Comparing the role of psychological flexibility and traditional pain management coping strategies in chronic pain treatment outcomes

Psychologically-based interventions for chronic pain traditionally include a mix of methods, including physical conditioning, training in relaxation or attention control, strategies to decrease irrational or dysfunctional thinking patterns, and activity management training. Recent developments suggest additional methods to promote acceptance, mindfulness, values-based action, and cognitive defusion (a cognitive process entailing change in the influences exerted by thoughts without necessarily changing their form or frequency). Collectively, these processes entail what is referred to as psychological flexibility. This study examined how changes in traditionally conceived methods of coping compare to changes in psychological flexibility in relation to improvements in functioning over the course of an interdisciplinary treatment program. Participants were 114 chronic pain sufferers. Results indicated that changes in the traditionally conceived methods were essentially unrelated to treatment improvements, while changes in psychological flexibility were consistently and significantly related to these improvements. We suggest that psychological flexibility appears highly relevant to the study of chronic pain and to future treatment developments. The utility of more traditionally conceived pain management strategies, on the other hand, may require a reappraisal.     

Follow-up results of a cognitive-behavioural treatment for chronic pain in a primary care setting

Abstract

An outpatient cognitive-behavioural treatment programme for pain control was administered to chronic pain patients in three primary care practices with a medical psychologist as a group therapist. The patients suffered from headaches, migraines, cervical pain, shoulder-arm pain, and low back pain. A matched sample of patients with the same disorders served as a waiting-list control group. The programme consisted of training in progressive muscle relaxation, several attention related techniques, and cognitive restructuring as well as reinforcing non-pain behaviour, and aimed at an improvement of self-control strategies. At the six month follow-up, the treated subjects showed improvements in their average scores of anxiety, depression and bodily symptoms compared with the untreated controls. Pain intensity was reduced by 34% in those subjects (9 out of 25) who were most adherent to the treatment regimen. Our results indicate a long-term improvement in well-being as a consequence of the treatment. This was confirmed by the ratings of the physicians and by the reduced number of patient-physician contacts three months post treatment as compared to the controls. Treatment adherence seems to be a most important agent in maintaining long-term reductions of pain intensity.     

Psychological treatment and reconstruction with a chronic pain patient

This article describes the psychological treatment of a chronic pain patient using a single case design methodology in order to evaluate changes in symptomatic measures as well as in Repertory Grid Test scores. These changes included a substantial reduction in levels of subjective pain and anxiety as well as a reduction in symptom superordinacy, level of self-dissatisfaction, and positive meaning (“payoff”) of anxiety. Results are discussed in relation to the literature on pain and on personal construct theory.     

Exploring the associations shared by mood,pain-related attention and pain outcomes related to sleep disturbance in a chronic pain sample

Objective: Sleep disturbance in chronic pain is common, occurring in two-thirds of patients. There is a complex relationship between chronic pain and sleep; pain can disrupt sleep and poor sleep can exaggerate pain intensity. This may have an impact on both depressive symptoms and attention to pain. This study aims to evaluate the relationship between chronic pain and sleep, and the role of mood and attention.

Methods: Chronic pain patients, recruited from a secondary care outpatient clinic, completed self-report measures of pain, sleep, depressive symptoms and attention to pain. Hierarchical regression and structural equation modelling were used to explore the relationships between these measures. Participants (n = 221) were aged between 20 and 84 (mean = 52) years.

Results: The majority of participants were found to be ‘poor sleepers’ (86%) with increased pain severity, depressive symptoms and attention to pain. Both analytical approaches indicated that sleep disturbance is indirectly associated with increased pain severity Instead the relationship shared by sleep disturbance and pain severity was further associated with depressive symptoms and attention to pain.

Conclusions: Our results indicate that sleep disturbance may contribute to clinical pain severity indirectly though changes in mood and attention. Prospective studies exploring lagged associations between these constructs could have critical information relevant to the treatment of chronic pain.     

Operant-behavioural and cognitive-behavioural treatment for chronic low back pain.

