A randomized trial to examine the mechanisms of cognitive, behavioral and mindfulness-based psychosocial treatments for chronic pain: Study protocol.

This randomized trial will evaluate the mechanisms of three chronic pain treatments: cognitive therapy (CT), mindfulness meditation (MM), and activation skills (AS). We will determine the extent to which late-treatment improvement in primary outcome (pain interference) is predicted by early-treatment changes in cognitive content, cognitive process, and/or activity level. The shared versus specific role of these mechanisms across the three treatments will be evaluated during treatment (Primary Aim), and immediately post-treatment to examine relapse mechanisms (Secondary Aim). We will enroll 300 individuals with chronic pain (with low back pain as a primary or secondary condition), with 240 projected to complete the study. Participants will be randomly assigned to eight, 1.5 h telehealth group sessions of CT, MM, or AS. Mechanisms and outcomes will be assessed twice daily during 2-week baseline, 4-week treatment period, and 4-week post-treatment epoch via random cue-elicited ecological momentary assessment (EMA); activity level will be monitored during these time epochs via daily monitoring with ActiGraph technology. The primary outcome will be measured by the PROMIS 5-item Pain Interference scale. Structural equation modeling (SEM) will be used to test the primary aims. This study is pre-registered on clinicaltrials.gov (Identifier: NCT03687762). This study will determine the temporal sequence of lagged mediation effects to evaluate rates of change in outcome as a function of change in mediators. The findings will provide an empirical basis for enhancing and streamlining psychosocial chronic pain interventions. Further, results will guide future efforts towards optimizing maintenance of gains to effectively reduce relapse risk.

A content review of cognitive process measures used in pain research within adult populations.

BACKGROUND AND OBJECTIVE: Previous research suggests that measures of cognitive process may be confounded by the inclusion of items that also assess cognitive content. The primary aims of this content review were to: (1) identify the domains of cognitive processes assessed by measures used in pain research; and (2) determine if pain-specific cognitive process measures with adequate psychometric properties exist. DATABASES AND DATA TREATMENT: PsychInfo, CINAHL, PsycArticles, MEDLINE, and Academic Search Complete databases were searched to identify the measures of cognitive process used in pain research. Identified measures were double coded and the measure's items were rated as: (1) cognitive content; (2) cognitive process; (3) behavioural/social; and/or (4) emotional coping/responses to pain. RESULTS: A total of 319 scales were identified; of these, 29 were coded as providing an un-confounded assessment of cognitive process, and 12 were pain-specific. The cognitive process domains assessed in these measures are Absorption, Dissociation, Reappraisal, Distraction/Suppression, Acceptance, Rumination, Non-Judgment, and Enhancement. Pain-specific, un-confounded measures were identified for: Dissociation, Reappraisal, Distraction/Suppression, and Acceptance. Psychometric properties of all 319 scales are reported in supplementary material. CONCLUSIONS: To understand the importance of cognitive processes in influencing pain outcomes as well as explaining the efficacy of pain treatments, valid and pain-specific cognitive process measures that are not confounded with non-process domains (e.g., cognitive content) are needed. The findings of this content review suggest that future research focused on developing cognitive process measures is critical in order to advance our understanding of the mechanisms that underlie effective pain treatment. SIGNIFICANCE: Many cognitive process measures used in pain research contain a 'mix' of items that assess cognitive process, cognitive content, and behavioural/emotional responses. Databases searched: PsychInfo, CINAHL, PsycArticles, MEDLINE and Academic Search Complete. This review describes the domains assessed by measures assessing cognitive processes in pain research, as well as the strengths and limitations of these measures.

Antidepressant use in multiple sclerosis: epidemiologic study of a large community sample.

Depressive symptoms and disorders among individuals with multiple sclerosis (MS) are more common when compared to other chronic illnesses and the general population, but relatively little is known about the use of antidepressant medication in this population. In this cross-sectional study of 542 community-dwelling adults with MS, we examined the prevalence of antidepressant use and employed multivariate logistic regression modeling to identify factors significantly associated with antidepressant use. Thirty-five percent of the sample reported currently using at least one antidepressant medication. Gender, marital status, insurance status, fatigue, and use of disease modifying therapies were all significantly associated with antidepressant use. Just over half of the sample endorsed a clinically significant level of depressive symptoms, and the majority of this group was not currently taking an antidepressant. Conversely, 41% of those with depressive symptoms reported taking at least one antidepressant medication. More research is needed to better understand why people with MS and depressive symptoms use or do not use antidepressant medications and to further explore the possibility of an under-treatment of depressive disorder in this population. Rigorous studies testing the feasibility, acceptability, and efficacy of currently available therapies for depression in the MS population should also be conducted.

