference and less positive function despite pain. BAS was associated with greater positive function despite pain but to a lesser degree than BIS.

CONCLUSIONS

As hypothesized, BIS and BAS both contributed to pain-related function; however, BIS displayed stronger associations with both pain interference and positive function despite pain. Thus, the hypothesis that BIS-BAS relationships would differ based on the nature of the functional outcome (BIS resulting in poorer function because of pain and BAS better function despite pain) was only partially supported. Findings of the current study suggest the role of BIS in chronic pain may be more pervasive across functional outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The roles of race, sex and cognitions in response to experimental pain

BACKGROUND

This study reports a multivariate test of sex and race differences in experimental pain, and the degree to which these differences could be uniquely attributable to three levels of cognition: primary appraisals (threat, challenge), secondary appraisals (pain catastrophizing) and/or cognitive processes (mindful observing, non-reactivity). Both the predictive and mediator role of the cognitive variables was of interest.

METHODS

The study employed a cross-sectional experimental design, with the cold pressor task employed as the pain stimulus. The total sample included N = 355 healthy adults (67% female, 33% male; 70% Caucasian, 30% Asian).

RESULTS

Significant sex and race differences on pain tolerance were found, with females and racial minorities reporting less pain tolerance (ps < 0.001). Males reported significantly higher challenge appraisals and non-reactivity, and lower pain catastrophizing than females; Asians reported significantly higher threat appraisals and pain catastrophizing than Caucasians. In multivariate analyses, challenge appraisals and non-reactivity emerged as the strongest predictors of pain tolerance. Furthermore, challenge appraisals mediated the sex-pain tolerance association (p = .017).

CONCLUSIONS

This study showed that race and sex differences, at least in part, may be accounted for by differences in pain-related cognitions.

SIGNIFICANCE

The three levels of cognition investigated in this research represent changeable, important processes for potentially mitigating the impact of pain in vulnerable groups.

Mental and Physical Health Correlates of Pain Treatment Utilization Among Veterans With Chronic Pain: A Cross-sectional Study

INTRODUCTION

The annual cost of treatment and lost productivity due to chronic pain is estimated to be $635 billion within the USA. Self-management treatments for chronic pain result in lower health care costs and lower utilization of provider-management treatments, such as hospitalization and medication use. The current study sought to identify and characterize patient factors and health conditions associated with chronic pain treatment utilization to inform ways to improve engagement in self-management pain treatment (e.g., applying heat or ice, exercising, or practicing relaxation). This study predicted (1) greater pain intensity and pain interference would be associated with greater utilization of self-management treatments and (2) this association would be moderated by patient factors (gender and age) and health comorbidities (anxiety, trauma, depression, and sleep disturbance).

MATERIALS AND METHODS

Baseline data from a three-arm clinical trial were collected for 127 Veterans seeking treatment for chronic pain. Veterans were recruited via clinician referral and medical record review at the Veterans Affairs Puget Sound Health Care System, Washington, USA.

RESULTS

Self-management treatments were more utilized than provider-management treatments. Pain intensity and pain interference were not uniquely associated with provider-management or self-management treatment utilization after controlling for demographics and mental health status. Sleep disturbance moderated the relationship between pain interference and provider-management treatment utilization. Depression moderated the relationship between pain intensity and provider-management treatment utilization.

CONCLUSIONS

While study conclusions may not generalize to all Veteran populations, findings suggest that Veterans with chronic pain were more likely to seek provider-management treatments when experiencing high-pain interference and high-sleep disturbance. In addition, Veterans were more likely to seek provider-management treatments when experiencing low-pain intensity and high-depression symptoms.

