The effects of telehealth-delivered mindfulness meditation, cognitive therapy, and behavioral activation for chronic low back pain: a randomized clinical trial.

BACKGROUND: Chronic low back pain (CLBP) is a significant problem affecting millions of people worldwide. Three widely implemented psychological techniques used for CLBP management are cognitive therapy (CT), mindfulness meditation (MM), and behavioral activation (BA). This study aimed to evaluate the relative immediate (pre- to post-treatment) and longer term (pre-treatment to 3- and 6-month follow-ups) effects of group, videoconference-delivered CT, BA, and MM for CLBP. METHODS: This is a secondary analysis of a three-arm, randomized clinical trial comparing the effects of three active treatments-CT, BA, and MM-with no inert control condition. Participants were N = 302 adults with CLBP, who were randomized to condition. The primary outcome was pain interference, and other secondary outcomes were also examined. The primary study end-point was post-treatment. Intent-to-treat analyses were undertaken for each time point, with the means of the changes in outcomes compared among the three groups using an analysis of variance (ANOVA). Effect sizes and confidence intervals are also reported. RESULTS: Medium-to-large effect size reductions in pain interference were found within BA, CT, and MM (ds from - .71 to - 1.00), with gains maintained at both follow-up time points. Effect sizes were generally small to medium for secondary outcomes for all three conditions (ds from - .20 to - .71). No significant between-group differences in means or changes in outcomes were found at any time point, except for change in sleep disturbance from pre- to post-treatment, improving more in BA than MM (d = - .49). CONCLUSIONS: The findings from this trial, one of the largest telehealth trials of psychological treatments to date, critically determined that group, videoconference-delivered CT, BA, and MM are effective for CLBP and can be implemented in clinical practice to improve treatment access. The pattern of results demonstrated similar improvements across treatments and outcome domains, with effect sizes consistent with those observed in prior research testing in-person delivered and multi-modal psychological pain treatments. Thus, internet treatment delivery represents a tool to scale up access to evidence-based chronic pain treatments and to overcome widespread disparities in healthcare. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03687762.

PREF-NET: a patient preference and experience study of lanreotide autogel administered in the home versus hospital setting among patients with gastroenteropancreatic neuroendocrine tumours in the UK.

PURPOSE: PREF-NET reported patients' experience of Somatuline® (lanreotide) Autogel® (LAN) administration at home and in hospital among patients with gastroenteropancreatic neuroendocrine tumours (GEP-NETs). METHODS: PREF-NET was a multicentre, cross-sectional study of UK adults (aged ≥ 18 years) with GEP-NETs receiving a stable dose of LAN, which comprised of (1) a quantitative online survey, and (2) qualitative semi-structured interviews conducted with a subgroup of survey respondents. The primary objective was the description of overall patient preference for home versus hospital administration of LAN. Secondary objectives included describing patient-reported opinions on the experience and associated preference for each administration setting, and the impact on healthcare utilisation, societal cost, activities of daily living and health-related quality of life (HRQoL). RESULTS: In the primary analysis (80 patients; mean age 63.9 years), 98.7% (95% confidence interval [CI]: 96.1-100.0) of patients preferred to receive LAN at home, compared with 1.3% (95% CI: 0.0-3.9) who preferred the hospital setting. Among participants, over half (60.3%) received their injection from a non-healthcare professional. Most patients (79.5% [95% CI: 70.5-88.4]) reported a positive effect on HRQoL after the switch from hospital to home administration. Qualitative interviews (20 patients; mean age 63.6 years) highlighted that patients preferred home administration because it improved overall convenience; saved time and costs; made them feel more comfortable and relaxed, and less stressed; and increased confidence in their ability to self-manage their treatment. CONCLUSION: Almost all patients preferred to receive LAN treatment at home rather than in hospital with increased convenience and psychological benefits reported as key reasons for this preference.

An evaluation of the behavioural inhibition system and behavioural activation system (BIS-BAS) model of pain in athletes.

