Buffer or amplifier? Longitudinal effects of social support for functional autonomy/dependence on older adults’ chronic-pain experiences

Objective: This longitudinal study aimed to investigate (a) the moderating role of formal social support for functional autonomy versus dependence on the relationship between pain intensity and pain-related disability among older adults with chronic pain and (b) the mediating role of pain-related self-efficacy and pain-related fear in this moderation. Method: One hundred and seventy older adults (Mage = 78.0; SD = 8.7) with chronic musculoskeletal pain participated in a 3-month prospective study, with 3 measurement moments. Participants filled out the Formal Social Support for Autonomy and Dependence in Pain Inventory, the Portuguese versions of the Brief Pain Inventory, the Pain Self-Efficacy Questionnaire, and the Tampa Scale of Kinesiophobia. Results: Using structural equation modeling, it was found that perceived promotion of autonomy, at Time 1, moderated the relationship between pain intensity (T1) and pain-related disability (T2); this moderation was fully mediated by pain-related self-efficacy (T2). Perceived promotion of dependence was not a significant moderator. Conclusions: These findings highlight the importance of social support for functional autonomy in buffering the impact of pain intensity on older adults’ pain-related disability. Also, they clarify the role of pain-related self-efficacy in this effect. Implications for the development of intervention programs, with formal caregivers, to reduce the impact of chronic pain on older adults’ healthy ageing process, are discussed.info:eu-repo/semantics/acceptedVersio

Novel three-day, community-based, nonpharmacological group intervention for chronic musculoskeletal pain (COPERS): a randomised clinical trial

Background Chronic musculoskeletal pain is the leading cause of disability worldwide. The effectiveness of pharmacological treatments for chronic pain is often limited, and there is growing concern about the adverse effects of these treatments, including opioid dependence. Nonpharmacological approaches to chronic pain may be an attractive alternative or adjunctive treatment. We describe the effectiveness of a novel, theoretically based group pain management support intervention for chronic musculoskeletal pain. Methods and Findings We conducted a multi-centre, pragmatic, randomised, controlled effectiveness and cost-effectiveness (cost–utility) trial across 27 general practices and community musculoskeletal services in the UK. We recruited 703 adults with musculoskeletal pain of at least 3 mo duration between August 1, 2011, and July 31, 2012, and randomised participants 1.33:1 to intervention (403) or control (300). Intervention participants were offered a participative group intervention (COPERS) delivered over three alternate days with a follow-up session at 2 wk. The intervention introduced cognitive behavioural approaches and was designed to promote self-efficacy to manage chronic pain. Controls received usual care and a relaxation CD. The primary outcome was pain-related disability at 12 mo (Chronic Pain Grade [CPG] disability subscale); secondary outcomes included the CPG disability subscale at 6 mo and the following measured at 6 and 12 mo: anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), pain acceptance (Chronic Pain Acceptance Questionnaire), social integration (Health Education Impact Questionnaire social integration and support subscale), pain-related self-efficacy (Pain Self-Efficacy Questionnaire), pain intensity (CPG pain intensity subscale), the census global health question (2011 census for England and Wales), health utility (EQ-5D-3L), and health care resource use. Analyses followed the intention-to-treat principle, accounted for clustering by course in the intervention arm, and used multiple imputation for missing or incomplete primary outcome data. The mean age of participants was 59.9 y, with 81% white, 67% female, 23% employed, 85% with pain for at least 3 y, and 23% on strong opioids. Symptoms of depression and anxiety were common (baseline mean HADS scores 7.4 [standard deviation 4.1] and 9.2 [4.6], respectively). Overall, 282 (70%) intervention participants met the predefined intervention adherence criterion. Primary outcome data were obtained from 88% of participants. There was no significant difference between groups in pain-related disability at 6 or 12 mo (12 mo: difference −1.0, intervention versus control, 95% CI −4.9 to 3.0), pain intensity, or the census global health question. Anxiety, depression, pain-related self-efficacy, pain acceptance, and social integration were better in the intervention group at 6 mo; at 12 mo, these differences remained statistically significant only for depression (−0.7, 95% CI −1.2 to −0.2) and social integration (0.8, 95% CI 0.4 to 1.2). Intervention participants received more analgesics than the controls across the 12 mo. The total cost of the course per person was £145 (US$214). The cost–utility analysis showed there to be a small benefit in terms of quality-adjusted life years (QALYs) (0.0325, 95$277], 95% CI −£125 [−US$184] to £501 [US$738]), resulting in an incremental cost-effectiveness ratio of £5,786 (US$8,521) per QALY. Limitations include the fact that the intervention was relatively brief and did not include any physical activity components. Conclusions While the COPERS intervention was brief, safe, and inexpensive, with a low attrition rate, it was not effective for reducing pain-related disability over 12 mo (primary outcome). For secondary outcomes, we found sustained benefits on depression and social integration at 6 and 12 mo, but there was no effect on anxiety, pain-related self-efficacy, pain acceptance, pain intensity, or the census global health question at 12 mo. There was some evidence that the intervention may be cost-effective based on a modest difference in QALYs between groups. Trial registration ISRCTN Registry 2442673

