Follow-up over 20 months confirms gains of online behavioural training in frequent episodic migraine.

Aim This study examined the change over 20 months in 178 participants with frequent episodic migraine under adequate treatment as usual, who had completed online behavioural training (oBT) in migraine self-management either directly (group 1, n = 120) or after 10 months of watchful waiting (group 2, n = 58). Methods Participants completed questionnaires and an online headache diary and migraine monitor following the International Classification of Headache Disorders at T0 (baseline), T1 (post-training), T2 (6-month follow-up; extended baseline in group 2), T3 (post-training, group 2 only) and T4 (group 1: 16-month follow-up; group 2: 6-month follow-up). Statistical analyses were conducted on the observed data without imputation of missing observations. Results Both groups were highly comparable. The data over time revealed benefits in response to oBT, with significant between-group differences in the change achieved in the training episodes T2-T0 (group 1) and T4-T2 (group 2). Improved attack frequency ( M = -23%) was higher in participants with more (i.e. 4-6) attacks per month at baseline, and the effects of oBT were durable over 16 months of follow-up. Conclusions oBT is beneficial in frequent episodic migraine, which deserves special efforts in care. Self-management variants such as oBT reach patients easily and supplement these efforts with durable results.

Long-term follow-up of home-based behavioral management training provided by migraine patients.

BACKGROUND: Behavioral migraine approaches are effective in reducing headache attacks. Availability of treatment might be increased by using migraine patients as trainers. Therefore, Mérelle and colleagues developed and evaluated a home-based behavioral management training (BMT) by lay trainers (1). The maintenance of effects at long-term follow-up is studied in the present study. METHOD: Measurements were taken pre-BMT (T0), post-BMT (T1), at six-month follow-up (T2), and at long-term follow-up, i.e. two to four years after BMT (T3). Data of 127 participants were analyzed with longitudinal multi-level analyses. RESULTS: Short-term improvements in attack frequency and self-efficacy post-BMT were maintained at long-term follow-up ( DT0T3 = -.34 and DT0T3 = .69, respectively). The level of internal control that increased during BMT decreased from post-BMT to long-term follow-up ( DT0T3 = .18). Quality of life and migraine-related disability improved gradually over time ( DT0T3 = .45 and DT0T3 = -.26, respectively). CONCLUSIONS: Although the results should be interpreted with caution because of the lack of a follow-up control group and the inability to gather information about additional treatments patients may have received during the follow-up period, the findings suggest that lay BMT for migraine may be beneficial over the long term. If so, this could make migraine treatments more widely available.

Team players against headache: multidisciplinary treatment of primary headaches and medication overuse headache.

Multidisciplinary approaches are gaining acceptance in headache treatment. However, there is a lack of scientific data about the efficacy of various strategies and their combinations offered by physiotherapists, physicians, psychologists and headache nurses. Therefore, an international platform for more intense collaboration between these professions and between headache centers is needed. Our aims were to establish closer collaboration and an interchange of knowledge between headache care providers and different disciplines. A scientific session focusing on multidisciplinary headache management was organised at The European Headache and Migraine Trust International Congress (EHMTIC) 2010 in Nice. A summary of the contributions and the discussion is presented. It was concluded that effective multidisciplinary headache treatment can reduce headache frequency and burden of disease, as well as the risk for medication overuse headache. The significant value of physiotherapy, education in headache schools, and implementation of strategies of cognitive behavioural therapy was highlighted and the way paved for future studies and international collaboration.

Qualities and health of lay trainers with migraine for behavioral attack prevention.