The scope and nature of pain in persons with multiple sclerosis.

Much remains unknown about the scope, nature, and impact of pain on the lives of persons with multiple sclerosis (MS). In the present study, 180 community dwelling adults with MS completed a postal survey that included demographic measures, MS disease measures, and several standardized measures of pain, including pain intensity, variability, location, and pain-related interference. Some 66% of the sample reported pain, 25% of whom reported severe pain. Persons with pain reported an average of 6.6 distinct pain sites. Using the Brief Pain Inventory Interference Scale, the average level of overall pain interference was 3.33 (0-10 scale) in the group reporting pain. The highest levels of pain interference were reported for sleep, recreational activities, and work in and outside the home. Persons with pain were more likely to report greater MS disease severity, poorer psychological functioning, and poorer health than persons with MS but not pain. Persons with pain were also less likely to be employed. These findings are consistent with previous research that shows that pain is common in MS, that it is severe in a substantial subset of these individuals and has the potential to negatively impact physical and psychosocial functioning over and above the effects of MS itself.

Alcohol and drug abuse among persons with multiple sclerosis.

OBJECTIVE: To examine the one-month prevalence and impact of substance abuse in a large community sample of persons with multiple sclerosis (MS). METHOD: Members of the Multiple Sclerosis Society of King County were surveyed by mail. This multifaceted health survey included questions pertaining to substance abuse. Seven hundred and thirty-nine out of 1374 potential participants (54%) returned the survey, while 708 reported a medically confirmed diagnosis of MS and provided sufficient data. RESULTS: Fourteen per cent of the sample screened positive for possible alcohol abuse or dependence, and 7.4% reported misusing illicit drugs or prescription medications within the previous month. Possible alcohol abuse and drug misuse were associated with younger age, less severe MS related disability and being employed, as well as greater self-reported depressive symptomatology. Most persons with alcohol problems indicated interest in learning more about ways to stop or cut down. CONCLUSIONS: Substance abuse may be present in up to 19% of this sample and contribute to high rates of depression. There may be greater risk of harm due to substance abuse in people with MS because of the potential magnification of motor and cognitive impairments. Comprehensive MS care should include substance abuse screening and advice to cut down or abstain.

Back pain as a secondary disability in persons with lower limb amputations.

OBJECTIVE: To evaluate the frequency, duration, intensity, and interference of back pain in a sample of persons with lower limb amputations. DESIGN: Retrospective, cross-sectional survey. SETTING: Community-based survey from clinical databases. PARTICIPANTS: Participants who were 6 or more months post lower limb amputation (n = 255). INTERVENTION: An amputation pain survey that included several standardized pain measures. MAIN OUTCOME MEASURES: Frequency, duration, intensity, and interference of back pain. RESULTS: Of the participants who completed the survey (return rate, 56%), 52% reported experiencing persistent, bothersome back pain. Of these, 43% reported average back pain intensity in the mild range (1-4 on 0-10 rating scale) and 25% reported pain of moderate intensity (5-6 on 0-10 scale). Most respondents with back pain rated the interference of their pain on function as none to minimal. However, nearly 25% of those with back pain described it as frequent, of severe intensity (>or=7 on 0-10 scale), and as severely interfering with daily activities including social, recreational, family, and work activities. CONCLUSIONS: Back pain may be surprisingly common in persons with lower limb amputations, and, for some who experience it, may greatly interfere with function.

Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation.

