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

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

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

Psychological therapies delivered remotely for the management of chronic pain (excluding headache) in adults

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To determine the efficacy and harms of remotely delivered psychological therapies compared to active control, waiting list, or treatment-as-usual for the management of chronic pain in adults.</p

Current evidence-based interdisciplinary treatment options for pediatric musculoskeletal pain

Purpose of the review. We review the prevalence of pediatric chronic musculoskeletal pain, the clinical need, the evidence for pharmacological, psychological, physical and complementary approaches to pain management, and the possible future development of interdisciplinary and distance care.  Recent Findings. We summarize the Cochrane Systematic Reviews on pharmacological interventions, which show a lack of evidence to support or refute the use of all classes of medication for the management of pain. The trials for NSAIDs did not show any superiority over comparators, nor did those of anti-depressants, and there are no trials for paracetamol, or of opioid medications. There are studies of psychological interventions which show promise, and increasing support for physical therapy. The optimal approach remains an intensive interdisciplinary programmatic treatment, although this service is not available to most.   Summary. 1. Given the absence of evidence a program of trials is now urgently required to establish the evidence base for analgesics that are widely prescribed for young people with chronic musculoskeletal pain. 2. Until that evidence becomes available, medicine review is an essential task in this population. 3. We need more examples and efficacy evaluations of intensive interdisciplinary interventions for chronic pain management, described in detail so that researchers and clinicians can unpack possible active treatment components. 4. Online treatments are likely to be critical in the future. We need to determine which aspects of treatment for which children can be effectively delivered in this way, which will help reduce the burden of the large number of patients needing support from a small number of experts

Predicting the consequences of physical activity: an investigation into the relationship between anxiety sensitivity, interoceptive accuracy and action

The ability to predict the consequences of our actions is imperative for the everyday success of our interactions. From negotiating an uneven surface, to mounting an immune response, we continually infer the limits of our body. The current investigation considered the impact that the inferred consequences of action has on the placement of limits. We hypothesised that the performance of individuals in a novel, sprint task would reflect both their ability to accurately detect changes in bodily arousal (Interoceptive Accuracy) and the inferred consequences associated with heightened arousal signals (Anxiety Sensitivity). We found that individuals who demonstrated accuracy associated with physiological arousal changes, and who showed a heightened fear of the consequences of arousal symptoms, modified their actions by decreasing their power output (mean Watts•kg-1) in a sprint task (∆R2= 0.19; F(1,34)=19.87);

The effect of pain on task switching: pain reduces accuracy and increases reaction times across multiple switching paradigms

Pain disrupts attention, which may have negative consequences for daily life for people with acute or chronic pain. It has been suggested that switching between tasks may leave us particularly susceptible to pain-related attentional disruption, because we need to disengage our attention from one task before shifting it onto another. Switching tasks typically elicit lower accuracies and/or longer reaction times when participants switch to a new task compared to repeating the same task, and pain may exacerbate this effect. We present three studies to test this hypothesis. In Study 1, participants completed two versions of an alternating runs switching task under pain free and thermal pain induction conditions. Pain did not affect performance on either task. In Studies 2 and 3, we examined seven versions of the switching task using large general population samples, experiencing a variety of naturally-occurring pain conditions, recruited and tested on the internet. On all tasks, participants with pain had longer reaction times on both switch and repeat trials compared to participants without pain, but pain did not increase switch costs. In Studies 2 and 3, we also investigated the effects of type of pain, duration of pain, and analgesics on task performance. We conclude that pain has a small dampening effect on performance overall on switching tasks. This suggests that pain interrupts attention even when participants are engaged in a trial, not only when attention has been disengaged for shifting to a new task set