Advancing psychological therapies for chronic pain

There is a strong tradition of therapy development and evaluation in the field of psychological interventions for chronic pain. However, despite this research production, the effects of treatments remain uncertain, and treatment development has stalled. This review summarises the current evidence but focusses on promising areas for improvement. Advancing psychological therapies for chronic pain will come from a radical re-imagining of the content, delivery, place, and control of therapy. The next generation of therapeutic interventions will also need alternative methods of measurement and evaluation, and options are discussed

Fear-avoidance model of chronic pain the next generation

Objective: The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability. Methods: A narrative review. Results: There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals. Discussion: To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals

Everyday worry in adolescents with and without chronic pain:A diary study

Young people report frequent worry, but we know little about the extent, character, or consequence of worry in adolescence, or individual differences associated with worry. Adolescents with chronic pain are one population that are known to have high levels of anxiety, which is associated with higher levels of disability and depression, impairing function. In this study we report a diary study: adolescents (N=60; aged 16-18) recorded their worry over seven days. Our first aim was to describe the characteristics of adolescent worry and its consequences in a community sample. Our second aim was to compare the experience of girls to boys, and to compare the experience of those with and without chronic pain. Adolescents reported characteristics of each worry they had throughout the week, including content, frequency, strength, interference, emotion, and the strength of emotion associated with worry content. Adolescents reported the consequence for each content and the strength of the consequence. Worry content and consequences were categorised into four categories; health, relationship, personal competence, and other. Adolescents reported 675 unique episodes of worry over the seven-day period that were predominantly about personal competence. The strength of worry content was (M=6.61, SD=1.27) and the strength associated with the worry consequence was (M=5.59, SD=1.41). Worries were not reported as highly interfering (M=4.14, SD=1.61). Contrary to predictions, there were no differences in worry characteristics between adolescents with and without chronic pain. To conclude, worry is a frequent occurrence in older adolescents and the characteristics of worry are discussed. Adolescents worry mostly about personal competence. Adolescents with and without chronic pain reported similar worry characteristics

An investigation of the effect of experimental pain on logical reasoning

Pain disrupts attention in order to prioritise avoidance of harm and promote analgesic behaviour. This could in turn have negative effects on higher-level cognitions which rely on attention. In the current paper we examined the effect of thermal pain induction on three measures of reasoning: the Cognitive Reflection Test, Belief Bias Syllogisms task, and Conditional Inference task. In Experiment 1, the thermal pain was set at each participant’s pain threshold. In Experiment 2, it was set to a minimum of 44°C or 7/10 on a VAS scale (whichever was higher). In Experiment 3, performance was compared in no pain, low intensity pain, and high intensity pain conditions. We predicted that the experience of pain would reduce correct responding on the reasoning tasks. However, this was not supported in any of the three studies. We discuss possible interpretations of our failure to reject the null hypothesis and the importance of publishing null results

An investigation of the effect of experimental pain on logical reasoning

Pain disrupts attention to prioritise avoidance of harm and promote analgesic behaviour. This could in turn have negative effects on higher-level cognitions, which rely on attention. In the current article, we examined the effect of thermal pain induction on 3 measures of reasoning: the Cognitive Reflection Test, Belief Bias Syllogisms task, and Conditional Inference task. In experiment 1, the thermal pain was set at each participant's pain threshold. In experiment 2, it was set to a minimum of 44°C or 7/10 on a visual analogue scale (whichever was higher). In experiment 3, performance was compared in no pain, low-intensity pain, and high-intensity pain conditions. We predicted that the experience of pain would reduce correct responding on the reasoning tasks. However, this was not supported in any of the 3 studies. We discuss possible interpretations of our failure to reject the null hypothesis and the importance of publishing null results.</p

Observer influences on pain: an experimental series examining same-sex and opposite-sex friends, strangers, and romantic partners

Despite the well-documented sex and gender differences, little is known about the relative impact of male–female social interactions on pain. Three experiments were conducted to investigate whether the type of interpersonal relationship men and women have with an observer affects how they respond to experimental pain. Study 1 recruited friends and strangers, study 2 examined the effects of same- and opposite-sex friends, whereas study 3 investigated the differences between opposite-sex friends and opposite-sex romantic partners. One hundred forty-four dyads were recruited (48 in each study). One person from each dyad completed 2 pain tasks, whereas the other person observed in silence. Overall, the presence of another person resulted in an increase in pain threshold and tolerance on the cold-pressor task and algometer. The sex status of the dyads also had a role, but only within the friendship groups. In particular, male friends had the most pronounced effect on men's pain, increasing pain tolerance. We suggest that the presence of an observer, their sex, and the nature of the participant–observer relationship all influence how pain is reported. Further research should focus on dyadic relationships, and their influence on how men and women report and communicate pain in specific contexts