Fifty-eight outpatients with chronic low back pain were randomly allocated to one of six experimental conditions. Four conditions were designated as treatment conditions and two as control conditions. The four treatment groups consisted of: cognitive treatment (either with or without relaxation training) and behavioural treatment (either with or without relaxation training). The cognitive and behavioural groups also received physiotherapy. The two control conditions consisted of: attention (physiotherapy plus discussion sessions) and no-attention (physiotherapy-only) conditions. All conditions, including the two controls, received the same physiotherapy back-education and exercise program. For the sample as a whole, improvements were obtained on measures of affective distress, functional impairment, medication use, pain-related dysfunctional cognitions and use of active coping strategies. These improvements were generally maintained at 6- and 12-month follow-ups. The combined psychological/physiotherapy treatment conditions improved significantly more than the physiotherapy-only conditions from pre to posttreatment on measures of pain intensity, self-rated functional impairment and pain-related dysfunctional cognitions. However, these differences were only weakly maintained at 6- and 12-month follow-ups. The behavioural conditions improved significantly more than the cognitive conditions from pre to posttreatment on the self-rated measure of functional impairment, but this difference was not maintained at 6- and 12-month follow-ups. Progressive relaxation training was found to make little contribution to either cognitive or behavioural treatments.     

Family treatment for chronic pain: State of the art

A variety of family therapy techniques have been used to treat chronic pain. In this paper, an attempt is made to examine those familytherapy methods. It is noted that to date there is virtually a total absence of research to determine the efficacy of family therapy to treat chronic benign pain. From a clinical perspective family therapy must be offered to famiies with chronic pain patients to counteract the negative impact of chronic pain on the entire family system.     

Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review

The number of acceptance- and mindfulness-based interventions for chronic pain, such as acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT), increased in recent years. Therefore an update is warranted of our former systematic review and meta-analysis of studies that reported effects on the mental and physical health of chronic pain patients. Pubmed, EMBASE, PsycInfo and Cochrane were searched for eligible studies. Current meta-analysis only included randomized controlled trials (RCTs). Studies were rated for quality. Mean quality did not improve in recent years. Pooled standardized mean differences using the random-effect model were calculated to represent the average intervention effect and, to perform subgroup analyses. Outcome measures were pain intensity, depression, anxiety, pain interference, disability and quality of life. Included were twenty-five RCTs totaling 1285 patients with chronic pain, in which we compared acceptance- and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Effect sizes ranged from small (on all outcome measures except anxiety and pain interference) to moderate (on anxiety and pain interference) at post-treatment and from small (on pain intensity and disability) to large (on pain interference) at follow-up. ACT showed significantly higher effects on depression and anxiety than MBSR and MBCT. Studies’ quality, attrition rate, type of pain and control group, did not moderate the effects of acceptance- and mindfulness-based interventions. Current acceptance- and mindfulness-based interventions, while not superior to traditional cognitive behavioral treatments, can be good alternatives.     

Predicting outcome of chronic pain treatment via a modified self-efficacy scale

This study utilized a modified self-efficacy scale and examined the relationship of perceived self-efficacy to treatment outcome in a chronic, intractable, benign pain population (N = 62). In two separate studies a self-efficacy scale was given to inpatients in a combined cognitive-behavioral and medical treatment program. The scale categories consisted of (1) walking distance, (2) lifting ability, (3) pain coping, (4) working ability, and (5) social and recreational engagement. Self-efficacy beliefs were found to be associated with the level of functioning of these patients and their response to treatment. Patients with higher self-efficacy scores following treatment rated themselves as more improved and demonstrated better overall functioning with greater reductions in chronic illness behavior at followup. These observations support the merits of self-efficacy measures as predictors of treatment outcome in chronic pain patients.     

A collaborative approach in the treatment of chronic pain

The impact of chronic pain on patients and their families can be devastating, with significant disruption and progressive deterioration of many life functions and roles. Typically, chronic pain patients have exhausted all standard medical treatment alternatives without finding relief from the pain. For chronic pain patients and their families, this leads to dependency on the health-care system which leaves patients and their families feeling helpless and hopeless in their struggle to survive their pain experiences. Assessment and treatment of chronic pain requires a comprehensive approach based on a multidimensional conceptualisation of pain that addresses cognitive, affective, behavioural, as well as sensory factors in the pain experience. A cognitive-behavioural treatment programme consisting of (a) a comprehensive multidimensional assessment, (b) a reconceptualisation aspect, (c) a skills acquisition phase, (d) a skills application, maintenance, and generalisation component, and (e) relapse prevention, is outlined. Emphasis is given to the important inter-related roles of the collaborative therapeutic relationship, reconceptualisation of the pain experience, and coping skills training, leading to self-management of life with pain as the ultimate treatment objective.     

