Concurrent and lagged associations among pain medication use, pain, and negative affect: a daily diary study of people with chronic low back pain.

ABSTRACT: People with chronic pain often attempt to manage pain and concurrent emotional distress with analgesic substances. Habitual use of such substances-even when not opioid-based-can pose side effect risks. A negative reinforcement model has been proposed whereby relief of pain and emotional distress following medication consumption increases the likelihood that the experience of elevated pain and distress will spur further medication use. People with chronic low back pain (N = 105) completed electronic diary assessments 5 times/day for 14 consecutive days. Lagged and cross-lagged analyses focused on links between time 1 pain and negative affect (NA) and time 2 analgesic medication use and vice versa. Sex differences were also explored. Primary results were as follows: (1) participants on average reported taking analgesic medication during 41.3% of the 3-hour reporting epochs (29 times over 14 days); (2) time 1 within-person increases in pain and NA predicted time 2 increases in the likelihood of ingesting analgesic medications; (3) time 1 within-person increases in medication use predicted time 2 decreases in pain and NA; and (4) lagged associations between time 1 pain/NA and time 2 medication use were strongest among women. Findings suggest that the use of analgesic medications for many people with chronic pain occurs frequently throughout the day. Results support the validity of a negative reinforcement model where pain and distress lead to pain medication use, which in turn leads to relief from pain and distress.

Empowered Relief, cognitive behavioral therapy, and health education for people with chronic pain: a comparison of outcomes at 6-month Follow-up for a randomized controlled trial.

Introduction: We previously conducted a 3-arm randomized trial (263 adults with chronic low back pain) which compared group-based (1) single-session pain relief skills intervention (Empowered Relief; ER); (2) 8-session cognitive behavioral therapy (CBT) for chronic back pain; and (3) single-session health and back pain education class (HE). Results suggested non-inferiority of ER vs. CBT at 3 months post-treatment on an array of outcomes. Methods: Here, we tested the durability of treatment effects at 6 months post-treatment. We examined group differences in primary and secondary outcomes at 6 months and the degree to which outcomes eroded or improved from 3-month to 6-month within each treatment group. Results: Empowered Relief remained non-inferior to CBT on most outcomes, whereas both ER and CBT remained superior to HE on most outcomes. Outcome improvements within ER did not decrease significantly from 3-month to 6-month, and indeed ER showed additional 3- to 6-month improvements on pain catastrophizing, pain bothersomeness, and anxiety. Effects of ER at 6 months post-treatment (moderate term outcomes) kept pace with effects reported by participants who underwent 8-session CBT. Conclusions: The maintenance of these absolute levels implies strong stability of ER effects. Results extend to 6 months post-treatment previous findings documenting that ER and CBT exhibit similarly potent effects on outcomes.

Cognitive Therapy, Mindfulness-Based Stress Reduction, and Behavior Therapy for the Treatment of Chronic Pain: Predictors and Moderators of Treatment Response.

Psychosocial interventions for people with chronic pain produce significant improvements in outcomes, but these effects on average are modest with much variability in the benefits conferred on individuals. To enhance the magnitude of treatment effects, characteristics of people that might predict the degree to which they respond more or less well could be identified. People with chronic low back pain (N = 521) participated in a randomized controlled trial which compared cognitive therapy, mindfulness-based stress reduction, behavior therapy and treatment as usual. Hypotheses regarding predictors and/or moderators were based on the Limit, Activate, and Enhance model; developed to predict and explain moderators/predictors of psychosocial pain treatments. Results were: 1) low levels of cognitive/behavioral function at pre-treatment predicted favorable pre- to post-treatment outcomes; 2) favorable expectations of benefit from treatment and sound working alliances predicted favorable pre- to post-treatment outcomes; 3) women benefited more than men. These effects emerged without regard to treatment condition. Of note, high levels of cognitive/behavioral function at pre-treatment predicted favorable outcomes only for people in the treatment as usual condition. Analyses identified a set of psychosocial variables that may act as treatment predictors across cognitive therapy, mindfulness-based stress reduction and behavior therapy, as hypothesized by the Limit, Activate, and Enhance model if these 3 treatments operate via similar mechanisms. