A review of implementation and evaluation frameworks for public health interventions to inform co-creation: a Health CASCADE study.

BACKGROUND: By including the needs and perspectives of relevant stakeholders, co-creation is seen as a promising approach for tackling complex public health problems. However, recommendations and guidance on how to plan and implement co-creation are lacking. By identifying and analysing existing implementation and evaluation frameworks for public health, this study aims to offer key recommendations for professional stakeholders and researchers wanting to adopt a co-creation approach to public health interventions. METHODS: Firstly, PubMed and CINAHL databases were screened for articles introducing original implementation and evaluation frameworks for public health interventions. Backwards snowballing techniques were applied to the included papers. Secondly, identified frameworks were classified and relevant data extracted, including steps and constructs present in the frameworks. Lastly, recommendations were derived by conducting thematic analysis on the included frameworks. RESULTS: Thirty frameworks were identified and data related to their nature and scope extracted. The frameworks' prominent steps and constructs were also retrieved. Recommendations related to implementation and evaluation in the context of co-creation were included. CONCLUSION: When engaging in co-creation, we recommend including implementation considerations from an early stage and suggest adopting a systems thinking as a way to explore multiple levels of influence, contextual settings and systems from an early planning stage. We highlight the importance of partnering with stakeholders and suggest applying an evaluation design that is iterative and cyclical, which pays particular attention to the experience of the engaged co-creators.

Conceptualization of a cognitively enriched walking program for older adults: a co-design study with experts and end users.

BACKGROUND: Research in controlled laboratory settings shows that physical activity programs enriched with cognitive challenges enhance the benefits of physical activity on cognition in older adults. This translational study aimed to conceptualise a real-life, cognitively enriched walking program for older adults (65+) by investigating (a) which cognitive tasks are most suited for cognitive enrichment of a walking program, and (b) how to embed these tasks in a walking program to become feasible, enjoyable and effective. METHODS: A co-design process was followed with input of 34 academic experts and 535 end users. First, an online, three-rounds Delphi process was used to obtain consensus amongst academic experts on the key characteristics that a real-life cognitively enriched walking program should have. Next, end users provided feedback and suggestions on what the experts concluded, and gave more insight into their preferences and concerns by means of an online/telephone survey. RESULTS: Combined input from experts and end users resulted in a list of recommendations to guide the further development of the cognitively enriched walking program. First, it is important to provide a range of cognitive tasks to choose from. Each of these tasks should (a) provide variation and differentiation, (b) be implemented with increasing levels of difficulty, and (c) be integrated in the walk. Second, divide the walk into three parts: 5-10 min brisk walking, cognitive tasks for most of the walk, and 5-10 min free walking. Finally, the program should strive for a minimal session frequency of twice a week, include competition occasionally and carefully, ensure safety and keep the walks fun. CONCLUSIONS: The co-design process resulted in recommendations to guide the next steps in the program development process. Additional studies will be performed to improve the enjoyability and feasibility, and to assess the effectiveness of the cognitively enriched walking program to improve cognitive functioning and physical activity in older adults (65+).

A Network Analysis of Potential Antecedents and Consequences of Pain-Related Activity Avoidance and Activity Engagement in Adolescents.

OBJECTIVE: This study sets out to identify potential daily antecedents and consequences of pain-related activity avoidance and engagement behavior in adolescents with chronic pain. METHODS: Adolescents (N = 65, Mage = 14.41) completed baseline self-reports and a diary for 14 days. Afternoon and evening reports were used to infer a network structure of within-day associations between pain intensity, pain-related fear, pain catastrophizing, affect, and pain-related activity avoidance and engagement behavior. Baseline psychological flexibility was examined as a potential resilience factor. RESULTS: Activity avoidance in the evening was predicted by pain-related fear and avoidance earlier that afternoon. Activity engagement was predicted by positive affect and activity engagement in the afternoon. Pain-related behavior in the afternoon was not related to subsequent changes in pain intensity, pain-related fear, pain catastrophizing, or affect. Pain-related fear in the afternoon was predictive of increased levels of pain and pain catastrophizing in the evening. Both pain-related fear and pain catastrophizing in the evening were predicted by negative affect in the afternoon. Psychological flexibility was associated with lower levels of daily activity avoidance and buffered the negative association between pain intensity and subsequent activity engagement. CONCLUSIONS: This study provides insight into unique factors that trigger and maintain activity avoidance and engagement and into the role of psychological flexibility in pediatric pain. Future work should focus on both risk and resilience factors and examine the role of psychological flexibility in chronic pediatric pain in greater detail.