Mindfulness-based cognitive therapy and cognitive behavioral therapy for chronic pain in multiple sclerosis: a randomized controlled trial protocol

BACKGROUND

Chronic pain is one of the most prevalent and disabling symptoms associated with multiple sclerosis (MS). Individuals with MS are interested in nonpharmacologic pain management approaches. Cognitive-behavioral therapy (CBT) is efficacious in improving MS-related pain outcomes. Mindfulness-based cognitive therapy (MBCT) is a promising, alternative approach. Little is known about moderators of these treatments' outcomes, however. This article describes the study protocol for the first randomized controlled trial comparing MBCT, CBT, and usual care and examining treatment effect moderators in individuals with chronic pain and MS.

METHODS

We will conduct a single-center, randomized, single blind, parallel-group trial comparing MBCT, CBT, and usual care in adults with MS and chronic pain. Both interventions will be delivered via eight group sessions using videoconferencing technology. Primary (average pain intensity) and secondary outcomes (including pain interference, depressive symptoms, fatigue, and sleep) will be assessed pre-treatment, mid-treatment, post-treatment, and at 6-month follow up. Potential treatment moderators will be assessed pre-treatment. We hypothesize that participants randomly assigned to MBCT or CBT will report significantly greater reductions in average pain intensity than participants assigned to usual care at post-treatment (primary study endpoint) and 6-month follow up. We also hypothesize that mindfulness, pain catastrophizing, and behavioral activation pre-treatment will moderate response to both active treatments, but not response to usual care.

DISCUSSION

Findings will provide important new information about the efficacy and moderators of two nonpharmacologic pain management approaches delivered using technology to overcome common barriers to treatment access. The knowledge gained may lead to better patient-treatment matching and, ultimately, better pain treatment outcomes in MS.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03782246. Registered on 20 December 2018.

An evaluation of the behavioral inhibition and behavioral activation system (BIS-BAS) model of pain

OBJECTIVE

This study evaluated the behavioral inhibition and activation system (BIS-BAS) model of pain. Frontal alpha asymmetry (FAA) as a possible neurophysiological correlate of the BIS-BAS was also explored, as was the role of personality factors.

RESEARCH METHOD

A cross-sectional study was completed at the University of (The University of Queensland). The sample was N = 69 adults with chronic low back pain. Self-report and data were collected as a part of a treatment outcome study. Correlational analyses were conducted between theorized BIS-BAS-related measures of cognitions (catastrophizing, control beliefs), emotion (depression, anxiety, happiness), and behavior (avoidance, engagement). Correlations and hierarchical regression were used to explore the association between these measures, pain intensity, personality factors, and FAA.

RESULTS

As hypothesized, the correlations between the BIS and BAS measures were all negative and mostly significant (ps < .05). The BIS-related measures were significantly positively associated with each other and Neuroticism (ps <.01). The BAS-related measures were positively correlated with each other and Extraversion, with most of these associations statistically significant. While pain intensity was significantly associated with several BIS and BAS measures (ps < .05), FAA was not significantly associated with pain or any BIS-BAS domain. BAS-related measures were most strongly associated with pain intensity (ΔR² = .13).

CONCLUSIONS

Few studies have concurrently investigated the intersection between brain state, pain-related variables and psychosocial factors. This is the first study to test these associations from the perspective of a BIS-BAS model of pain. The findings provide preliminary support for the central tenets of this framework. The clinical implications of the findings are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Pilot Randomized Controlled Trial Comparing Mindfulness Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain

Objective

This pilot trial compared the feasibility, tolerability, acceptability, and effects of group-delivered mindfulness meditation (MM), cognitive therapy (CT), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP).

Setting

University of Queensland Psychology Clinic.

Subjects

Participants were N = 69 (intent-to-treat [ITT] sample) adults with CLBP.

Design

A pilot, assessor-blinded randomized controlled trial.

Methods

Participants were randomized to treatments. The primary outcome was pain interference; secondary outcomes were pain intensity, physical function, depression, and opioid medication use. The primary study end point was post-treatment; maintenance of gains was evaluated at three- and six-month follow-up.