OBJECTIVES: To determine the characteristics of phantom limb sensation, phantom limb pain, and residual limb pain, and to evaluate pain-related disability associated with phantom limb pain. DESIGN: Retrospective, cross-sectional survey. Six or more months after lower limb amputation, participants (n = 255) completed an amputation pain questionnaire that included several standardized pain measures. SETTING: Community-based survey from clinical databases. PARTICIPANTS: A community-based sample of persons with lower limb amputations. MAIN OUTCOME MEASURES: Frequency, duration, intensity, and quality of phantom limb and residual limb pain, and pain-related disability as measured by the Chronic Pain Grade. RESULTS: Of the respondents, 79% reported phantom limb sensations, 72% reported phantom limb pain, and 74% reported residual limb pain. Many described their phantom limb and residual limb pain as episodic and not particularly bothersome. Most participants with phantom limb pain were classified into the two low pain-related disability categories: grade I, low disability/low pain intensity (47%) or grade II, low disability/high pain intensity (28%). Many participants reported having pain in other anatomic locations, including the back (52%). CONCLUSIONS: Phantom limb and residual limb pain are common after a lower limb amputation. For most, the pain is episodic and not particularly disabling. However, for a notable subset, the pain may be quite disabling. Pain after amputation should be viewed from a broad perspective that considers other anatomic sites as well as the impact of pain on functioning.

The management of self-inflicted burn injuries and disruptive behavior for patients with borderline personality disorder.

One of the greatest behavioral and ethical challenges faced by a burn team is the treatment of a patient whose burn injury is the result of parasuicidal behavior. Parasuicidal behavior is defined as intentional self-injurious behavior that, although not fatal, may result in tissue damage or risk of death. There are a number of reasons, usually psychiatric, that patients engage in parasuicidal behavior; however, our contention is that the majority of these patients have a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis II diagnosis of borderline personality disorder. We describe the nature of borderline personality disorder and how it leads to disruptive behavior, including self-harm behavior, on the burn unit, We also argue that if staff members fail to recognize the borderline personality disorder diagnosis, it will lead to responses from staff that can heighten disruptive behavior. We present a series of recommendations for treating such patients with burns and an illustrative case report.

Post-traumatic stress symptoms and distress 1 year after burn injury.

The occurrence and predictors of post-traumatic stress symptoms 1 year after a burn injury were assessed in a large prospective sample (N = 172). Participants completed a self-report post-traumatic stress symptom checklist at 3 time points: within 24 hours of admission to a burn center, 1 month after the injury, and 1 year after the injury. A notable number of participants had a range of post-traumatic stress symptoms both at 1 month and at 1 year after the burn injury. More than half of the sample reported recurrent intrusive recollections of the burn injury at 1 month and at 1 year. Other commonly endorsed symptoms were sleep disturbance, avoidance of thoughts or feelings associated with the burn, and distress at reminders of the burn. The number of post-traumatic stress symptoms endorsed at 1 month was the only significant predictor of post-traumatic stress symptoms at 1 year. These results suggest that it is common for patients to have some post-traumatic symptoms 1 year after a burn injury and that early experiences of post-traumatic stress symptoms may be associated with the development or maintenance of post-traumatic stress disorder. We recommend that burn care professionals identify and intervene with patients who have clinically significant distress as a result of their burn injuries.

Post-traumatic stress symptoms and distress following acute burn injury.

The occurrence and predictors of acute post-traumatic stress symptoms were assessed in a large, prospective sample of persons with new burn injuries (N = 172). Participants completed a self-report post-traumatic stress symptom checklist, pain ratings, and a premorbid mental health inventory within 24 h of admission to a burn center (Day 1). Over half of the sample reported sleep disturbance and recurrent, intrusive recollections of the burn injury on Day 1. Other commonly endorsed symptoms were difficulties concentrating, avoidance of thoughts/feelings associated with the burn, flashbacks, and exaggerated startle response. Persons with less favorable premorbid mental health and larger burns reported a greater number of stress symptoms on Day 1. These results suggest that experiencing some post-traumatic stress symptoms immediately following a burn trauma is normal. It is recommended that burn care professionals identify and intervene with patients who are suffering clinically significant distress early in the hospitalization.

Phantom limb, residual limb, and back pain after lower extremity amputations.

