Racial Differences in Movement-Related Appraisals and Pain Behaviors Among Adults With Chronic Low Back Pain.

Research documents racial disparities in chronic low back pain (CLBP). Few studies have examined racial disparities in movement-related appraisals and no studies have examined anticipatory appraisals prior to or pain behaviors during functional activities among individuals with CLBP. This cross-sectional study examined racial differences in anticipatory appraisals of pain, concerns about harm, and anxiety, appraisals of pain and anxiety during movement, and observed pain behaviors during 3 activities of daily living (supine-to-standing bed task, sitting-to-standing chair task, floor-to-waist lifting task) in a sample (N = 126) of non-Hispanic Black (31.0%), Hispanic (30.2%), and non-Hispanic White (38.9%) individuals with CLBP. Hispanic participants reported more expected pain, concerns about harm, and pre-movement anxiety prior to the bed and chair tasks compared to non-Hispanic White participants. Hispanic participants reported more pain during the bed task and more anxiety during the bed and chair tasks compared to non-Hispanic White participants. Non-Hispanic Black participants reported more expected pain, concerns about harm, and pre-movement anxiety prior to the bed task and more pre-movement anxiety prior to the chair task compared to non-Hispanic White participants. Non-Hispanic Black participants reported more anxiety during the bed and chair tasks compared to non-Hispanic White participants. Non-Hispanic Black participants were observed to have significantly more verbalizations of pain during the bed task compared to non-Hispanic White participants. Current findings identify racial disparities in important cognitive-behavioral and fear-avoidance mechanisms of pain. Results indicate a need to revisit traditional theoretical and treatment models in CLBP, ensuring racial disparities in pain cognitions are considered. PERSPECTIVE: This study examined racial disparities in anticipatory and movement-related appraisals, and pain behaviors during activities of daily living among Non-Hispanic Black, Non-Hispanic White, and Hispanic individuals with CLBP. Racial disparities identified in the current study have potentially important theoretical implications surrounding cognitive-behavioral and fear-avoidance mechanisms of pain.

Race, Ethnicity, and Belief in a Just World: Implications for Chronic Pain Acceptance Among Individuals with Chronic Low Back Pain.

Chronic pain acceptance is a psychological process consistently linked with improved functional outcomes. However, existing research on this construct has not considered the role of racial or ethnic background, despite growing evidence of racialized disparities in pain experience and treatment. This study aimed to examine racial differences in chronic pain acceptance, as measured by the chronic pain acceptance questionnaires (CPAQ), in a multicultural sample of individuals with chronic low back pain (N = 137-37.2% White, 31.4% Hispanic, and 31.4% Black/African American). We further sought to examine moderating effects of discrimination, pain-related perceived injustice (PI), and just world belief (JWB). Analyses consisted of cross-sectional one-way analyses of variance with Bonferroni-corrected post hoc comparisons, followed by regression models with interaction terms, main effects, and relevant covariates. Results indicated higher scores on the CPAQ for White individuals compared to Black or Hispanic individuals. Significant interactions were noted between race/ethnicity and JWB in predicting pain acceptance, after controlling for demographic and pain-related variables, such that the positive association between JWB and pain acceptance was significant for White participants only. Race/ethnicity did not show significant interactions with PI or prior racial discrimination. Findings highlight racial differences in levels of chronic pain acceptance, an adaptive pain coping response, and a stronger JWB appears to have a positive impact on pain acceptance for White individuals only. Results further confirm that members of disadvantaged racial groups may be more susceptible to poorer pain adjustment, which is the result of complex, multi-level factors. PERSPECTIVE: This study identifies racial differences in levels of pain acceptance, an adaptive psychological response to chronic pain, such that White individuals with chronic low back pain demonstrate higher levels of pain acceptance. The article further explores the impacts of intrapersonal and sociocultural variables on racial differences in pain acceptance.

Reducing clinician inefficiency and restoring meaning in practice: A professional coaching approach for family medicine residents.