Resilience Factors in Children with Juvenile Idiopathic Arthritis and Their Parents: The Role of Child and Parent Psychological Flexibility.

OBJECTIVE: Chronic pain is central to juvenile idiopathic arthritis (JIA) and is predictive of impaired functioning. Whereas most work has focused on identifying psychosocial risk factors for maladaptive outcomes, we explored the idea that child and parental psychological flexibility (PF) represent resilience factors for adaptive functioning of the child. We also explored differences between general vs pain-specific PF in contributing to child outcomes. METHODS: Children with JIA (age eight to 18 years) and (one of) their parents were recruited at the Department of Pediatric Rheumatology at the Ghent University Hospital in Belgium. They completed questionnaires assessing child and parent general and pain-specific PF and child psychosocial and emotional functioning and disability. RESULTS: The final sample consisted of 59 children and 48 parents. Multiple regression analyses revealed that child PF contributed to better psychosocial functioning and less negative affect. Child pain acceptance contributed to better psychosocial functioning, lower levels of disability, and lower negative affect, and also buffered the negative influence of pain intensity on disability. Bootstrap mediation analyses demonstrated that parental (general) PF indirectly contributed to child psychosocial functioning and affect via the child's (general) PF. Parent pain-specific PF was indirectly linked to child psychosocial functioning, disability, and negative affect via child pain acceptance. CONCLUSIONS: Our findings indicate that child and parental PF are resilience factors and that pain acceptance buffers the negative impact of pain intensity. Implications for psychosocial interventions that target (pain-specific) PF in children and parents are discussed.

Sedentary patterns and health outcomes in the oldest-old: a latent profile analysis.

Background: Sedentary behavior is most prevalent among those aged 80 years and above, referred to as the oldest-old. Current literature emphasizes the significance of sedentary behavior patterns, but further evidence is required to understand how these patterns relate to specific health outcomes and to identify at-risk profiles for tailored interventions in the oldest-old. Therefore, the aim of this study was to identify profiles of adults aged 80+ years based on their sedentary patterns and health outcomes, and to examine associations between profiles and socio-demographics. Methods: A cross-sectional study was conducted in Flanders (Belgium) from February 2021 to December 2022 recruiting 90 older adults (80+) through convenience sampling, employing word of mouth, social media and local service centers. Latent profile analysis identified device-based sedentary patterns and assessed their associations with physical and cognitive functioning, mental health-related quality of life (QoL), and social isolation. Associations of these profiles with socio-demographic factors were analyzed. Results: Three distinct profiles were identified: (1) the 'cognitively and physically frail' profile, (2) the 'healthy' profile and (3) the 'lower mental health-related QoL' profile. Those in the 'cognitively and physically frail' profile exhibited the least favorable sedentary pattern, and had a higher likelihood of residing in a nursing home. No significant differences were found for the other socio-demographic variables, being age, sex, educational degree and family situation. Conclusions: Three distinct profiles in the oldest-old population, based on cognitive and physical functioning, mental health-related QoL, and sedentary behavior patterns, were identified. Lower physical and cognitive functioning was associated with unhealthy sedentary patterns. Further research with larger samples is crucial to uncover potential links between socio-demographics and at-risk subgroups, enhancing our understanding of sedentary behavior and geriatric health outcomes in this population.

Child and Parent Risk and Resilience Factors as Predictors of Long-term Recovery in Youth Undergoing Spinal Fusion Surgery.