Results

Ratings of acceptability, and ratios of dropout and attendance showed that MBCT was acceptable, feasible, and well tolerated, with similar results found across conditions. For the ITT sample, large improvements in post-treatment scores for pain interference, pain intensity, physical function, and depression were found (P < 0.001), with no significant between-group differences. Analysis of the follow-up data (N = 43), however, revealed that MBCT participants improved significantly more than MM participants on pain interference, physical function, and depression. The CT group improved more than MM in physical function. The MBCT and CT groups did not differ significantly on any measures.

Conclusions

This is the first study to examine MBCT for CLBP management. The findings show that MBCT is a feasible, tolerable, acceptable, and potentially efficacious treatment option for CLBP. Further, MBCT, and possibly CT, could have sustained benefits that exceed MM on some important CLBP outcomes. A future definitive randomized controlled trial is needed to evaluate these treatments and their differences.

The Association Between Mindfulness and Hypnotizability: Clinical and Theoretical Implications

Mindfulness-based interventions and hypnosis are efficacious treatments for addressing a large number of psychological and physical conditions, including chronic pain. However, there continues to be debate surrounding the relative uniqueness of the theorized mechanisms of these treatments-reflected by measures of mindfulness facets and hypnotizability-with some concern that there may be so much overlap as to make the mechanism constructs (and, therefore, the respective interventions) redundant. Given these considerations, the primary aim of the current study was to examine the degree of unique versus shared variance between two common measures of mindfulness facets and hypnotizability: the Five Facet Mindfulness Questionnaire and the Stanford Hypnotic Clinical Scale. A cross-sectional survey was conducted with a sample of (N = 154) veterans with heterogeneous chronic pain conditions. Bivariate Pearson correlations were used to examine the associations between the target scales. Results showed that the correlations between the Five Facet Mindfulness Questionnaire scales and Stanford Hypnotic Clinical Scale total score were uniformly weak, although significant negative correlations were found between mindfulness facets of observe and nonreact with hypnotizability (ps < 0.05). Thus, not only are the mindfulness and hypnotizability constructs unique, but when significantly associated, hypnotic suggestibility corresponds with a tendency to be less mindful. These findings have important implications for future research aimed toward matching patients to the treatment most likely to be of benefit, and suggest that matching patients on the basis of these theoretically derived "unique" moderators may hold potential.

USE OF NEUROFEEDBACK AND MINDFULNESS TO ENHANCE RESPONSE TO HYPNOSIS TREATMENT IN INDIVIDUALS WITH MULTIPLE SCLEROSIS: Results From a Pilot Randomized Clinical Trial

This pilot study evaluated the possibility that 2 interventions hypothesized to increase slower brain oscillations (e.g., theta) may enhance the efficacy of hypnosis treatment, given evidence that hypnotic responding is associated with slower brain oscillations. Thirty-two individuals with multiple sclerosis and chronic pain, fatigue, or both, were randomly assigned to 1 of 2 interventions thought to increase slow wave activity (mindfulness meditation or neurofeedback training) or no enhancing intervention, and then given 5 sessions of self-hypnosis training targeting their presenting symptoms. The findings supported the potential for both neurofeedback and mindfulness to enhance response to hypnosis treatment. Research using larger sample sizes to determine the generalizability of these findings is warranted.

Measuring the Cognitions, Emotions, and Motivation Associated With Avoidance Behaviors in the Context of Pain: Preliminary Development of the Negative Responsivity to Pain Scales

OBJECTIVES

We recently proposed a Behavioral Inhibition System-Behavioral Activation System (BIS-BAS) model to help explain the effects of pain treatments. In this model, treatments are hypothesized to operate primarily through their effects on the domains within 2 distinct neurophysiological systems that underlie approach (BAS) and avoidance (BIS) behaviors. Measures of the model's domains are needed to evaluate and modify the model.

METHODS

An item pool of negative responses to pain (NRP; hypothesized to be BIS related) and positive responses (PR; hypothesized to be BAS related) were administered to 395 undergraduates, 325 of whom endorsed recurrent pain. The items were administered to 176 of these individuals again 1 week later. Analyses were conducted to develop and validate scales assessing NRP and PR domains.