Burnout is widespread among primary care physicians (PCPs). Several key drivers of burnout in this specialty that have been increasingly recognized are the growing complexity and work demands placed on PCPs by outpatient clinical work environments. These high demands, from the perspective of the physician, detract from other valued tasks which provide meaning in daily work such as relationship-building and fellowship with the medical team. Given these trends, we believe that a viable means to address burnout can be found in utilizing a performance coaching approach to equip resident physicians for the practical and emotional demands of the primary care work environment into which they are entering. Specifically, we recommend a focus on clinical efficiency as an area for coaching development due to its potential impact on resident physician well-being. In this brief review article, we provide a summary of evidence for coaching interventions, along with evidence supporting an expansion to these approaches in clinical efficiency in outpatient settings based on the connection between workflow and engagement in meaningful medical practice. Lastly, we outline a prospective coaching approach which targets common sources of clinic inefficiency for resident practitioners.

Family Medicine Faculty Time Allocation and Burnout: A Residency Research Network of Texas Study.

BACKGROUND: Burnout among graduate medical education (GME) faculty is a well-documented phenomenon, but few studies have explored the relationship between faculty time allocation and burnout. OBJECTIVE: Our objectives were to (1) characterize time allocation of academic family physicians, (2) measure the difference between actual versus preferred time spent on various tasks, and (3) examine this difference in relation to burnout. METHODS: From January to March 2017, family medicine GME faculty across Texas completed anonymous online surveys for burnout (Maslach Burnout Inventory) and occupational stress (Primary Care Provider Stress Checklist). They also reported the percentage of time they actually versus prefer to allocate across 5 categories of tasks: direct patient care, nondirect clinical duties, teaching, administration, and research. Difference scores between actual and preferred time allocation were calculated and correlated with burnout and stress scores. RESULTS: Of the faculty physicians surveyed, 53% provided complete responses (103 of 195). On average they engaged in their preferred amount of time on direct patient care (30% of their time) and administrative duties (15%). Meanwhile, faculty preferred to increase time spent teaching (37% to 41%, P = .002) and conducting research (4% to 7%, P ≤ .001), while reducing time spent on nondirect clinical duties (14% to 7%, P < .001). Those with higher misalignment in their weekly schedules reported higher levels of professional burnout and occupational stress. CONCLUSIONS: Many family medicine GME faculty spent 20% or more of their time in a manner incongruent with their preferences, which may place them at higher risk for burnout and occupational stress.

Validating Invalidation: Examining the Construct Validity of the Illness Invalidation Inventory Among Individuals With Chronic Low Back Pain.

OBJECTIVES: The Illness Invalidation Inventory (3*I) was designed to assess individuals' perceived invalidation regarding chronic pain experiences. However, no study has yet investigated the psychometric properties of the 3*I among individuals with chronic low back pain (CLBP). Given the personal and societal impact of CLBP and the potential for invalidation associated with this condition, the current study sought to examine the psychometric properties of the 3*I among individuals with CLBP. MATERIALS AND METHODS: Community-dwelling adults with CLBP living in the Southwestern United States (N=134) completed the 3*I. In line with previous literature, current analyses focused on the 3*I "family members" subscale. Exploratory and confirmatory factor analysis was performed on participant responses. Hierarchical linear regression analyses examined the relationship between the identified factors and participant self-reported pain severity, disability, and depression. RESULTS: Exploratory factor analysis conducted on the 3*I "family members" subscale found 2 factors with high internal consistency (α>0.70) that cumulatively accounted for 49.04% of the variance in scores. Consistent with previous findings, factor loadings suggested that these factors correspond to "discounting" and "lack of understanding." Subsequent confirmatory factor analysis found that this 2-factor model demonstrated a good fit with the data. Greater perceived discounting by family members was associated with greater pain severity, disability, and depression. DISCUSSION: The 2-factor model of the 3*I "family members" subscale identified in the current study reflects previous findings and extends the psychometric validity of the 3*I to a US multiethnic sample of individuals with CLBP.