OBJECTIVES: Undertreated pediatric postsurgical pain negatively affects health-related quality of life (HRQOL) and functioning and may lead to chronic postsurgical pain (CPSP). Predictors of recovery have been identified but more research is needed, particularly regarding resilience, social factors, and long-term effects. The aim of the present study was to investigate child and parent risk and resilience factors as predictors of long-term postsurgical recovery for adolescents. METHODS: Participants were patients with Adolescent Idiopathic Scoliosis (AIS), 12 to 18 years old, undergoing spinal fusion, and their parents. Recruitment occurred at the orthopedic units at 4 hospitals in Belgium. Data were collected before surgery (T0), at 3 (T1) and 6 weeks (T2), 6 months (T3), and 1 year (T4) post surgery. Multiple regression models were used to evaluate the predictive effect of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance on long-term functioning, HRQOL, and pain. RESULTS: The sample comprised 100 adolescents and 61 parents. Pain at T0, T1, and T3 and adolescent pain catastrophizing (T0) predicted health-related quality of life, functioning, and pain at T4 (while pain at T2 predicted HRQOL and pain). Parent pain catastrophizing predicted pain at T4. Adolescent and parental psychological flexibility predicted HRQOL, and parent psychological flexibility also predicted pain at T4. Adolescent acceptance at T1 predicted pain, and acceptance at T2 predicted HRQOL, at T4. DISCUSSION: The study identified pain and adolescent pain catastrophizing as risk factors, and adolescent and parental psychological flexibility and adolescent pain acceptance as resilience factors, for long-term recovery in youths undergoing spinal fusion. Postsurgical pain management targeting these factors may therefore promote recovery for these adolescents.

A Two-Phased Pilot Study Evaluating the Feasibility and Acceptability of the Cognitively Enriched Walking Program "Take a Walk with Your Brain" for Older Adults.

Given the aging population, finding solutions to retain optimal cognitive capacity is a research priority. The potential of physical activity to reduce the risk of cognitive decline and to enhance cognitive functioning is established. Combining physical with cognitive activity has been put forward as a potentially even more effective way to promote healthy cognitive aging. Most studies on combined interventions have however been conducted in laboratory settings. This paper reports on a two-phased pilot study evaluating the acceptability and feasibility of a newly developed real-life cognitively enriched walking program for adults aged 65+ years. In Phase I, the feasibility and enjoyability of the cognitive tasks was evaluated by conducting walk-along interviews with older adults (n = 163). In Phase II, the cognitively enriched walking program was piloted in two groups of older adults (n = 19), and the feasibility and acceptability of the program and cognitive tasks was evaluated by means of questionnaires and focus groups. The cognitive tasks (i.e., median scores of ≥3 on a total of 4 (Phase I) and ≥6 on a total of 10 (Phase II) for most of the tasks) and the cognitively enriched walking program (i.e., median scores of ≥7 on a total of 10) were considered feasible and acceptable. Based on the input of the participants, key considerations for a feasible and acceptable program were defined: participants should be sufficiently challenged cognitively and physically, social interaction is an important motivator, cognitive tasks should make use of stimuli reflecting daily life and be conducted in group, the rationale for the tasks should be explained to participants, the frequency of the group sessions should be maximum 2 times a week, and the program should be supervised by a trained coach. These results warrant future research to establish the effectiveness of this program.

An examination of the reciprocal associations between physical activity and anxiety, depressive symptoms, and sleep quality during the first 9 weeks of the COVID-19 pandemic in Belgium.

During the initial outbreak of the global COVID-19 pandemic, many countries imposed a total lockdown (containment at home). Although it was still allowed in Belgium to be physically active or exercise with people from your household in the vicinity of your home, engaging in sports or physical activity in a group or club context was no longer permitted. To examine whether a lack of physical activity was potentially threatening to the mental well-being of citizens and vice versa, the present study examined concurrent and reciprocal relationships between physical activity and anxiety, depressive symptoms, and sleep quality during the COVID-19 lockdown in a 9-week longitudinal design. In a sample of 983 Belgian adults (75.1% female; M age = 43.78, range = 18-82 years), we explored these relationships at both the between- and within-person levels through random intercept cross-lagged panel models. The findings indicate that more physical activity was associated with lower symptoms of anxiety and depression and better sleep quality, a finding observed both at the between-person (across weeks; ßanxiety = -0.25, ßdepression = -0.30, ßsleep quality = 0.24, p < .001) and within-person level (within weeks; ßanxiety = -0.10, ßdepression = -0.14, ßsleep quality = 0.11, p < .05). Moreover, at the within-person level, an increase in feelings of anxiety and depression at one moment predicted lower levels of physical activity one week later (ßanxiety = -0.04, ßdepression = -0.06, p < .05). Since poor mental health poses a threat to the maintenance of physical activity, the current findings suggest that it is critical to invest in the mental health of individuals during distressing times.