This study examined coping and pain responses using a behavioural inhibition (BIS) - behavioural activation (BAS) framework in 489 student athletes (M(age) = 20, SD = 4; 69% female). Two samples of athletes (226 pain-free athletes and 232 athletes with current pain) completed surveys assessing BIS- and BAS-related cognitions, emotions, and behaviours. Distinct groupings of BAS-related variables were identified in both samples, evidenced by significant positive correlations within BAS-related variables (positive affect, pain openness, approach thoughts and behaviours). Most BIS-related variables (depression, anxiety, harm beliefs, pain catastrophizing and avoidance behaviours) were also correlated in the sample of athletes with pain; however, this was not observed in pain-free athletes. In athletes with pain, BIS-related variables were significantly associated with pain variables, with this association stronger than that found for BAS-related variables. Regression analyses highlighted the pivotal role of pain catastrophizing as a predictor of pain unpleasantness and intensity. Findings shed light on the factors shaping athletes' coping, pain perception and decisions as to whether to pause or push through. Future investigations to explore these dynamics in more depth may aid in the development of targeted interventions that enhance athletes' ability to cope and to manage pain more effectively.

Are Prayer-Based Interventions Effective Pain Management Options? A Systematic Review and Meta-analysis of Randomized Controlled Trials.

This review examined the effects of private and communal participatory prayer on pain. Nine databases were searched. Six randomized controlled trials were included. For private prayer, medium to large effects emerged for 67% to 69% of between-group comparisons; participants in the prayer condition reported lower pain intensity (0.59 < d < 26.17; 4 studies) and higher pain tolerance (0.70 < d < 1.05; 1 study). Pre- to post-intervention comparisons yielded medium to large effects (0.76 < d < 1.67; 2 studies); pain intensity decreased. Although firm conclusions cannot be made because meta-analysis was based on only two studies, the analysis suggested prayer might reduce pain intensity (SMD = - 2.63, 95% CI [- 3.11, - 2.14], I = 0%). (PROSPERO: CRD42020221733).

Transdiagnostic Cognitive Processes in Chronic Pain and Comorbid PTSD and Depression in Veterans.

BACKGROUND: Chronic pain in Veterans is a major problem compounded by comorbid posttraumatic stress disorder (PTSD) and depression. Adopting a transdiagnostic framework to understanding "shared territory" among these diagnoses has the potential to inform our understanding of the underlying cognitive processes and mechanisms that transverse diagnostic boundaries. PURPOSE: To examine the associations between pain-related cognitive processes (diversion, distancing, absorption, and openness), pain intensity, PTSD and depressive symptoms, and the extent to which Veterans with chronic pain with and without comorbid PTSD and depression engage in different/similar pain-related cognitive processes. METHODS: Secondary analysis of pretreatment data with a subsample (n = 147) of Veterans with chronic pain from a larger clinical trial. Pretreatment PCL-5 and PROMIS Depression scales were used to categorize participants into three groups: (a) Pain-only; (b) Pain-PTSD; and (c) Pain-PTSD-DEP. RESULTS: Compared to the Pain-only group, the Pain-PTSD and Pain-PTSD-DEP groups reported significantly greater pain intensity, PTSD and depressive symptoms, and ruminative pain absorption. The Pain-PTSD-DEP group had significantly lower pain diversion and pain openness scores. When diversion and openness were used within the Pain-PTSD-DEP group, however, they were both associated with lower pain intensity and openness was additionally associated with lower PTSD scores. However, in the Pain-PTSD group, pain openness was associated with higher depression scores. CONCLUSIONS: Across increasing complexity of comorbidity profiles (i.e., one vs. two comorbid conditions), ruminative absorption with pain emerged as a cognitive process that transverses diagnoses and contributes to worse outcomes. Nonjudgmental acceptance may not be universally beneficial, potentially depending upon the nature of comorbidity profiles.

The Flares of Low back pain with Activity Research Study (FLAReS): study protocol for a case-crossover study nested within a cohort study.

BACKGROUND: Although it is generally accepted that physical activity and flares of low back pain (LBP) are related, evidence for the directionality of this association is mixed. The Flares of Low back pain with Activity Research Study (FLAReS) takes a novel approach to distinguish the short-term effects of specific physical activities on LBP flares from the cumulative effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. The first aim is to estimate the short-term effects (≤ 24 h) of specific physical activities on LBP flares among Veterans in primary care in the Veterans Affairs healthcare system. The second aim is to estimate the cumulative effects of specific activities on LBP-related functional limitations at 1-year follow-up. METHODS: Up to 550 adults of working age (18-65 years) seen for LBP in primary care complete up to 36 "Scheduled" surveys over 1-year follow-up, and also complete unscheduled "Flare Window" surveys after the onset of new flares. Each survey asks about current flares and other factors associated with LBP. Surveys also inquire about activity exposures over the 24 h, and 2 h, prior to the time of survey completion (during non-flare periods) or prior to the time of flare onset (during flares). Other questions evaluate the number, intensity, duration, and/or other characteristics of activity exposures. Other exposures include factors related to mood, lifestyle, exercise, concurrent treatments, and injuries. Some participants wear actigraphy devices for weeks 1-4 of the study. The first aim will examine associations between 10 specific activity categories and participant-reported flares over 1-year follow-up. The second aim will examine associations between the frequency of exposure to 10 activity categories over weeks 1-4 of follow-up and long-term functional limitations at 12 months. All analyses will use a biopsychosocial framework accounting for potential confounders and effect modifiers. DISCUSSION: FLAReS will provide empirically derived estimates of both the short-term and cumulative effects of specific physical activities for Veterans with LBP, helping to better understand the role of physical activities in those with LBP. TRIAL REGISTRATION: ClinicalTrials.gov NCT04828330 , registered April 2, 2021.