Behaviour change interventions for the management of Raynaud's phenomenon : a systematic review protocol

Introduction Raynaud's phenomenon (RP) describes excessive peripheral vasospasm to cold exposure and/or emotional stress. RP episodes are associated with digital colour changes, pain and reduced quality of life. Pharmacological interventions are of low to moderate efficacy and often result in adverse effects such as facial flushing and headaches. Recommended lifestyle and behavioural interventions have not been evaluated. The objectives of the proposed systematic review are to assess the comparative safety and efficacy of behaviour change interventions for RP and identify what we can learn to inform future interventions. Methods and analysis Studies eligible for inclusion include randomised controlled trials testing behaviour change interventions with a control comparator. A comprehensive search strategy will include peer review and grey literature up until 30 April 2017. Search databases will include Medline, Embase, PsychINFO and Cochrane. Initial sifting, eligibility, data extraction, risk of bias and quality assessment will be subject to review by two independent reviewers with a third reviewer resolving discrepancies. Risk of bias assessment will be performed using Cochrane risk of a bias assessment tool with quality of evidence assessed using Grading of Recommendations Assessment, Development and Evaluation(GRADE). A meta-analysis will be performed if there are sufficient data. Two subgroup analyses are planned: primary versus secondary RP outcomes; comparison of theoretically informed interventions with pragmatic interventions. Ethics and dissemination This review does not require ethical approval as it will summarise published studies with non-identifiable data. This protocol complies with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Findings will be disseminated in peer-reviewed articles and reported according to PRISMA. This review will make a significant contribution to the management of RP where no review of behaviour-change interventions currently exist. The synopsis and protocol for the proposed systematic review is registered in the International Prospective Register of Systematic Reviews (registration number CRD42017049643)

Systematic reviews do not (yet) represent the ‘gold standard’ of evidence: a position paper

The low quality of included trials, insufficient rigour in review methodology, ignorance of key pain issues, small size, and over-optimistic judgements about the direction and magnitude of treatment effects all devalue systematic reviews, supposedly the ‘gold standard’ of evidence. Available evidence indicates that almost all systematic reviews in the published literature contain fatal flaws likely to make their conclusions incorrect and misleading. Only 3 in every 100 systematic reviews are deemed to have adequate methods and be clinically useful. Examples of research waste and questionable ethical standards abound: most trials have little hope of providing useful results, and systematic review of hopeless trials inspires no confidence. We argue that results of most systematic reviews should be dismissed. Forensically critical systematic reviews are essential tools to improve the quality of trials and should be encouraged and protected

Behaviour change interventions for the management of Raynaud's Phenomenon: A systematic review

Objectives Raynaud’s phenomenon (RP) is a significant cause of morbidity. Vasodilator medications cause unwanted adverse effects, with behavioural and lifestyle changes forming the mainstay of self-management; this is difficult to implement successfully. The objectives of this study were to evaluate the efficacy of behaviour change interventions for RP and identify learning points for future treatment development.Design Systematic literature review and narrative synthesis of findings.Data sources EMBASE, MEDLINE, Cochrane and PsycINFO were searched for eligible studies on 22 August 2017.Eligibility criteria Randomised controlled trials (RCTs) of behaviour change interventions with at least one control comparator arm.Data extraction and synthesis Study selection, data extraction and risk of bias were assessed independently by two reviewers, reaching consensus with a third when necessary. Primary outcomes of interest included severity/impact, frequency and duration of RP episodes, pain, disability, adverse events and study withdrawal.Results Of 638 articles retrieved, eight studies fulfilled criteria for inclusion. Biofeedback was the active behaviour change treatment arm for seven studies, with one study reporting a behavioural intervention. Studies were published 1978–2002; six were USA-based studies, one German and one Swedish. Using Cochrane Risk of Bias assessment, studies were assessed to be overall at high risk of bias, with the exception of one large RCT. The total sample included 495 participants (study median=29), with a median age of 39.5 years and preponderance towards females (73%). Five studies reported significant effects in primary outcomes of interest; however, due to missing data, relative efficacy of interventions could not be reliably assessed.Conclusions There is no evidence to support or refute claims of the efficacy of behaviour change interventions for the management of RP. There remains a strong case for developing and testing behaviour change interventions that focus on self-management; however, theoretical development and advancement in trial quality is imperative to underpin future work