Hope in a strengths-based group activity for individuals with chronic pain

While hope has been described as the ability to imagine a future in which one wishes to participate, individuals with chronic pain can have difficulty maintaining hope due to the pervasive impact of pain on multiple facets of their lives. This research examines client experiences of hope during a hope and strengths activity offered as part of a group treatment plan for individuals experiencing chronic pain. Entitled Being Hopeful in the Face of Chronic Pain, the group was developed in order to focus on hope and generative emotional experiences, experiences often lacking for individuals with chronic pain. The group activity being studied specifically addressed participants’ current strengths and strengths they hope-to-have-more-of. The study employed basic qualitative inquiry and utilized interpersonal process recall individual interviews to stimulate participant recall. Twelve participants (spanning three separate group offerings) individually discussed their personal experiences as they unfolded during a specific hope and strengths-focused activity. Participants described experiences during the group activity that fostered personal hope via perspective shifts, communion, comparison and connection with other group members. Findings are discussed in the context of current literature on hope, chronic pain, positive psychology and group interventions.     

A contingency management technique for increasing student attention in a small group setting

Fifty-four elementary school children previously identified as consistently inattentive were involved in an extraclassroom treatment program comparing three conditions. In the E condition, attention was reinforced by making the earning of token points (exchangeable for rewards) contigent upon appropriate responses to a signal detection task embedded in the lessons. C1 condition subjects participated in the same lessons without the token system, while C2 subjects remained in their regular classrooms throughout the study. Four participating classroom teachers received brief training in behavior modification techniques for maintaining student attention. Subjects in the E condition were found to be significantly more attentive during the treatment lessons. Changes did not transfer to the regular classroom, however, and training for teachers did not affect in-class attention scores of subjects.     

Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase

The concept of acceptance is receiving increased attention as an alternate approach to the suffering that is often associated with persistent and disabling pain. This approach differs from established treatments in that it does not principally focus on reducing pain, but on reducing the distressing and disabling influences of pain as they concern important areas in patients' lives. The present analyses represent a preliminary evaluation of an acceptance-based approach to chronic pain within an interdisciplinary treatment program. One hundred and eight patients with complex chronic pain conditions completed treatment and provided data for the current study. Treatment was conducted in a 3- or 4-week residential or hospital-based format. It included a number of exposure-based, experiential, and other behavior change methods focused on increasing (a) engagement in daily activity regardless of pain and (b) willingness to have pain present without responding to it. Significant improvements in emotional, social, and physical functioning, and healthcare use were demonstrated following treatment. The majority of improvements continued at 3-months post-treatment. Improvements in most outcomes during treatment were correlated with increases in acceptance, supporting the proposed process of treatment.     

The effects of divided attention on information processing in manual tracking.

Six subjects performed a manual tracking task concurrently uith each of two secondary tasks: in input task (auditory signal detection) and an output task (application of a constant force). A feedback-control analysis of tracking performance was utilized to analyze the time-sharing decrements observed in mean squared errer, in terms of components due to processing delay, addition of internal processing noise, and change in response bias (tracking gain). The results indicated that only the parameters measuring noise and gain were sensitive to time-sharing conditions, and these only to concurrent performance of the force application task. It is concluded that limits of attention in dual-task performance are more severe in output than in input stages of processing, but that these limits are not necessarily those of a single-channel bottleneck. Instead, a broader conception of attention is proposed: one that included changes in processing noise and shifts in response bias, as attention-related phenomena.     

MMPI-2 characteristics in a chronic pain population

This study investigated the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) characteristics of 209 chronic pain patients in an inpatient pain treatment program. Patients completed the MMPI-2, Zung Self-Rating Depression Scale, and Oswestry Low Back Pain Disability Questionnaire. Participants in this sample were matched with comparison participants from the MMPI-2 normative sample on the demographic variables gender, age, and ethnicity. Chronic pain patients reported higher levels of general maladjustment and affective distress than did the normative control group, including more anxiety, depressive symptomatology, and somatic complaints. The MMPI-2 basic scales Hypochondriasis, Depression, and Hysteria were the most useful discriminating factors between chronic pain patients and normal controls, and the content scales Health Concerns and Depression showed significant elevations for the chronic pain group. The 1-3/3-1, 1-2/2-1, and 2-3/3-2 code types accounted for more than two thirds of all two-point classifications for the chronic pain group, and four cluster analysis types classified nearly half of all of these protocols.