Mindfulness-Based Analgesia or Placebo Effect? The Development and Evaluation of a Sham Mindfulness Intervention for Acute Experimental Pain.

OBJECTIVE: Meta-analyses indicate that mindfulness meditation is efficacious for chronic and acute pain, but most available studies lack active control comparisons. This raises the possibility that placebo-related processes may account, at least in part, for mindfulness effects. The objective of this study was to develop a closely matched sham mindfulness condition to establish whether placebo effects contribute to mindfulness-based interventions for pain. METHODS: We developed and validated a closely matched sham mindfulness intervention then compared it with 6 × 20-minute sessions of focused-attention mindfulness and a no-treatment condition in 93 healthy volunteers undergoing acute experimental heat pain. RESULTS: The sham mindfulness intervention produced equivalent credibility ratings and expectations of improvement as the mindfulness intervention but did not influence mindfulness-related processes. In contrast, mindfulness increased "observing" relative to no treatment but not sham. Mindfulness (F(1,88) = 7.06, p = .009, ηp2 = 0.07) and sham (F(1,88) = 6.47, p = .012, ηp2 = 0.07) moderately increased pain tolerance relative to no treatment, with no difference between mindfulness and sham (F(1,88) = 0.01, p = .92, ηp2 < 0.001). No differences were found for pain threshold. Similarly, neither mindfulness nor sham reduced pain intensity or unpleasantness relative to no treatment, although mindfulness reduced pain unpleasantness relative to sham (F(1,88) = 5.03, p = .027, ηp2 = 0.05). CONCLUSIONS: These results suggest that placebo effects contribute to changes in pain tolerance after mindfulness training, with limited evidence of specific effects of mindfulness training on pain unpleasantness relative to sham, but not no treatment. To disentangle the specific analgesic effects of mindfulness from placebo-related processes, future research should prioritize developing and incorporating closely matched sham conditions.Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12618001175268).

Change in Brain Oscillations as a Mechanism of Mindfulness-Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain.

OBJECTIVE: Psychological treatments for chronic low back pain (CLBP) are effective. However, limited research has investigated their neurophysiological mechanisms. This study examined electroencephalography- (EEG-) assessed brain oscillation changes as potential mechanisms of cognitive therapy (CT), mindfulness-meditation (MM), and mindfulness-based cognitive therapy (MBCT) for CLBP. The a priori bandwidths of interest were changes in theta, alpha and beta power, measured at pre- and post-treatment. DESIGN: A secondary analysis of a clinical trial. SETTING: University of Queensland Psychology Clinic. SUBJECTS: Adults (N = 57) with CLBP who completed pre- and post-treatment EEG and pain outcome assessments. METHODS: EEG data were examined for five regions of interest (ROIs); the primary outcome was pain intensity. RESULTS: A significant reduction in theta (P=.015) and alpha (P=.006) power in the left frontal ROI across all treatments was found, although change in theta and alpha power in this region was not differentially associated with outcome across treatments. There were significant reductions in beta power in all five ROIs across all treatments (P≤.013). Beta power reduction in the central ROI showed a significant association with reduced pain intensity in MBCT only (P=.028). Changes in other regions were not statistically significant. CONCLUSIONS: These findings provide support for the capacity of psychological CLBP treatments to induce changes in brain activity. The reduced beta power in all five ROIs indicated that all three treatments engendered a state of lowered cortical arousal. The growing body of research in this area could potentially inform novel directions towards remedying central nervous system abnormalities associated with CLBP.

Prosthetic Rehabilitation in Practice: An Exploration of Experiential Knowledge in the Multidisciplinary Team.