Embedded motivational interviewing combined with a smartphone app to increase physical activity in people with sub-acute low back pain: study protocol of a cluster randomised control trial

Background: Motivational Interviewing is an evidence-based, client-centred counselling technique that has been used effectively to increase physical activity, including for people with low back pain. One barrier to implementing Motivational Interviewing in health care settings more broadly is the extra treatment time with therapists. The aim of this paper is to describe the design of a cluster randomised controlled trial evaluating the effect of an intervention that pairs Motivational Interviewing embedded into usual physiotherapy care with a specifically designed app to increase physical activity in people with sub-acute low back pain. Methods: The study is a cluster randomised controlled in which patients aged over 18 years who have sub-acute low back pain (3–12 weeks duration) are recruited from four public hospital outpatient clinics. Based on the recruitment site, participants either receive usual physiotherapy care or the Motivational Interviewing intervention over 6 consecutive weekly outpatient sessions with a specifically designed app designed to facilitate participant-led physical activity behaviour change in between sessions. Outcome measures assessed at baseline and 7 weeks are: physical activity as measured by accelerometer (primary outcome), and pain-related activity restriction and pain self-efficacy (secondary outcomes). Postintervention interviews with physiotherapists and participants will be conducted as part of a process evaluation. Discussion: This intervention, which comprises trained physiotherapists conducting conversations about increasing physical activity with their patients in a manner consistent with Motivational Interviewing as part of usual care combined with a specifically designed app, has potential to facilitate behaviour change with minimal extra therapist time

Understanding the link between feelings of mental defeat, self-efficacy and the experience of chronic pain

© 2018, © The British Pain Society 2018. Objectives: ‘Mental defeat’ (MD) has been identified among people with chronic pain as a type of self-processing related to social role and rank. Research has linked it to anxiety, pain interference and functional disability. The relationship between MD and other cognitive constructs, such as hopelessness and depression, remains poorly understood. This study considers the association between MD, pain symptomatology and self-efficacy in the context of other cognitive factors. Methods: In total, 59 participants completed a questionnaire pack assessing anxiety, depression, hopelessness, pain catastrophising and MD in order to examine the relationship with pain symptomatology and self-efficacy. Results: Linear multiple regression analyses showed that anxiety was most strongly associated with pain symptomatology, accounting for 26% of the variance, while catastrophising showed the strongest association with sensory pain and MD the strongest association with affective pain. Finally, MD was found to be strongly associated with pain-related self-efficacy, accounting for 47% of the variance. Conclusion: This research has demonstrated the potential importance of assessing MD in chronic pain patients, suggesting that targeting these cognitions during interventions and therapy could be valuable. Furthermore, the study indicates that MD differs from related cognitive constructs involved in pain, such as depression, hopelessness and catastrophising

Do pain-related beliefs influence adherence to multidisciplinary rehabilitation? A systematic review