Monitoring the initial recovery after fusion surgery using activity trackers in adolescent idiopathic scoliosis: going in the lumbar spine decreases the daily step count.

PURPOSE: Although the functional outcome (e.g. the return to daily activities) plays an important role in the evaluation of treatment success for the paediatric patient, clinicians currently cannot make accurate and objective predictions regarding the very early (≤ 6 weeks) functional outcome and its recovery over time. The purpose of the present study is to objectively measure initial postoperative physical activity levels and examine the relationship with patient characteristics, fusion levels and pain. METHODS: Step count (SC) was obtained pre- (Pre-Op) and postoperatively (Post-3W: 3 weeks after surgery; Post-6W: 6 weeks after surgery) using an accelerometer. Patients were grouped based on LIV (thoracic (T-group) and lumbar (L-group)) and fusion length (FL ≤ 10 levels = SF-group and FL ≥ 11 levels = LF-group). Differences in the daily SC between groups (LIV and FL) and the three timepoints was investigated using a two-way ANOVA. RESULTS: The SC was significantly lower at both Post-3W (p < 0.001) and Post-6W (p < 0.001) compared to the preoperative SC, and significantly (p < 0.001) increased from Post-3W to Post-6W (Pre-Op = 13,049 ± 3214 steps/day; Post-3W = 6486 ± 2925 steps/day; Post-6W = 8723 ± 3020 steps/day). At both post-op timepoints the T-group had a higher SC compared to the L-group. CONCLUSION: A fusion surgery with the LIV at L2 or below has a negative impact on the very early postoperative activity levels. The initial functional outcome level of AIS patients was not related to the presently collected patient characteristics. This suggests that objective activity trackers provide novel information and could have an added value in very early rehabilitation programs.

The GRANDPACT Project: The Development and Evaluation of an Intergenerational Program for Grandchildren and Their Grandparents to Stimulate Physical Activity and Cognitive Function Using Co-Creation.

In recent years, increased attention has been devoted to intergenerational physical activity (PA) programs because they may have several benefits for both children and older adults (e.g., the reduction of ageism). An intergenerational PA program focusing on grandchildren and grandparents in a 'standard' family setting that combines PA and cognitive function is innovative and may hold potential for promoting PA and improving cognitive functioning in both grandchildren and grandparents. The aim of this study is to describe the protocol of the GRANDPACT (GRANDparents and GRANDchildren improve their Physical Activity and Cognitive functions using co-creaTion) Project, focusing on the development of an intergenerational, cognitively enriched, movement program for grandchildren and grandparents using the theoretical framework of the "Behaviour Change Wheel" in combination with a co-creation approach. Two co-creation trajectories will be organized to develop the program, followed by a pilot study to refine the program and an RCT with a pre-test (at baseline), a post-test (after 24 weeks), and a follow-up (after 36 weeks) to measure the outcomes of co-PA, cognitive functions, psychosocial well-being, and the quality of the family relationship ingrandchildren and grandparents. The outcomes will be measured using accelerometry for PA, the Cambridge Neuropsychological Test Automated Battery (CANTAB) for cognitive functions, and questionnaires for the psychological well-being and quality of the family relationship. Co-development with end-users and stakeholders during both co-creation trajectories is expected to result in an effective, attractive, and feasible program. Co-PA is expected to improve PA, cognitive functioning, psychosocial well-being, and the quality of the family relationships between grandchildren and grandparents.

Association of parental and adolescent emotion-related factors with adolescent chronic pain behaviors.

ABSTRACT: Chronic pain is a prevalent condition in youth, and the pain experience is strongly influenced by emotional processes. Studying emotion variability and regulation (ER) may help better understand pain behavior. As the development of emotion-related abilities predominantly takes place in the family context, examining ER within parent-adolescent dyads is important. We set out to test the association of parent and adolescent ER and adolescent emotional variability with adolescent pain behavior (ie, pain interference, activity avoidance, and activity engagement). A sample of 56 adolescents (Mage = 14.5, 85.7% women) with chronic pain and one of their parents (92.9% mothers) participated in this study. Adolescents completed baseline measures of average pain intensity, ER, and mean positive and negative affect. Furthermore, adolescents completed an electronic diary for 14 consecutive days, reporting on emotional state, activity avoidance, activity engagement, and pain interference. Parents completed measures of ER and their own history of pain. We performed a variable selection procedure, the least absolute shrinkage and selection operator method, to determine important predictors of adolescent pain behavior. Adolescent high positive affect was associated with more activity engagement, less pain interference, and less activity avoidance, indicating that positive affect might enhance the willingness to engage in activities in the presence of pain. Adolescent ER strategy emotional reappraisal and parents' own history of pain were predictors of less activity engagement. Parent ER was not related to adolescent ER. In conclusion, our results highlight the potential of enhancing positive affect as an intervention target for chronic pain.