The aim of this research was to explore the experiential knowledge of patient-facing staff working in a prosthetic rehabilitation center in the United Kingdom. Eleven members of staff with varied roles and levels of experience took part in semi-structured interviews. Transcripts were analyzed using thematic analysis. Six themes were identified: (a) defining successful rehabilitation, (b) the complex reality of patient-centered care, (c) organizational and interpersonal challenges, (d) who provides psychological support? (e) prosthetic as a panacea, and (f) crash landing. These findings highlight the impact of rotational roles in an environment reliant on experiential knowledge, the challenge of applying patient-centered care models, and the negative effect of unrealistic beliefs about prosthetics on patients and staff. This study contributes to a limited pool of literature articulating the experiential knowledge of staff in the context of rehabilitation after major lower limb loss, facilitating the translation of practice-based evidence into evidence-based practice.

Narratives of Recovery Over the First Year After Major Lower Limb Loss.

The objectives of this research were to extend previous research by exploring the psychosocial experiences of patients over the first year after major lower limb amputation (MLLA) and identify implications for rehabilitation practice. This research took place at a United Kingdom-based National Health Service-operated prosthetic rehabilitation center. Thirty patients were recruited who had experienced MLLA within the last year and were undertaking prosthetic rehabilitation. Data were collected through semi-structured narrative interviews, observation, and a reflexive journal and analyzed using dialogical narrative analysis. The concept of well-being was used to map patients' recovery trajectories, and five narrative typologies were identified: accelerated decline, adaptation, illusory cure, muddling along, and projection. This article advances knowledge by opening up new possibilities for anticipating patients' future needs through the stories they are telling in the present and provides the basis for additional resources supporting psychosocial recovery.

Does Mindfulness-Based Cognitive Therapy for Migraine Reduce Migraine-Related Disability in People with Episodic and Chronic Migraine? A Phase 2b Pilot Randomized Clinical Trial.

OBJECTIVE: The current Phase 2b study aimed to evaluate the efficacy of mindfulness-based cognitive therapy for migraine (MBCT-M) to reduce migraine-related disability in people with migraine. BACKGROUND: Mindfulness-based interventions represent a promising avenue to investigate effects in people with migraine. MBCT teaches mindfulness meditation and cognitive-behavioral skills and directly applies these skills to address disease-related cognitions. METHODS: Participants with migraine (6-30 headache days/month) were recruited from neurology office referrals and local and online advertisements in the broader New York City area. During the 30-day baseline period, all participants completed a daily headache diary. Participants who met inclusion and exclusion criteria were randomized in a parallel design, stratified by chronic migraine status, to receive either 8 weekly individual MBCT-M sessions or 8 weeks of waitlist/treatment as usual (WL/TAU). All participants completed surveys including primary outcome evaluations at Months 0, 1, 2, and 4. All participants completed a headache diary during the 30-day posttreatment evaluation period. Primary outcomes were the change from Month 0 to Month 4 in the headache disability inventory (HDI) and the Migraine Disability Assessment (MIDAS) (total score ≥ 21 indicating severe disability); secondary outcomes (headache days/30 days, average headache attack pain intensity, and attack-level migraine-related disability [Migraine Disability Index (MIDI)]) were derived from the daily headache diary. RESULTS: Sixty participants were randomized to receive MBCT-M (n = 31) or WL/TAU (n = 29). Participants (M age = 40.1, SD = 11.7) were predominantly White (n = 49/60; 81.7%) and Non-Hispanic (N = 50/60; 83.3%) women (n = 55/60; 91.7%) with a graduate degree (n = 35/60; 55.0%) who were working full-time (n = 38/60; 63.3%). At baseline, the average HDI score (51.4, SD = 19.0) indicated a moderate level of disability and the majority of participants (50/60, 83.3%) fell in the "Severe Disability" range in the MIDAS. Participants recorded an average of 16.0 (SD = 5.9) headache days/30 days, with an average headache attack pain intensity of 1.7 on a 4-point scale (SD = 0.3), indicating moderate intensity. Average levels of daily disability reported on the MIDI were 3.1/10 (SD = 1.8). For the HDI, mean scores decreased more from Month 0 to Month 4 in the MBCT-M group (-14.3) than the waitlist/treatment as an usual group (-0.2; P < .001). For the MIDAS, the group*month interaction was not significant when accounting for the divided alpha, P = .027; across all participants in both groups, the estimated proportion of participants falling in the "Severe Disability" category fell significantly from 88.3% at Month 0 to 66.7% at Month 4, P < .001. For diary-reported headache days/30 days an average headache attack pain intensity, neither the group*month interaction (Ps = .773 and .888, respectively) nor the time effect (Ps = .059 and .428, respectively) was significant. Mean MIDI scores decreased in the MBCT-M group (-0.6/10), whereas they increased in the waitlist/treatment as an usual group (+0.3/10), P = .007. CONCLUSIONS: MBCT-M demonstrated efficacy to reduce headache-related disability and attack-level migraine-related disability. MBCT-M is a promising emerging treatment for addressing migraine-related disability.