OBJECTIVES: To understand how pain-related cognitions predict and influence treatment retention and adherence during and after a multidisciplinary rehabilitation program. METHODS: Electronic databases including Medline, CINAHL, PsycINFO, Academic Search Complete, and Scopus were used to search three combinations of keywords: chronic pain, beliefs, and treatment adherence. RESULTS: The search strategy yielded 591 results, with an additional 12 studies identified through reference screening. 81 full-text papers were assessed for eligibility and 10 papers met the inclusion and exclusion criteria for this review. The pain-related beliefs that have been measured in relation to treatment adherence include: pain-specific self-efficacy, perceived disability, catastrophizing, control beliefs, fear-avoidance beliefs, perceived benefits and barriers, as well as other less commonly measured beliefs. The most common pain-related belief investigated in relation to treatment adherence was pain-related self-efficacy. Findings for the pain-related beliefs investigated among the studies were mixed. Collectively, all of the aforementioned pain-related beliefs, excluding control beliefs, were found to influence treatment adherence behaviours. DISCUSSION: The findings suggest that treatment adherence is determined by a combination of pain-related beliefs either supporting or inhibiting chronic pain patients\u27 ability to adhere to treatment recommendations over time. In the studies reviewed, self-efficacy appears to be the most commonly researched predictor of treatment adherence, its effects also influencing other pain-related beliefs. More refined and standardised methodologies, consistent descriptions of pain-related beliefs and methods of measurement will improve our understanding of adherence behaviours

THE ROLE OF PSYCHOSOCIAL FACTORS ON PRE AND POSTOPERATIVE PAIN IN PATIENTS WITH FEMORAL ACETABULAR IMPINGEMENT

Femoral acetabular impingement (FAI) is a bony hip condition that often results in tears to the acetabular labrum. Patients with FAI experience pain, decreased function, and quality of life. FAI and its’ sequela are treated definitively with hip arthroscopy. Hip arthroscopy is being performed with increasing frequency, and while most patients respond favorably, a subset of 10-20% of patients have suboptimal outcomes. Previous research suggests that mental status may be a primary driver in the way patients with FAI respond to and feel pain. Measures of mental status include the presence of mood disorders and psychosocial patient reported outcomes (PROs). Psychosocial constructs that have yet to be examined in patients with FAI include self-efficacy, kinesophobia, and pain catastrophizing. The Pain Self-Efficacy Questionnaire (PSEQ) gauges an individual’s confidence, or self-efficacy, in their ability to complete tasks despite their current pain. Previous research has established that a patient’s self-efficacy is an important determinant of long-term success following orthopedic surgery. Kinesophobia, measured via the Tampa Scale for Kinesiophobia (TSK), is a measure of movement-related fear. In contrast to self-efficacy, fear of movement has been identified as a predictor of early success following orthopedic surgery. Lastly, pain catastrophizing is a set of maladaptive behaviors including ruminating on pain, feeling helpless to overcome painful situations, and magnifying the circumstances surrounding the painful experience. Catastrophizing behaviors, measured via the Pain Catastrophizing Scale (PCS), have been repeatedly linked to increased pain and decreased functionality in a variety of orthopedic populations. To date, the relationship between these psychosocial variables and pain has not been examined in patients with FAI. The primary aim of this dissertation was to evaluate the role of psychosocial factors on pre and postoperative pain in patients with FAI undergoing hip arthroscopy. To accomplish this aim we performed a series of three studies. The first study was a retrospective chart review to determine the prevalence of mental health disorders and compare preoperative clinical presentation between patients with and without mental health disorders. The second was a cross-sectional study designed to determine if any psychosocial variables could predict preoperative hip pain. The final study utilized a longitudinal, cohort design. Patients were tested preoperatively and at 12-weeks postoperative. The primary outcomes measured were self-efficacy, kinesiophobia, pain catastrophizing, and hip pain at rest and during activity measured via a visual analog scale (VAS). The purpose of this study was to determine the effect of preoperative psychosocial variables on postoperative pain, and to determine if these variables were predictive of persistent postoperative pain three months following hip arthroscopy. Based on the results from these studies we can conclude the following: 1) Mental health disorders are more common in patients with FAI than other orthopedic populations, and self-reported pain and function are worse in this subset of patients, but neither symptom chronicity nor the severity of joint deformity differs; 2) Low self-efficacy is predictive of worse preoperative pain in patients with FAI; and 3) Patients with high preoperative pain catastrophizing or low self-efficacy are more likely to have increased postoperative pain. Low preoperative self-efficacy is predictive of persistent hip pain during activity three months following hip arthroscopy, while low self-efficacy and mental health disorders are predictive of persistent hip pain at rest. Future studies are necessary to develop and implement interventions targeting low self-efficacy and elevated catastrophizing in patients undergoing hip arthroscopy to improve patient outcomes for this high-risk group