RESULTS

Three NRP scales (Despondent Response to Pain, Fear of Pain, and Avoidant Response to Pain) and 2 PR scales (Happy/Hopeful Responses and Approach Response) emerged. Consistent with the model, the scales formed 2 relatively independent overarching domains. The scales also demonstrated excellent internal consistency, and associations with criterion variables supported their validity. However, whereas the NRP scales evidenced adequate test-retest stability, the 2 PR scales were not adequately stable.

DISCUSSION

The study yielded 3 brief scales assessing NRP, which may be used to further evaluate the BIS-BAS model and to advance research elucidating the mechanisms of psychosocial pain treatments. The findings also provide general support for the BIS-BAS model, while also suggesting that some minor modifications in the model are warranted.

Mindfulness-based cognitive therapy for headache pain: An evaluation of the long-term maintenance of effects

OBJECTIVES

This study aimed to examine the durability of gain patterns following an 8-week Mindfulness-Based Cognitive Therapy (MBCT) for headache pain program.

DESIGN

A secondary analysis of a randomized controlled trial was conducted. Participants (N=19) were individuals with headache pain who completed both the MBCT program as well as a 6-month follow-up assessment at a headache clinic or a university psychology clinic. Standardized measures of the primary outcomes (pain intensity and pain interference) and secondary outcomes (pain catastrophizing, mindfulness, activity engagement, pain willingness, and self-efficacy) were administered. Paired-samples t tests and effect sizes were examined.

RESULTS

Significant (uncorrected ps<.05) pre- to post-treatment gains were found for pain intensity, pain interference, pain catastrophizing, activity engagement and self-efficacy, and these gains were maintained at 6-months post-treatment. Effect sizes for the significant changes from pre- to post-treatment, and from pre-treatment to follow-up were mostly consistent across epochs (.62≤ds≤-1.40), indicating steady maintenance of effects. Improvement in mindfulness and pain willingness was non-significant immediately post-treatment and at follow-up, with small effects observed.

CONCLUSIONS

This study adds to a growing body of literature supporting the durability of MBCT for painful conditions. Results indicated a consistent pattern of maintenance of treatment-related gains across a number of key pain-related outcomes. Future research with a larger sample is needed to investigate the mechanisms underlying these continued gains in order to optimize targeted relapse-prevention.

A content review of cognitive process measures used in pain research within adult populations

BACKGROUND AND OBJECTIVE

Previous research suggests that measures of cognitive process may be confounded by the inclusion of items that also assess cognitive content. The primary aims of this content review were to: (1) identify the domains of cognitive processes assessed by measures used in pain research; and (2) determine if pain-specific cognitive process measures with adequate psychometric properties exist.

DATABASES AND DATA TREATMENT

PsychInfo, CINAHL, PsycArticles, MEDLINE, and Academic Search Complete databases were searched to identify the measures of cognitive process used in pain research. Identified measures were double coded and the measure's items were rated as: (1) cognitive content; (2) cognitive process; (3) behavioural/social; and/or (4) emotional coping/responses to pain.

RESULTS

A total of 319 scales were identified; of these, 29 were coded as providing an un-confounded assessment of cognitive process, and 12 were pain-specific. The cognitive process domains assessed in these measures are Absorption, Dissociation, Reappraisal, Distraction/Suppression, Acceptance, Rumination, Non-Judgment, and Enhancement. Pain-specific, un-confounded measures were identified for: Dissociation, Reappraisal, Distraction/Suppression, and Acceptance. Psychometric properties of all 319 scales are reported in supplementary material.

CONCLUSIONS

To understand the importance of cognitive processes in influencing pain outcomes as well as explaining the efficacy of pain treatments, valid and pain-specific cognitive process measures that are not confounded with non-process domains (e.g., cognitive content) are needed. The findings of this content review suggest that future research focused on developing cognitive process measures is critical in order to advance our understanding of the mechanisms that underlie effective pain treatment.