Injustice Appraisal, but not Pain Catastrophizing, Mediates the Relationship Between Perceived Ethnic Discrimination and Depression and Disability in Low Back Pain.

Despite growing evidence of significant racial disparities in the experience and treatment of chronic pain, the mechanisms by which these disparities manifest have remained relatively understudied. The current study examined the relationship between past experiences of racial discrimination and pain-related outcomes (self-rated disability and depressive symptomatology) and tested the potential mediating roles of pain catastrophizing and perceived injustice related to pain. Analyses consisted of cross-sectional path modeling in a multiracial sample of 137 individuals with chronic low back pain (Hispanics: n = 43; blacks: n = 43; whites: n = 51). Results indicated a positive relationship between prior discriminatory experiences and severity of disability and depressive symptoms. In mediation analyses, pain-related appraisals of injustice, but not pain catastrophizing, were found to mediate these relationships. Notably, the association between discrimination history and perceived injustice was significantly stronger in black and Hispanic participants and was not statistically significant in white participants. The findings suggest that race-based discriminatory experiences may contribute to racial disparities in pain outcomes and highlight the specificity of pain-related, injustice-related appraisals as a mechanism by which these experiences may impair physical and psychosocial function. Future research is needed to investigate temporal and causal mechanisms suggested by the model through longitudinal and clinical intervention studies. PERSPECTIVE: More frequent prior experiences of racial discrimination are associated with greater depressive symptomatology and pain-related disability in individuals with chronic low back pain. These associations are explained by the degree of injustice perception related to pain, but not pain catastrophizing, and were stronger among black and Hispanic participants.

Examining Injustice Appraisals in a Racially Diverse Sample of Individuals With Chronic Low Back Pain.

Injustice perception has emerged as a risk factor for problematic musculoskeletal pain outcomes. Despite the prevalence and impact of chronic low back pain (CLBP), no study has addressed injustice appraisals specifically among individuals with CLBP. In addition, despite racial/ethnic disparities in pain, existing injustice research has relied almost exclusively on white/Caucasian participant samples. The current study examined the associations between perceived injustice and pain, disability, and depression in a diverse community sample of individuals with CLBP (N = 137) -51 (37.2%) white, 43 (31.4%) Hispanic, 43 (31.4%) black or African American). Anger variables were tested as potential mediators of these relationships. Controlling for demographic and pain-related covariates, perceived injustice accounted for unique variance in self-reported depression and disability outcomes, but not pain intensity. State and trait anger, and anger inhibition mediated the association between perceived injustice and depression; no additional mediation by anger was observed. Significant racial differences were also noted. Compared with white and Hispanic participants, black participants reported higher levels of perceived injustice related to CLBP, as well as higher depression and pain-related disability. Black participants also reported higher pain intensity than white participants. Current findings provide initial evidence regarding the role of injustice perception specifically in the context of CLBP and within a racially diverse participant sample. Results highlight the need for greater diversity within injustice and CLBP research as well as research regarding socially informed antecedents of injustice appraisals. Perspective: Perceived injustice predicted worse outcomes in CLBP, with effects partially mediated by anger. Black participants reported worse pain outcomes and higher injustice perception than their white or Hispanic counterparts. Given racial inequities within broader health and pain-specific outcomes, this topic is critical for CLBP and perceived injustice research.

The Effect of Perceived Injustice on Appraisals of Physical Activity: An Examination of the Mediating Role of Attention Bias to Pain in a Chronic Low Back Pain Sample.

