Pain-related acceptance and physical impairment in individuals with chronic pain

Treatments using acceptance-based approaches have been utilized for a variety of health care concerns with data regarding their application to a chronic pain population recently emerging. These approaches may be particularly suited to chronic pain as they target potentially harmful avoidance and ineffective pain control strategies. Acceptance of chronic pain is related to psychosocial constructs generally (e.g., depression, pain-related anxiety); however, its relation to the overt behavioral variables associated with such states remains unevaluated. The present investigation assessed the specific effects of an acceptance-based versus control-based instructional set on demonstrated physical impairment in 74 individuals with chronic low back pain. Participants completed a baseline evaluation of physical impairment and then listened to audiotaped instructions detailing one of three approaches (pain acceptance, pain control, and no change). They then repeated the physical impairment assessment and were asked to utilize the approach detailed in the audiotaped instructions to guide behavior during the tasks. Results indicated that, after controlling for baseline levels of physical impairment, individuals receiving the acceptance instructions were less physically impaired at the second assessment compared to the other two groups, which did not differ from one another. Further, individuals in the acceptance group exhibited a 16.3% improvement in impairment level, while the pain control group worsened by 8.3% and the no change group worsened by 2.5%; these changes were also statistically different from one another. Group membership was generally unrelated to pain reported during the physical impairment assessment, a finding theoretically consistent with acceptance models. These results lend further support to the value of acceptance in actual patient behavior, as well as the ability of a relatively simple acceptance-based intervention to improve functioning over the short term in a sample of individuals with chronic pain. Additionally, the findings highlight some of the possible risks in focusing solely on pain control and avoidance, as this method was associated with poorer physical performance compared with the acceptance group. Although the present study was analogue in nature, and thus its findings cannot be directly attributable to clinical realms, it does provide some initial support for these types of approaches within chronic pain

Examining Committed Action in Chronic Pain:Further Validation and Clinical Utility of the Committed Action Questionnaire

Psychosocial treatments for chronic pain conditions, such as Acceptance and Commitment Therapy, have highlighted minimizing pain avoidance behaviors and increasing engagement in valued activities as key treatment targets. In terms of salient processes within Acceptance and Commitment Therapy, committed action is considered essential to the pursuit of a meaningful life, as it entails a flexible persistence over time in living consistently with one's values. To date, however, only 1 study has examined the association between measures of committed action and important aspects of pain-related functioning. The purpose of the present study was to analyze the reliability of the Committed Action Questionnaire (CAQ) in a sample of 149 chronic pain patients, perform a confirmatory analysis of its factor structure, and examine how CAQ scores uniquely account for variance in functioning. Confirmatory factor analyses provided support for a 2-factor model, and regression analyses, which examined the cross-sectional direct effects of the 2 subscales on health-related functioning, indicated that the CAQ accounted for significant variance in functioning after controlling for relevant covariates. Overall, these findings provide further support for the CAQ as a measure of adaptive functioning in those with longstanding pain. PERSPECTIVE: This article presents additional evidence for the reliability and validity of the CAQ with chronic pain patients. Confirmatory factor analyses provided support for the 2-factor model, with both subscales demonstrating significant associations with multiple facets of health- and pain-related functioning

The Impact of Adolescent Chronic Pain on Functioning: Disentangling the Complex Role of Anxiety

A number of adolescents with chronic pain have clinically significant disability across physical, social, and academic activities, and pain severity only explains a portion of the variance in functioning. Thus, it is important to identify therapeutic options to improve adolescents’ functioning. In contrast to studies with adults with chronic pain, research in pediatric pain has not consistently found anxiety to be a good predictor of pain-related disability. The present study evaluated pain, anxiety, and functioning in 222 adolescents with chronic pain. Results indicated that pain was consistently and linearly related to disability across measures of physical and social functioning, school attendance, and physician visits. The relation between anxiety and functioning was complex; increased anxiety was related to poorer physical and social functioning and was related to fewer physician visits, although it was not associated with school attendance. Additional analyses revealed that anxiety serves to moderate the relation between pain and functioning. Specifically, at high anxiety, pain was not related to functioning, but at low anxiety pain consistently predicted disability. In other words, highly anxious adolescents were functioning poorly regardless of the level of pain. The moderating role of anxiety highlights a number of research and clinical possibilities to explore with adolescents with chronic pain-related disability. Data suggest that high anxiety is associated with poor functioning irrespective of pain intensity. At low anxiety, higher pain predicted greater disability. Anxiety is important to assess when investigating potential reasons for pain-related disability

Exploring What Factors Mediate Treatment Effect: Example of the STarT Back Study High-Risk Intervention

Interventions developed to improve disability outcomes for low back pain (LBP) often show only small effects. Mediation analysis was used to investigate what led to the effectiveness of the STarT Back trial, a large primary care-based trial that treated patients consulting with LBP according to their risk of a poor outcome. The high-risk subgroup, randomized to receive either psychologically-informed physiotherapy (n = 93) or current best care (n = 45), was investigated to explore pain-related distress and pain intensity as potential mediators of the relationship between treatment allocation and change in disability. Structural equation modeling was used to generate latent variables of pain-related distress and pain intensity from measures used to identify patients at high risk (fear-avoidance beliefs, depression, anxiety, and catastrophizing thoughts). Outcome was measured using the Roland–Morris Disability Questionnaire. Change in pain-related distress and pain intensity were found to have a significant mediating effect of .25 (standardized estimate, bootstrapped 95% confidence interval, .09–.39) on the relationship between treatment group allocation and change in disability outcome. This study adds to the evidence base of treatment mediation studies in pain research and the role of distress in influencing disability outcome in those with complex LBP. Perspective Mediation analysis using structural equation modeling found that change in pain-related distress and pain intensity mediated treatment effect in the STarT Back trial. This type of analysis can be used to gain further insight into how interventions work, and lead to the design of more effective interventions in future