SIGNIFICANCE

Many cognitive process measures used in pain research contain a 'mix' of items that assess cognitive process, cognitive content, and behavioural/emotional responses. Databases searched: PsychInfo, CINAHL, PsycArticles, MEDLINE and Academic Search Complete. This review describes the domains assessed by measures assessing cognitive processes in pain research, as well as the strengths and limitations of these measures.

The mediating role of pain acceptance during mindfulness-based cognitive therapy for headache

OBJECTIVES

This study aimed to determine if mindfulness-based cognitive therapy (MBCT) engenders improvement in headache outcomes via the mechanisms specified by theory: (1) change in psychological process, (i.e., pain acceptance); and concurrently (2) change in cognitive content, (i.e., pain catastrophizing; headache management self-efficacy).

DESIGN

A secondary analysis of a randomized controlled trial comparing MBCT to a medical treatment as usual, delayed treatment (DT) control was conducted. Participants were individuals with headache pain who completed MBCT or DT (N=24) at the Kilgo Headache Clinic or psychology clinic. Standardized measures of the primary outcome (pain interference) and proposed mediators were administered at pre- and post-treatment; change scores were calculated. Bootstrap mediation models were conducted.

RESULTS

Pain acceptance emerged as a significant mediator of the group-interference relation (p<.05). Mediation models examining acceptance subscales showed nuances in this effect, with activity engagement emerging as a significant mediator (p<.05), but pain willingness not meeting criteria for mediation due to a non-significant pathway from the mediator to outcome. Criteria for mediation was also not met for the catastrophizing or self-efficacy models as neither of these variables significantly predicted pain interference.

CONCLUSIONS

Pain acceptance, and specifically engagement in valued activities despite pain, may be a key mechanism underlying improvement in pain outcome during a MBCT for headache pain intervention. The theorized mediating role of cognitive content factors was not supported in this preliminary study. A large, definitive trial is warranted to replicate and extend the findings in order to streamline and optimize MBCT for headache.

Toward a theoretical model for mindfulness-based pain management

Mindfulness, as both a process and a practice, has received substantial research attention across a range of health conditions, including chronic pain. Previously proposed mechanisms underlying the potential health-related benefits of mindfulness and mindfulness-based interventions (MBIs) are based on a strong theoretical background. However, to date, an empirically grounded, integrated theoretical model of the mechanisms of MBIs within the context of chronic pain has yet to be proposed. This is a surprising gap in the literature given the exponential growth of studies reporting on the benefits of MBIs for heterogeneous chronic pain conditions. Moreover, given the importance of determining how, and for whom, psychological interventions for pain management are effective, it is imperative that this gap in the literature be addressed. The overarching aim of the current theoretical paper was to propose an initial integrated, theoretically driven, and empirically based model of the mechanisms of MBIs for chronic pain management. Theoretical and research implications of the model are discussed. The theoretical considerations proposed herein can be used to help organize and guide future research that will identify the mechanisms underlying the benefits of mindfulness-based treatments, and perhaps psychosocial treatments more broadly, for chronic pain management.

PERSPECTIVE

This focus article presents an initial framework for an empirically based, theoretical model of the mechanisms of MBIs for chronic pain management. Implications of the framework for refining theory and for future research are addressed.

Predictors of anxiety in multiple sclerosis

PURPOSE/OBJECTIVES

The aims of this study were to (1) identify the predictors of symptoms of anxiety, and (2) evaluate the differential association of somatic and nonsomatic symptoms of depression on anxiety over time in persons with multiple sclerosis (MS).