OBJECTIVES: To evaluate the qualities of lay trainers with migraine and to quantify their self-management results. BACKGROUND: Little is known about the qualities of lay trainers with chronic diseases and the benefits for their own health. METHODS: Thirteen lay trainers (12 F, 1 M) completed a 3-step program that consisted of self-experience of a behavioral training (BT), providing BT to one fellow patient, and subsequently to a small group at home. Successful mastery of own migraine attacks was required for participation, and lay trainers received intensive guidance. Evaluation of the qualities of trainers took place post-BT by means of a specially constructed questionnaire. Their self-management was measured before self-experience of BT, post-BT, and at 6-month follow-up by a headache diary and questionnaires. RESULTS: The qualities of the 13 trainers were positively evaluated by 95 trainees, particularly their warmth, expertise, organization, explanation of BT, active control, and advice and guidance. Higher active control of lay trainers during the group sessions was significantly related to improvements on migraine frequency and internal locus of control in their trainees post-BT. Advice and guidance increased the likelihood of less attacks at follow-up and supportive encouragement promoted a higher internal locus of control. However, humor slightly increased the likelihood of more attacks post-BT, while fellowship and individualization negatively influenced internal locus of control. Lay trainers showed significantly more improvement in migraine frequency than their trainees at follow-up, as well as enhanced internal locus of control and quality of life. CONCLUSIONS: Participation in a stepwise training program can produce capable trainers and may positively influence their own health. Lay trainers may be more motivated to enhance their self-management skills as they have to present the benefits to their trainees.

Health and physiological effects of an emotional disclosure intervention adapted for application at home: a randomized clinical trial in rheumatoid arthritis.

BACKGROUND: The efficacy of emotional disclosure in alleviating psychological and physical stress has been well documented in controlled laboratory studies. A next step is to evaluate its clinical utility in 'real world' settings. We adapted the emotional disclosure intervention for use in home-based settings by stimulating the suggested effective ingredients of cognitive-emotional processing, and evaluated its psychological and clinical effectiveness. Reviews indicated the need to examine the physiological changes brought about by emotional disclosure, which may be particularly relevant in immune-mediated diseases. This study was the first to examine neuroendocrine and immune changes after emotional disclosure in patients with rheumatoid arthritis. METHODS: Sixty-eight patients were randomly assigned to four weekly oral emotional disclosure or time management sessions. At baseline and 1 week and 3 months after the sessions, depressed and cheerful mood, joint scores, erythrocyte sedimentation rate, cortisol, noradrenaline, interleukin-6 (IL-6), interferon-gamma (IFN-gamma), and IL-10 were evaluated. Repeated measures analyses of variance were performed. RESULTS: No effect on psychological well-being and clinical outcome was found (p > or = 0.10). Cortisol (p = 0.01) and the serum level of the pro-inflammatory cytokine IFN-gamma (p = 0.05) were differentially affected by the two conditions. The change of IL-6 nearly reached significance (p = 0.07). CONCLUSIONS: The physiological changes are in agreement with theories on the mechanisms underlying emotional disclosure benefits and are suggestive of better disease control after emotional disclosure. General and study-specific reasons for the absence of psychological and clinical effects are discussed. The findings warn against widespread implementation of this home-based emotional disclosure intervention in unselected rheumatoid arthritis samples.

Lay trainers with migraine for a home-based behavioral training: a 6-month follow-up study.

OBJECTIVE: To evaluate the changes at 6-month follow-up after a home-based behavioral training (BT) provided by lay trainers with migraine to small groups of fellow patients. BACKGROUND: The need for self-management programs and cost-effective treatments gave rise to this study. METHODS: In a previous randomized controlled trial, we compared the BT group with a waitlist-control group, receiving usual care. The control group was trained directly after their waitlist period. The present study examined the follow-up results in both groups and measurements were held pre BT, post BT, and at 6-month follow-up. RESULTS: Six months after BT, 42% was categorized as responders (>or=-50% decrease in attack frequency), 42% did not change (-49 to 49%), and 16% responded adversely (>or=50% increase). In the group as a whole (n = 95), attack frequency significantly decreased from 3.0 attacks at baseline to 2.5 post BT and to 2.3 at 6-month follow-up (-23%, medium effect size 0.6). The strong improvements of perceived control over and self-confidence in attack prevention were maintained at follow-up. Disability and health status were unchanged but quality of life significantly improved over time (P = .007). BT was more beneficial for patients who entered the training with a high attack frequency. Linear regression analysis demonstrated that a stronger belief at baseline that the occurrence of migraine is due to chance (external control) significantly predicted a lower attack frequency at follow-up. CONCLUSION: Lay trainers with migraine can train small groups of fellow patients at home in behavioral attack prevention. At 6-month follow-up, attack frequency and quality of life were significantly but modestly improved and feelings of control and self-confidence remained strongly improved.

Influence of sleep on symptom improvement and return to work in clinical burnout.