Risk and Resilience Predictors of Recovery After Spinal Fusion Surgery in Adolescents.

OBJECTIVE: This prospective study examined risk and resilience predictors of pain and functional recovery in the first 6 months after spinal fusion surgery in adolescents. METHODS: Adolescents with adolescent idiopathic scoliosis undergoing spinal fusion surgery (n=100, aged 12 to 18 y, 77% girls) completed assessments before surgery and at 3 weeks, 6 weeks, and 6 months after surgery. Recovery trajectories in pain, health-related quality of life (HRQOL), and objectively registered physical activity were identified. Presurgical pain catastrophizing and pain intensity (risk), and psychological flexibility, and postsurgical pain acceptance (resilience) were examined as predictors of recovery. RESULTS: Latent growth class analyses revealed 4 distinct pain recovery trajectories (ie, Severe-Moderate [11%, n=9], Mild-No [58%, n=49], Moderate-Mild [24%, n=20], and Moderate-Severe [7%, n=6] pain trajectory), 2 HRQOL recovery trajectories; 2 trajectories characterizing recovery in average daily physical activity at moderate-to-vigorous intensity (MVPA); and 3 trajectories characterizing recovery in total physical activity volume characterized by the average daily number of steps. Subsequent multivariate analyses of variance revealed that presurgical pain intensity (partial η2=0.21, P<0.001) and pain catastrophizing (partial η2=0.13, P<0.01) were both predictive of poorer recovery in HRQOL, and pain catastrophizing additionally predicted poorer pain recovery (partial η2=0.15, P<0.05). Psychological flexibility (partial η2=0.25, P<0.001) and postsurgical pain acceptance (partial η2=0.07, P<0.05) were predictive of more favorable recovery trajectories in HRQOL, and psychological flexibility additionally predicted more favorable recovery trajectories in postsurgical pain (partial η2=0.15, P<0.05). Daily MVPA trajectories were not significantly predicted by any of the hypothesized factors, while presurgical pain catastrophizing levels were predictive of a delayed recovery trajectory in the daily amount of steps (partial η2=0.17 P<0.01). CONCLUSIONS: Presurgical screening could include assessment of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance to identify adolescents who are at risk for poorer recovery. These are potentially modifiable factors that can be targeted in presurgical interventions to prevent poor and foster adaptive outcomes after major surgery in adolescents.

When, why, and how do People Deviate from Physical Distancing Measures During the COVID-19 Pandemic: A Mixed-Methods Study.

INTRODUCTION: To limit the spread of COVID-19, many countries, including Belgium, have installed physical distancing measures. Yet, adherence to these newly installed behavioral measures has been described as challenging and effortful. Based on the Health Action Process Approach (HAPA) model, this study performed an in-depth evaluation of when, why, and how people deviated from the physical distancing measures. METHODS: An online mixed-method study was conducted among Belgian adults (N = 2055) in the beginning of May 2020. Participants were recruited via an open call through email and social media platforms, using snowball sampling. Conditions wherein people deviated from the physical distancing measures were assessed by means of an open-ended question. HAPA determinants were assessed in a quantitative way. RESULTS: Half of the sample reported to deviate from the measures. Further, deviation from the measures was associated with each determinant outlined by the HAPA. Findings highlight that many people deviated from the measures because of their need for social contact. The majority of the people who deviated from the measures stated that they carefully weighed the risks of their behavior. CONCLUSIONS: Need for social contact pushed people to deviate from physical distancing measures in a deliberate manner. Potential areas for future interventions aimed at promoting adherence to physical distancing measures and enhancing psychosocial well-being are discussed.

Adherence to the Physical Distancing Measures during the COVID-19 Pandemic: A HAPA-Based Perspective.