Is there a relationship between self-efficacy, disability, pain and sociodemographic characteristics in chronic low back pain? A multicenter retrospective analysis

Background: Pain-related self-efficacy is defined as the beliefs held by people with chronic pain that certain activities can be carried out despite the pain. Poor self-efficacy is an obstacle to the recovery and predicts longterm disability. The aims of this study are to investigate the prevalence of poor pain self-efficacy in Italian subjects with chronic low back pain (LBP), and to inquire the relationships between self-efficacy, disability, pain, and main demographic and clinical characteristics. Methods: A secondary multicenter retrospective analysis was done on 310 outpatients with chronic non-specific LBP. The pain self-efficacy measured with the Pain Self-Efficacy Questionnaire (PSEQ), the disability measured with the Roland & Morris Disability Questionnaire, and the pain intensity measured with the Numerical Rating Scale were considered variables to investigate, whereas demographic and clinical variables were considered predictors or potential confounders. A 40/60 PSEQ score was adopted as cut-off to distinguish between good and poor selfefficacy. Results: 199 subjects (64.2% of the sample) showed poor self-efficacy. The odds of having poor self-efficacy appeared significantly related to female gender (OR=1.80, 95%CI [1.12;2.90]; p =0.015) and drugs use (OR=1.68, 95%CI [1.06;2.70]; p=0.029). Significant relationships also emerged between disability and higher age (\u3b2=0.07, 95%CI [0.01; 0.12]; p =0.02), being female (\u3b2=1.80, 95%CI [0.32;3.29]; p=0.018), low educational level (\u3b2= 121.68, 95%CI [ 122.59;-3.29]; p<0.001), higher height (\u3b2= 120.08, 95%CI [ 120.158;-0.002]; p=0.045), pain duration [mos] (\u3b2= 0.01, 95%CI [0.001;0.021]; p=0.041), and drugs use (\u3b2=2.86, 95%CI [1.44;4.27]; p<0.001). The amount of pain appeared significantly related to educational level (\u3b2= 120.47, 95%CI [ 120.76;-0.182]; p <0.001), smoking (\u3b2=0.56, 95%CI [0.09; 1.03]; p=0.021), height (\u3b2= 120.03, 95%CI [ 120.05; 120.002]; p=0.036), and drugs use (\u3b2=0.81, 95%CI [0.399;1.22]; p <0.001). No significant correlation appeared among weight, body mass index, and referred pain neither in relation to self-efficacy, nor in relation to pain/disability. Conclusions: The majority of our sample, composed of Italian people complained of chronic LBP, shows poor selfefficacy. Female gender and drugs use are significantly related to poor self-efficacy, low educational level negatively influences the amount of perceived pain and disability, and older age and smoking are related to disability and pain intensity, respectively. The knowledge of these sociodemographic and clinical characteristics potentially influencing chronic LBP may be useful to address more efforts towards the most negatively impacted subjects, among the entire population complained of chronic LBP

The relationship between perceived promotion of autonomy/dependence and pain-related disability in older adults with chronic pain: the mediating role of self-reported physical functioning

Chronic pain is prevalent among older adults and is usually associated with high levels of functional disability. Social support for the promotion of functional autonomy and dependence has been associated with pain-related disability and self-reported physical functioning. Nevertheless, these relationships need further inquiry. Our aims were to investigate: (1) the relationship between perceived promotion of autonomy/dependence and pain-related disability and (2) the extent to which self-reported physical functioning mediated these relationships. 118 older adults (Mage = 81.0) with musculoskeletal chronic pain completed the Portuguese versions of the revised formal social support for Autonomy and Dependence in Pain Inventory, the pain severity and interference scales of the Brief Pain Inventory, and the physical functioning scale of the Medical Outcomes Study-Short-Form 36 v2. Higher levels of perceived promotion of autonomy were associated with lower pain-related disability; this relationship was partially mediated by self-reported physical functioning (B = -.767, p < .001 decreasing to B' = -.485, p < .01). Higher perceived promotion of dependence was associated with higher pain-related disability; this effect was also partially accounted for by self-reported physical functioning (B = .889, p < .01 decreasing to B' = .597, p < .05). These results highlight the importance of perceived promotion of autonomy and dependence for managing older adults' experience of chronic pain