OBJECTIVES: The current study examined the extent to which symptom improvement and full return to work occurs among clinically burnt-out employees and what the influence of concurring sleep problems is with respect to health recovery. METHODS: Fifty-nine burnt-out employees on extended sick leave assessed their symptoms for 2 weeks using an electronic diary. After 6 months, the measurements were repeated. Symptom levels were compared with those of a healthy reference group that was assessed only once. RESULTS: After 6 months, all burnout symptoms had decreased significantly, and full return to work was achieved by 37% of the burnt-out individuals. The symptom levels at 6 months of follow-up among those who had fully returned to work were similar to healthy levels and significantly lower than the levels of those still on sick leave. The persons who benefited poorly from sleep at baseline had higher exhaustion levels at follow-up than those who benefited from sleep. Trouble falling asleep and less refreshing sleep at baseline hampered eventual full work resumption. CONCLUSIONS: The results show that a significant number of clinically burnt-out employees is able to recover in a 6-month period and that sleep plays an important role both in symptom improvement and in return to work.

Exhaustion and endocrine functioning in clinical burnout: an in-depth study using the experience sampling method.

The current study investigates the relationship between HPA-axis functioning and burnout symptoms by employing an electronic symptom diary. This diary method circumvents the retrospection bias induced by symptom questionnaires and allows to study relationships within-in addition to between-subjects. Forty two clinically burned-out participants completed the exhaustion subscale of the Maslach burnout inventory and kept an electronic diary for 2 weeks to assess momentary exhaustion and daily recovery through sleep. On 3 consecutive weekdays within the diary period, saliva was sampled to determine the cortisol awakening response (CAR), levels of dehydroepiandrosterone-sulphate (DHEAS) on the first 2 weekdays, and to conduct the dexamethasone suppression test (DST) on the third weekday. We found significant relationships between endocrine values and general momentary symptom severity as assessed with the diary, but not with the retrospective questionnaire-assessed burnout symptoms. Simultaneous assessments of endocrine values and burnout symptoms assessed with the diary after awakening rendered significant associations between persons, and a trend within persons. More severe burnout symptoms were consistently associated with a lower level and smaller increase of CAR, higher DHEAS levels, smaller cortisol/DHEAS ratios and a stronger suppression after DST. Burnout symptoms were significantly related to endocrine functioning in clinical burnout under the best possible conditions of symptom measurement. This adds support to the view that severity of burnout symptoms is associated with HPA-axis functioning.

Evidence that impaired sleep recovery may complicate burnout improvement independently of depressive mood.

OBJECTIVE: This article examines recovery through sleep in relation to sleep quality, exhaustion, and depression in clinical burnout. We focus on actual recovery per night, given its relevance to burnout improvement. METHODS: Sixty clinically burned-out participants and 40 healthy controls recorded symptoms with an electronic diary for 2 weeks at random times per day. Recovery through sleep was defined as the difference in fatigue between late evening and the next morning. RESULTS: In clinical burnout, sleep quality and recovery are impaired, and depression is elevated. Poor recovery through sleep is associated with poor same-night sleep quality, clarifying the mechanisms underlying poor recovery. Individual differences in recovery though sleep were related to differences in refreshed awakening, but not to other sleep problems. Impaired recovery was also related to severity of exhaustion, but not to severity of depressive mood, indicating that, in burnout, nonprofit from sleep is a symptom of energy depletion, not a sign of depression. CONCLUSION: Impaired recovery through sleep may hamper recovery from burnout independently of the influence of depression.

Feasibility and induced cognitive-emotional change of an emotional disclosure intervention adapted for home application.

OBJECTIVE: Emotional engagement, cognitive restructuring, and positive future directedness are considered core elements to induce change in emotional disclosure interventions. Our aim was to examine the induction of these elements and the feasibility of an emotional disclosure intervention adapted for home application. METHODS: The intervention emphasized expression of negative and positive emotions (session 1-4), search for meaning (session 3), and a positive future-oriented ending (session 4). A randomized clinical trial in patients with rheumatoid arthritis compared the adapted intervention (n=40) with a time management control condition (n=28). Feasibility was evaluated regarding adherence, compliance with instructions, perceived viability, and clinical safety. Induction of core elements was evaluated by analysis of change in immediate affective responses and by computerized text analysis of word use. RESULTS: Feasibility criteria were successfully met. The disclosure condition produced higher immediate negative affect and use of emotion, insight, and optimism words compared to control, and induced the elements of change within sessions as intended. CONCLUSION: The adapted intervention is feasible for home application and induces change in variables that indicate emotional engagement, cognitive restructuring, and positive future directedness. PRACTICE IMPLICATIONS: Empirical support of health benefits of this emotional disclosure intervention will extend its applicability in patient self-care.