A Pilot Randomized Controlled Trial Comparing Mindfulness Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain.

OBJECTIVE: This pilot trial compared the feasibility, tolerability, acceptability, and effects of group-delivered mindfulness meditation (MM), cognitive therapy (CT), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP). SETTING: University of Queensland Psychology Clinic. SUBJECTS: Participants were N = 69 (intent-to-treat [ITT] sample) adults with CLBP. DESIGN: A pilot, assessor-blinded randomized controlled trial. METHODS: Participants were randomized to treatments. The primary outcome was pain interference; secondary outcomes were pain intensity, physical function, depression, and opioid medication use. The primary study end point was post-treatment; maintenance of gains was evaluated at three- and six-month follow-up. RESULTS: Ratings of acceptability, and ratios of dropout and attendance showed that MBCT was acceptable, feasible, and well tolerated, with similar results found across conditions. For the ITT sample, large improvements in post-treatment scores for pain interference, pain intensity, physical function, and depression were found (P < 0.001), with no significant between-group differences. Analysis of the follow-up data (N = 43), however, revealed that MBCT participants improved significantly more than MM participants on pain interference, physical function, and depression. The CT group improved more than MM in physical function. The MBCT and CT groups did not differ significantly on any measures. CONCLUSIONS: This is the first study to examine MBCT for CLBP management. The findings show that MBCT is a feasible, tolerable, acceptable, and potentially efficacious treatment option for CLBP. Further, MBCT, and possibly CT, could have sustained benefits that exceed MM on some important CLBP outcomes. A future definitive randomized controlled trial is needed to evaluate these treatments and their differences.

Contraceptive Methods and the Impact of Menstruation on Daily Functioning in Women with Sickle Cell Disease.

OBJECTIVES: Women with sickle cell disease (SCD) are living longer as a result of advances in the care of their underlying disease. With the population growing of women living with SCD, reproductive health issues in this population have become an emphasized area of medical care. We sought to describe current patterns of contraception use, menstruation, and quality-of-life (QOL) measures in women with SCD. METHODS: Using a cross-sectional study design, we administered paper surveys at two academic medical centers to women aged 10 to 55 years with SCD to capture current contraceptive use, characteristics of menstrual cycles, and QOL metrics. RESULTS: Of the 103 women who participated, 12.7% (13/102) experienced a duration of menses >7 days (defined here as prolonged menstrual bleeding). Approximately half of women (51.5%, 53/103) used some form of contraception, with depot medroxyprogesterone acetate injections and condoms being the most common. During their last menstrual periods, women with both dysmenorrhea and prolonged menstrual bleeding (6.9%, 7/102) were more likely to experience more days of poor QOL, with more nights with sleep disturbance (P = 0.001) and more days with trouble taking care of themselves (P = 0.003), as well as being unable to do things they previously enjoyed (P = 0.001), compared with those with neither phenomenon (28.2%, 29/103). CONCLUSIONS: Dysmenorrhea and prolonged menstrual bleeding negatively affect the QOL of women with SCD. Menstrual histories and preventive measures for menstruation-related morbidity should be incorporated into routine evaluations of women with SCD.

Children with HbSß0 thalassemia have higher hemoglobin levels and lower incidence rate of acute chest syndrome compared to children with HbSS.