METHOD/DESIGN

Participants were 513 persons with MS who previously enrolled in a study exploring the experience of living with MS and completed a 4-month follow-up survey. The main outcome measure used was the Hospital Anxiety and Depression Scale-Anxiety. Demographic, disease-associated variables (time since onset of MS, Expanded Disability Status Scale Mobility, pain, and fatigue), and Time 1 psychological variables were entered into a hierarchical regression model to examine predictors at baseline for anxiety symptoms at Time 2.

RESULTS

A large portion of the sample was White (92%), female (82%), and had relapsing-remitting MS (57%). After adjusting for demographic and disease related variables, anxiety (β <.001), employment (β = .07), and nonsomatic depressive symptoms (β = .10) at baseline significantly predicted anxiety at Time 2, ps < .05. Interactions revealed significant effects for time since onset of MS and somatic symptoms as well as time since onset and nonsomatic symptoms, ps < .05. Nonsomatic symptoms were more linked to anxiety early in the disease and somatic symptoms were more prominently linked to anxiety later in the disease.

CONCLUSIONS

Findings suggest that nonsomatic symptoms of depression and employment predict anxiety in MS. The relationship between different aspects of depression and anxiety may change over the course of the disease.

Cerebrovascular collaterals correlate with disease severity in adult North American patients with Moyamoya disease

BACKGROUND AND PURPOSE

Cerebrovascular collaterals have been increasingly recognized as predictive of clinical outcomes in Moyamoya disease in Asia. The aim of this study was to characterize collaterals in North American adult patients with Moyamoya disease and to assess whether similar correlations are valid.

MATERIALS AND METHODS

Patients with Moyamoya disease (n = 39; mean age, 43.5 ±10.6 years) and age- and sex-matched control subjects (n = 33; mean age, 44.3 ± 12.0 years) were graded via angiography. Clinical symptoms of stroke or hemorrhage were graded separately by imaging. Correlations between collateralization and disease severity, measured by the modified Suzuki score, were evaluated in patients with Moyamoya disease by fitting a regression model with clustered ordinal multinomial responses.

RESULTS

The presence of leptomeningeal collaterals (P = .008), dilation of the anterior choroidal artery (P = .01), and the posterior communicating artery/ICA ratio (P = .004) all correlated significantly with disease severity. The presence of infarct or hemorrhage and posterior steno-occlusive disease did not correlate significantly with the modified Suzuki score (P = .1). Anterior choroidal artery changes were not specific for hemorrhage. Patients with Moyamoya disease were statistically more likely than controls to have higher posterior communicating artery/ICA ratios and a greater incidence of leptomeningeal collaterals.

CONCLUSIONS

As with Moyamoya disease in Asian patients, the presence of cerebrovascular collaterals correlated with the modified Suzuki score for disease severity in North American patients with Moyamoya disease. However, anterior choroidal artery changes, which correlated with increased rates of hemorrhage in Asian studies, were not specific to hemorrhage in North Americans.

Neuromodulatory treatments for chronic pain: efficacy and mechanisms

Chronic pain is common, and the available treatments do not provide adequate relief for most patients. Neuromodulatory interventions that modify brain processes underlying the experience of pain have the potential to provide substantial relief for some of these patients. The purpose of this Review is to summarize the state of knowledge regarding the efficacy and mechanisms of noninvasive neuromodulatory treatments for chronic pain. The findings provide support for the efficacy and positive side-effect profile of hypnosis, and limited evidence for the potential efficacy of meditation training, noninvasive electrical stimulation procedures, and neurofeedback procedures. Mechanisms research indicates that hypnosis influences multiple neurophysiological processes involved in the experience of pain. Evidence also indicates that mindfulness meditation has both immediate and long-term effects on cortical structures and activity involved in attention, emotional responding and pain. Less is known about the mechanisms of other neuromodulatory treatments. On the basis of the data discussed in this Review, training in the use of self-hypnosis might be considered a viable 'first-line' approach to treat chronic pain. More-definitive research regarding the benefits and costs of meditation training, noninvasive brain stimulation and neurofeedback is needed before these treatments can be recommended for the treatment of chronic pain.