Mobile Web-based monitoring and coaching: feasibility in chronic migraine.

BACKGROUND: The Internet can facilitate diary monitoring (experience sampling, ecological momentary assessment) and behavioral coaching. Online digital assistance (ODA) is a generic tool for mobile Web-based use, intended as an adjuvant to face-to-face or Internet-based cognitive behavioral treatment based. A current ODA application was designed to support home-based training of behavioral attack prevention in chronic migraine, focusing on the identification of attack precursors and the support of preventive health behaviour. OBJECTIVE: The aim was to establish feasibility of the ODA approach in terms of technical problems and participant compliance, and ODA acceptability on the basis of ratings of user-friendliness, potential burden, and perceived support of the training for behavioral attack prevention in migraine. METHODS: ODA combines mobile electronic diary monitoring with direct human online coaching of health behavior according to the information from the diary. The diary contains three parts covering the following: (1) migraine headache and medication use, (2) attack precursors, and (3) self-relaxation and other preventive behavior; in addition, menstruation (assessed in the evening diary) and disturbed sleep (assessed in the morning diary) is monitored. The pilot study consisted of two runs conducted with a total of five women with chronic migraine without aura. ODA was tested for 8.5 days (range 4-12 days) per participant. The first test run with three participants tested 4-5 diary prompts per day. The second run with another three participants (including one subject who participated in both runs) tested a reduced prompting scheme (2-3 prompts per day) and minor adaptations to the diary. Online coaching was executed twice daily on workdays. RESULTS: ODA feasibility was established on the basis of acceptable data loss (1.2% due to the personal digital assistant; 5.6% due to failing Internet transmission) and good participant compliance (86.8% in the second run). Run 1 revealed some annoyance with the number of prompts per day. Overall ODA acceptability was evident by the positive participant responses concerning user-friendliness, absence of burden, and perceived support of migraine attack prevention. The software was adapted to further increase the flexibility of the application. CONCLUSIONS: ODA is feasible and well accepted. Tolerability is a sensitive issue, and the balance between benefit and burden must be considered with care. ODA offers a generic tool to combine mobile coaching with diary monitoring,independently of time and space. ODA effects on improvement of migraine remain to be established.

Electronic diary evidence on energy erosion in clinical burnout.

Burnout is generally defined as a state of severe exhaustion. So far, research has predominantly focused on relatively mild burnout in employees able to work despite their complaints. This study examines energy depletion in clinical burnout (e.g., the severest cases on extended sick leave) by comparing the diurnal patterns of fatigue and exhaustion with those of healthy individuals. Sixty clinically burned-out and 40 healthy participants kept an electronic diary for 14 days, 7 times a day, yielding a total of 8,116 diary entries. This study shows that burned-out individuals typically suffer continuously from a severe fatigue throughout the day. The resulting flattened diurnal cycles mark a stable exhaustion that is uncommon in healthy persons. The current results provide novel support for the existence of severe energy erosion in clinical burnout.

Electronic momentary assessment in chronic pain II: pain and psychological pain responses as predictors of pain disability.

OBJECTIVES AND METHODS: More than 7,100 electronic diaries from 80 patients with chronic pain (mean: 89.3, range 30-115) entered multilevel analyses to establish the statistical prediction of disability by pain intensity and by psychological functioning (fear avoidance, cognitive, and spousal pain responses). We also tested the differences between pre-chronic, recently chronic, and persistently chronic pain in the prediction of disability (impaired physical and mental capacity, pain interference with activities, immobility due to pain). RESULTS: Pain intensity explained 8% to 19% of the disability variance. Beyond this psychological functioning explained 7% to 16%: particularly fear-avoidance and cognitive pain responses predicted chronic pain disorder disability; spousal responses predicted immobility better than other aspects of disability. Immobility due to actual pain occurred infrequently. When it did, however, it was better predicted by avoidance behavior in the patient and by spousal discouragement of movement than by actual pain intensity. The prediction of immobility due to pain by, respectively, avoidance behavior and catastrophizing was better in chronic pain (>6 months) and that of physical impairment by catastrophizing better in persistently chronic pain (>12 months) than in pain of shorter duration. DISCUSSION: The psychological prediction of chronic pain disorder disability was determined beyond that accounted for by pain intensity. Nonetheless, psychological functioning explained substantial variance in chronic pain disorder disability. The psychological prediction of immobility and physical impairment was stronger with longer pain duration. Patient characteristics and momentary states of disability-and in particular of immobility-should be carefully distinguished and accounted for in chronic pain disorder.