BACKGROUND: The COVID-19 pandemic requires massive and rapid behavior change. The Health Action Process Approach (HAPA) describes personal determinants that play a key role in behavior change. This study investigated whether these determinants are associated with adherence to physical distancing measures to prevent the spread of COVID-19 (i.e. keeping 1.5 m physical distance and staying at home). Decreased psychosocial well-being and lack of social support were explored as barriers to adherence. METHODS: Two cross-sectional surveys were conducted among adults in Belgium. The first survey (N = 2,379; March 2020) focused on adherence to physical distancing measures. The second survey (N = 805; April 2020) focused on difficulty with, and perseverance in, adhering to these measures. Linear regression models were fitted to examine associations with HAPA determinants, psychosocial well-being, and social support. RESULTS: Self-efficacy, outcome expectancies, intention, action planning, and coping planning were related to adhering to, difficulty with, and perseverance in, adhering to physical distancing measures. Decreased psychosocial well-being and lack of social support were related to more difficulties with adhering to physical distancing and lower perseverance. CONCLUSIONS: Health action process approach determinants are associated with adherence to physical distancing measures. Future work could design HAPA-based interventions to support people in adhering to these measures.

Investigating How Parental Instructions and Protective Responses Mediate the Relationship Between Parental Psychological Flexibility and Pain-Related Behavior in Adolescents With Chronic Pain: A Daily Diary Study.

BACKGROUND: Parental behavior can influence how well adolescents cope with chronic pain. Previous research has largely focused on how parents negatively impact adolescent functioning. Yet more recent work suggests that parents - and particularly parental psychological flexibility - can foster better adolescent pain-related functioning. In this study we examined if parental protective responses and instructions to engage in activities in the presence of pain mediate the impact of parental psychological flexibility and acceptance of adolescent pain on adolescents' daily pain-related behavior. METHOD: Fifty-six adolescents with chronic pain (M age = 14.5 years, 86% girls) and one of their parents (93% mothers) were recruited at initial evaluation at two pediatric pain clinics in the US. Parents completed baseline questionnaires assessing psychologically flexible parenting and acceptance of adolescent pain. Next, parents and adolescents completed a 14-day self-report diary assessing adolescent activity-avoidance and activity-engagement in the presence of pain (adolescent report), and parental protective responses and instructions for their adolescent to engage in activities (parent report). RESULTS: Psychologically flexible parenting and acceptance of adolescent pain in parents were indirectly related to lower daily adolescent activity-avoidance, via their negative association with daily parental protective responses. Positive associations also emerged between baseline psychologically flexible parenting and overall levels of adolescent activity-engagement via its negative association with overall levels of parental protectiveness across the 14-day period. Psychologically flexible parenting and parental acceptance of adolescent pain were also indirectly related to daily decreases in adolescent activity-avoidance via their association with daily increases in parental activity-engagement instructions. These baseline parental resilience factors were also positively related to overall levels of parental engagement instructions, a route via which an indirect association with both higher overall activity-engagement as well as higher overall activity-avoidance in the adolescent was observed. CONCLUSION: Our findings suggest an (indirect) adaptive role of parental psychological flexibility on adolescent daily pain-related behavior via its impact on parental protective behavior. If our findings replicate, they would suggest that these parental behaviors could be targeted in pain treatments that include both adolescents and their parents. Future research could further examine the impact of parental instructions on pain-related behavior in adolescents with chronic pain.

How an Understanding of Our Ability to Adhere to Verbal Rules Can Increase Insight Into (Mal)adaptive Functioning in Chronic Pain.

Research on chronic pain has traditionally focused on how direct pain experiences lead to maladaptive thoughts, feelings, and actions that set the stage for, and maintain, pain-related disability. Yet the capacity for language (and more specifically verbal instructions or rules) to put people into indirect contact with pain has never been systematically investigated. In this article, we introduce a novel theoretical perspective on verbal processes and discuss how the study of verbal rules may increase our understanding of both maladaptive and adaptive functioning in chronic pain. Several useful characteristics of verbal rules and rule-following in the context of chronic pain are outlined. Future research directions and implications for clinical practice are then discussed. Perspective: This focus article argues that, by studying verbal rules and rule-following, we will gain a better understanding of (mal)adaptive functioning in the context of chronic pain. Future research directions are outlined and suggestions for improving clinical practice are considered.