BACKGROUND: Based on the presumed clinical similarity between the two most severe sickle cell disease (SCD) genotypes, hemoglobin (Hb) Sß0 thalassemia and HbSS, randomized controlled trials (RCTs) have included both genotypes. Our group has demonstrated that healthcare providers inadequately distinguish the two diagnoses through clinical and laboratory parameters. PROCEDURE: In a retrospective cohort study utilizing data from the Silent Cerebral Infarct Transfusion trial (NCT00072761), we tested the hypothesis that children with genotypic diagnoses of HbSß0 thalassemia, when compared to HbSS, have significantly different rates of SCD comorbidities. Exclusion criteria included those with previous overt stroke or treatment with hydroxyurea or regular blood transfusion therapy. RESULTS: Among children with HbSß0 thalassemia (n = 22) and HbSS (n = 786), the mean hemoglobin was higher in children with HbSß0 thalassemia (9.2 g/dl) compared to HbSS (8.1 g/dl, P < 0.001). In children with HbSß0 thalassemia, when compared to HbSS, the incidence rate of acute chest syndrome (ACS) was 3.0 and 14.4 events per 100 patient-years (P = 0.028), and mean transcranial Doppler (TCD) velocities were 112.6 and 135.6 cm/sec, respectively (P = 0.026). The number of children with HbSß0 thalassemia and HbSS with conditional TCD velocities were zero (0%) and 26 (4.9%), respectively (P = 1.00), and the number with silent cerebral infarcts were five (27.8%) and 209 (30.8%), respectively (P = 0.78). CONCLUSIONS: We have provided preliminary evidence that clinically relevant differences occur in ACS rates and TCD velocities between children with HbSß0 thalassemia and HbSS. Future SCD RCTs should consider balanced allocation of these SCD genotypes, particularly when ACS and abnormal TCD velocities are primary outcome measures.

Predictors of Responsivity to Interdisciplinary Pain Management.

Objective: This study investigated for whom interdisciplinary pain management (IPM) is most effective. Identification of predictors of treatment responsivity would facilitate development of patient-treatment matching algorithms to optimize outcomes. Design: Repeated measures prospective study of consecutive admissions to a two-week IPM program. Setting: Brisbane Pain Rehabilitation Service in Brisbane, Australia. Subjects: A total of 163 adults referred for chronic pain management. Methods: Self-report questionnaires and measures of physical performance were obtained at program entry and completion. Group-level analyses were performed using standard parametric statistics. Individual-level change was assessed using recommended criteria. Multivariate analysis of variance and logistic regression were used to examine outcomes and predictors of response. Results: Significant improvements were observed across psychological, social, and physical outcome domains. Up to 50% of participants had clinically meaningful improvements, while less than 10% deteriorated. Higher baseline depression, anxiety, stress, and pain catastrophizing scores predicted better group-level outcomes (Ps < 0.05). Participants with higher baseline depression scores were most likely to show significant individual-level improvement on at least one outcome (Ps < 0.05). Participants with nociceptive pain were more than four times more likely than those with neuropathic pain to show clinically meaningful improvement on multiple outcomes, while those participants who were older were more likely to be multidomain responders. Conclusions: Physical, psychological, and social outcomes all improved in a significant proportion of participants following the IPM. High baseline depression was a clinically reliable predictor of individual-level improvement. Individuals with nociceptive pain and those who were older, respectively, showed the largest response across multiple outcomes and domains.

The Pain-Related Cognitive Processes Questionnaire: Development and Validation.

Objective: Cognitive processes may be characterized as how individuals think, whereas cognitive content constitutes what individuals think. Both cognitive processes and cognitive content are theorized to play important roles in chronic pain adjustment, and treatments have been developed to target both. However, the evaluation of treatments that target cognitive processes is limited because extant measures do not satisfactorily separate cognitive process from cognitive content. The current study aimed to develop a self-report inventory of potentially adaptive and presumed maladaptive attentional processes that may occur when someone is experiencing pain. Methods: Scales were derived from a large item pool by successively applying confirmatory factor analysis to item data from two undergraduate samples (N = 393 and 233). Results: Items, which were generated to avoid confounding of cognitive content with cognitive processes, represented nine constructs: Suppression, Distraction, Enhancement, Dissociation, Reappraisal, Absorption, Rumination, Nonjudgment, and Acceptance. The resulting nine scales formed the Pain-Related Cognitive Process Questionnaire (PCPQ), and scale correlations produced four conceptually distinct composite scales: Pain Diversion, Pain Distancing, Pain Focus, and Pain Openness. Internal consistency reliabilities of the nine scales were adequate (α ≥ 0.70) to good, and the four composite scales had α values of 0.79 or higher. Correlations with pain-related criterion variables were generally consistent with putative constructs. Conclusions: The developed PCPQ scales offer a comprehensive assessment of important cognitive processes specific to pain. Overall, the findings suggest that the PCPQ scales may prove useful for evaluating the role of pain-related cognitive processes in studies of chronic pain.

Understanding the Role of Therapist Quality in Accounting for Heterogeneity of Patient Outcomes in Psychosocial Chronic Pain Treatments.

A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.