Electronic momentary assessment in chronic pain I: psychological pain responses as predictors of pain intensity.

OBJECTIVES AND METHODS: Electronic momentary assessment was employed to substantiate the relevance of psychological functioning in chronic pain. More than 7,100 electronic diaries from 80 patients with varying IASP classified types of chronic pain served to investigate to what extent fear-avoidance, cognitive and spousal solicitous and punishing pain responses explained fluctuations in pain intensity and whether patients with pre-chronic, recently chronic and persistently chronic pain differed in this regard. RESULTS: Psychological pain responses explained 40% of the total variance in pain intensity: almost 24% concerned pain variance that occurred between the CPD patients and 16% pertained to pain variance due to momentary differences within these patients. Separately tested fear-avoidance and cognitive responses each explained about 28% of the total pain variance, while spousal responses explained 9%. Catastrophizing emerged as the strongest pain predictor, followed by pain-related fear and bodily vigilance. Results did not differ with the duration of chronicity. DISCUSSION: Exaggerated negative interpretations of pain, and fear that movement will induce or increase pain strongly predicted CPD pain intensity. Spousal responses-assessed only when the spouse was with the patient who at that moment was in actual pain-may more strongly affect immobility due to pain than pain intensity per se (see part II of the study). The findings substantiate the importance of catastrophizing, fear and vigilance identified primarily in low back pain and extend this to other forms of chronic pain. The compelling evidence of momentary within-patients differences underscores that these must be accounted for in chronic pain research and practice.

The preliminary effectiveness of migraine lay trainers in a home-based behavioural management training.

OBJECTIVES: This pilot study examined the effectiveness and trainer skills of the first migraine lay trainers (MLTs). METHODS: In a stepwise training program eight MLTs participated in a behavioural management training (BMT) aimed at the prevention of migraine attacks by proactive relaxation and trigger management. After successful reduction of their migraine attacks, three MLTs provided BMT under supervision at home to one fellow patient and subsequently to a small group. RESULTS: Migraine frequency was significantly reduced in five out of eight patients trained by MLTs (mean 48%) and medication use decreased substantially in four patients (mean 47%). Qualities of MLTs concerned their motivational assistance, knowledge of premonitory symptoms and exchange of disease specific problems. Pitfalls were that migraine symptoms hampered an active guidance of the sessions and providing tailored feedback was difficult. CONCLUSION: The first MLTs were successful in training fellow patients in behavioural prevention of migraine attacks. PRACTICE IMPLICATIONS: Continuous supervision of MLTs health and trainer skills is recommended but is likely to have implications for cost-effectiveness.

Prevalence of chronic benign pain disorder among adults: a review of the literature.

In this review epidemiological studies concerning chronic benign pain among adults are discussed. To this end, studies focusing on chronic pain, reporting prevalences at a population or primary health care level, including subjects aged between 18 and 75 years have been collected and analyzed. Focus of analysis was on research methods, definitions of chronic benign pain used, and reported prevalences. Prevalences varied between 2% and 40% of the population. Nor method used (telephone survey, postal survey, nor definition of chronicity (>1 month; >3 months; >6 months) clearly explained the differences in prevalence in the various studies. Implications for future research are discussed.

The effect of support on internet-delivered treatment for insomnia: does baseline depression severity matter?