This study describes the sensations and pain reported by persons with unilateral lower extremity amputations. Participants (n = 92) were recruited from two hospitals to complete the Prosthesis Evaluation Questionnaire which included questions about amputation related sensations and pain. Using a visual analog scale, participants reported the frequency, intensity, and bothersomeness of phantom limb, residual limb, and back pain and nonpainful phantom limb sensations. A survey of medication use for each category of sensations also was included. Statistical analyses revealed that nonpainful phantom limb sensations were common and more frequent than phantom limb pain. Residual limb pain and back pain were also common after amputation. Back pain surprisingly was rated as more bothersome than phantom limb pain or residual limb pain. Back pain was significantly more common in persons with above knee amputations. These results support the importance of looking at pain as a multidimensional rather than a unidimensional construct. They also suggest that back pain after lower extremity amputation may be an overlooked but very important pain problem warranting additional clinical attention and study.

The quota system in burn rehabilitation.

This article describes the quota system as a treatment for the helplessness behaviors and depressive symptoms that develop in some patients with burn injuries. With an A-B single-case design, the quota system was implemented for a patient who had sustained a particularly severe burn injury. A series of baseline behaviors were measured for 3 days, and then 80% of the patient's average performance on each of the targeted behaviors was computed and used as the initial quota value. The behavioral quotas were increased systematically and gradually by approximately 5% to 10% every day. The results suggest that the quota system may have been effective in decreasing an overall trend toward passivity, in increasing 3 of 4 targeted rehabilitation behaviors, and in reducing depressive symptoms in a patient with a particularly devastating injury.

Rates of dysfunction in parents of pediatric patients with burns.

The purpose of the current study was to examine the rates of family and child dysfunction in a prospectively, consecutively admitted sample of children. One hundred eleven parents of children consecutively admitted for burn treatment were interviewed using a demographic questionnaire during their child's stay. Results of the questionnaire indicated that in 36% of the families, at least one parent reported significant dysfunction (history of substance abuse, involvement with Child Protective Services, incarceration, or psychiatric history). Results also indicated that 29% of the children over the age of 4 years had significant dysfunction (physical or sexual abuse, or both, psychiatric disorder, behavior problems, or learning disability. It was concluded that (1) parents of children with burns had a substantially high rate of dysfunction, (2) psychologic and preventive interventions should be focused on parents as well as children, and (3) burn injuries often should be regarded as a symptom rather than a cause of psychosocial problems in the family.

Hypnosis in the treatment of patients with severe burns.

Burn injuries are a frequent form of trauma, the care for which typically involves repeated, intrusive procedures and acute, excruciating levels of pain. Although research in the use of hypnosis with burn patients is largely anecdotal there is emerging evidence that the burn unit may be one of the most useful arenas for the clinical application of this technique. The acute, identifiable nature of burn care procedures and the emotional state of patients in trauma care both provide an often receptive setting for the use of this intervention.

The impact of Magic Johnson's HIV serostatus disclosure on unmarried college students' HIV knowledge, attitudes, risk perception, and sexual behavior.

Unmarried heterosexual college students' HIV knowledge, attitudes, risk perception, and sexual behavior were assessed before and after "Magic" Johnson revealed his HIV-positive serostatus. Students examined after the disclosure showed a small, though statistically significant, increase in scores on HIV knowledge. Analyses did not reveal any other differences between the pre- and postdisclosure samples. Several differences between men's and women's scores were found, however. In addition, participants in both groups demonstrated generally positive attitudes toward HIV and people with HIV disease; rated their risk of future HIV infection as none to minimal; and reported frequently engaging in vaginal, oral, and anal intercourse without the use of condoms. These results suggest that Magic's disclosure did not significantly affect these students' attitudes, risk perception, or sexual behavior and that such students continue to engage in behaviors that may put them at risk for HIV infection.

The role of family structure, functioning, and pain modeling in headache.

In an initial attempt to examine relationships between family functioning and chronic headache disorders, the present study examined: a) family structure characteristics, b) family functioning, and c) family pain modeling. Subjects completed an assessment battery consisting of several measures of family functioning. Analyses showed that migraine sufferers (N = 42) as compared to headache-free controls (N = 59) were more likely to describe their families as emphasizing clear organization, structure, rules, and overall control, but less likely to encourage emotional expression. No differences were found between tension headache subjects (N = 43) and headache-free controls. While only an initial exploration of the importance of family characteristics in chronic headache, these results suggest that there are important differences in headache subjects' (particularly migraine) reports of family environment and functioning.