Die Entstehung, Aufrechterhaltung und Therapie chronischer Schmerzen im Kontext von Erwartungsverletzungen

Erwartungen in Form von befürchteter Schädlichkeit von Bewegungen (‚threat beliefs‘) wird bei der Entstehung und Aufrechterhaltung chronischer Schmerzen eine entscheidende Rolle zugeschrieben und können einen Ansatzpunkt zur Optimierung von Expositionstherapie darstellen. Der Einfluss von Erwartungen und Erwartungsveränderungen ist im Zusammenhang mit chronischen Schmerzen bislang nur unzureichend verstanden. Das Ziel der vorliegenden Dissertation war es daher den Einfluss von Erwartungen auf die Entstehung und Aufrechterhaltung von chronischen Schmerzstörungen und die Nutzbarmachung von Erwartungen in der psychologischen Schmerztherapie zu untersuchen. Mit einer längsschnittlichen prospektiven Befragung von PatientInnen mit akuten Schmerzen (N = 30) wurde untersucht, ob selbstkonzeptrelevante Erwartungen die Entstehung chronischer Schmerzstörungen begünstigen (Studie I). Die Befürchtung, aufgrund der Schmerzen nicht den eigenen Ansprüchen gerecht zu werden (= Selbstverstrickung), sagte die Schmerzbeeinträchtigung drei Monate später über den Einfluss von Katastrophisierung und Schmerzangst hinaus vorher. In einem experimentellen Paradigma mit längsschnittlicher Erweiterung (Studie II) wurde an ProbandInnen mit subklinischen Schmerzstörungen (N = 73) untersucht, ob induzierte schmerzbezogene Erwartungen durch wiederholte gegenteilige Erfahrung angepasst werden. ProbandInnen, die eine Schmerzsteigerung erwarteten, berichteten eine größere Erwartungs-verletzung durch die sinkenden Hitzereize als ProbandInnen, die eine Schmerzreduktion erwarteten. Entgegen unserer Hypothese zeigte sich eine stärkere Erwartungsanpassung in der Gruppe, die eine Schmerzreduktion erwartete. Unabhängig von der experimentellen Bedingung korrelierte die Stärke der Erwartungsverletzung mit einer Erwartungsveränderung und einer Generalisierung der Lernerfahrung auf Selbstwirksamkeitserwartungen. In einer dritten, ebenfalls experimentellen und längsschnittlichen Studie (III) mit gesunden weiblichen Probandinnen (N = 116) untersuchten wir, ob sich die Wirksamkeit und Ökonomie von Schmerzkonfrontationen durch eine therapeutische Anleitung zur Erwartungs-überprüfung im Vergleich zur therapeutischen Anleitung zur Habituation optimieren lassen. Während das Expositionskriterium in der Erwartungsüberprüfungsbedingung nach deutlich weniger Durchgängen erreicht wurde als in der Habituationsbedingung, unterschieden sich die beiden Bedingungen nicht bezüglich der Veränderung in schmerzbezogenen Zielgrößen (Schmerztoleranz und kognitiver Bewältigung), weder direkt im Anschluss noch eine Woche später. Zusammenfassend liefern die Ergebnisse des vorliegenden Dissertationsprojekts Hinweise dafür, dass Erwartungen in Form von Befürchtungen eine relevante Rolle bei der Entstehung und Aufrechterhaltung chronischer Schmerzstörungen durch Beeinflussung der Schmerzwahrnehmung und Persistenz gegenüber gegenteiligen Erfahrungen spielen. Gleichzeitig scheint eine direkte Adressierung idiosynkratrischer Befürchtungen und die therapeutische Anleitung zur Befürchtungsüberprüfung expositionsbasierte Ansätze optimieren zu können. Daraus ergeben sich relevante Hinweise für Optimierung von Prävention und Intervention von chronischen Schmerzstörungen (z.B. durch Ansätze zur kognitiven Vorbereitung der Exposition)