Internet-delivered cognitive-behavioral treatment is effective for insomnia. However, little is known about the beneficial effects of support. Recently we demonstrated that motivational support moderately improved the effects of Internet-delivered treatment for insomnia. In the present study, we tested whether depressive symptoms at baseline moderate the effect of support on Internet-delivered treatment for insomnia. We performed a multilevel intention-to-treat analysis on 262 participants in a randomized controlled trial. We found that baseline depressive symptoms moderated the effect of support on sleep efficiency, total sleep time, and sleep onset latency (but not on wake after sleep onset, number of nightly awakenings, or the Insomnia Severity Index). This means that for these variables, people with high levels of depressive symptoms benefit from support, whereas people with low levels of depressive symptoms improve regardless of support. The data show that baseline depression severity plays an important role in the way Internet treatments need to be delivered. These findings open up opportunities to personalize the support offered in Internet-delivered treatments.

Prodromal functioning of migraine patients relative to their interictal state--an ecological momentary assessment study.

Smartphones were used in an online Ecological Momentary Assessment (EMA) design to test prodromal functioning relative to the interictal state in migraine patients. Eighty-seven participants completed an electronic diary 4 times daily during 3-6 weeks to monitor their migraine attacks. Twice daily the diary additionally included 16 multi-answer questions covering physical symptoms (30 items), cognitive-affective functioning (25 items) and external factors (25 items). Eight clustered prodromal features were identified in the current study: sensory sensitivity, pain/stiffness, fatigue, cognitive functioning, positive affect, negative affect, effort spent and stressors encountered. Per feature, individual change scores with interictal control days--excluding 24-hour post-attack recovery--were computed for six 12-hour pre-attack time windows covering three prodromal days. Linear mixed model (fixed-effect) analysis established significant increases in sensory sensitivity, pain/stiffness and fatigue, and a tendency for increased negative affect, in the 12 hours prior to the attack. Positive affect and cognitive functioning were impaired both in the 25-36 hour and--more strongly--in the 12-hour time window before the attack. No effects were found for effort spent and stressors encountered. Exploratory (random effect) analysis revealed significant individual differences in the change scores in sensory sensitivity, pain/stiffness, fatigue and negative affect. It is concluded that the prodromal change in migraine--relative to interictal functioning--predominantly exists within the last 12 hours before attack onset. Individual diversity is large, however. Future research should zoom in to identify prodrome development within the 12 pre-attack hours as well as to isolate individual patterns.

Motivational support provided via email improves the effectiveness of internet-delivered self-help treatment for insomnia: a randomized trial.

Internet-delivered treatment is effective for insomnia, but little is known about the beneficial effects of support. The aim of the current study was to investigate the additional effects of low-intensity support to an internet-delivered treatment for insomnia. Two hundred and sixty-two participants were randomized to an internet-delivered intervention for insomnia with (n = 129) or without support (n = 133). All participants received an internet-delivered cognitive behavioral treatment for insomnia. In addition, the participants in the support condition received weekly emails. Assessments were at baseline, post-treatment, and 6-month follow-up. Both groups effectively ameliorated insomnia complaints. Adding support led to significantly higher effects on most sleep measures (d = 0.3-0.5; p < 0.05), self-reported insomnia severity (d = 0.4; p < 0.001), anxiety, and depressive symptoms (d = 0.4; p < 0.01). At the 6-month follow-up, these effects remained significant for sleep efficiency, sleep onset latency, insomnia symptoms, and depressive symptoms (d = 0.3-0.5; p < 0.05). Providing support significantly enhances the benefits of internet-delivered treatment for insomnia on several variables. It appears that motivational feedback increases the effect of the intervention and encourages more participants to complete the intervention, which in turn improves its effectiveness.

User acceptance of an Internet training aid for migraine self-management.

We have developed an Internet training aid (MyMigraine) for migraine self-management derived from an evidence-based protocol for behavioural attack prevention. Its acceptance was tested in two studies concerning the opinions of new patients (n = 10), and the opinions of expert patients acquainted with the protocol (n = 6). The questionnaires employed 5-point scales. In study 1, all lessons were rated positively regarding clarity, instructiveness, importance and easy execution. After training, the patients were positive about user-friendliness and clarity (mean score 3.9), training content (3.5), satisfaction (3.6) and benefits (attack risk detection: 3.7; preventive coping: 3.9). In study 2, the expert patients provided positive ratings for the web application (mean score 4.1), digital support (3.8-4.4) and web adaptation of the protocol (4.1-4.8). The expert patients considered MyMigraine instructive, captivating and fun to work with, but emphasized the necessity of patient-to-patient contact. The training aid was very well accepted by new and experienced patients with chronic migraine.