The current study examined the relationship between perceived injustice and attentional bias (AB) toward pain among individuals with chronic low back pain asked to perform and appraise the pain and difficulty of a standardized set of common physical activities. A pictorial dot-probe task assessed AB toward pain stimuli (ie, pain faces cueing pain), after which participants performed the physical tasks. Participants also rated face stimuli in terms of pain, sadness, and anger expression. As hypothesized, perceived injustice was positively associated with AB toward pain stimuli; additionally, perceived injustice and AB were positively associated with appraisals of pain and difficulty. Counter to expectations, AB did not mediate the relationship between perceived injustice and task appraisals, suggesting that AB is insufficient to explain this relationship. Exploratory analyses indicated that participants with higher levels of perceived injustice rated stimulus faces as sadder and angrier; no such differences emerged for pain ratings. To our knowledge, this is the first study to examine the association between perceived injustice and AB toward pain, as well as perceived injustice and in vivo appraisals of common physical activity. Results extend existing literature and suggest that attentional and potential interpretive bias should be considered in future research. PERSPECTIVE: This article identifies significant associations between perceived injustice, biased attention to pain, and appraisals of common physical activities among individuals with chronic low back pain. These findings suggest targets for intervention as well as directions for future research regarding individuals with high perceptions of injustice related to pain.

Perceived injustice after traumatic injury: Associations with pain, psychological distress, and quality of life outcomes 12 months after injury.

OBJECTIVE: There is growing recognition that individuals who experience traumatic injuries perceive themselves as victims of injustice and that elevated levels of perceived injustice are associated with problematic physical and psychological outcomes. To date, research regarding injustice perception and injury outcomes has been restricted to a small number of musculoskeletal pain conditions. No research to date has examined the potential impact of perceived injustice among individuals admitted for trauma care. METHOD: As part of this cross-sectional study, individuals (n = 155) admitted to a Level-1 trauma center completed measures of perceived injustice, pain, depression, posttraumatic stress, and health related (physical and mental/emotional) quality of life (HRQoL) outcomes 12 months after trauma admission. RESULTS: Bivariate analyses revealed significant associations between perceived injustice and demographic variables (education, income, race, and age) as well as injury-related variables (type of injury and length of hospital stay). Perceived injustice was correlated with greater pain intensity, depression, and PTSD symptoms, as well as poorer physical and mental HRQoL. Controlling for relevant demographic and injury-related variables, perceived injustice accounted for unique variance in pain intensity, depression severity, the presence and intensity of PTSD symptoms, mental HRQoL, and was marginally significant for physical HRQoL. CONCLUSIONS: This is the first study to examine perceived injustice in a trauma sample. Results support the presence of injustice perception in this group and its associations with pain and quality of life outcomes. Additional research is suggested to explore the impact of perceived injustice on recovery outcomes among individuals who have sustained traumatic injury.

The promise and challenge of virtual gaming technologies for chronic pain: the case of graded exposure for low back pain.

Virtual reality (VR) technologies have been successfully applied to acute pain interventions and recent reviews have suggested their potential utility in chronic pain. The current review highlights the specific relevance of VR interactive gaming technologies for pain-specific intervention, including their current use across a variety of physical conditions. Using the example of graded-exposure treatment for pain-related fear and disability in chronic low back pain, we discuss ways that VR gaming can be harnessed to optimize existing chronic pain therapies and examine the potential limitations of traditional VR interfaces in the context of chronic pain. We conclude by discussing directions for future research on VR-mediated applications in chronic pain.

Cortisol and politics: variance in voting behavior is predicted by baseline cortisol levels.

Participation in electoral politics is affected by a host of social and demographics variables, but there is growing evidence that biological predispositions may also play a role in behavior related to political involvement. We examined the role of individual variation in hypothalamic-pituitary-adrenal (HPA) stress axis parameters in explaining differences in self-reported and actual participation in political activities. Self-reported political activity, religious participation, and verified voting activity in U.S. national elections were collected from 105 participants, who were subsequently exposed to a standardized (nonpolitical) psychosocial stressor. We demonstrated that lower baseline salivary cortisol in the late afternoon was significantly associated with increased actual voting frequency in six national elections, but not with self-reported non-voting political activity. Baseline cortisol predicted significant variation in voting behavior above and beyond variation accounted for by traditional demographic variables (particularly age of participant in our sample). Participation in religious activity was weakly (and negatively) associated with baseline cortisol. Our results suggest that HPA-mediated characteristics of social, cognitive, and emotional processes may exert an influence on a trait as complex as voting behavior, and that cortisol is a better predictor of actual voting behavior, as opposed to self-reported political activity.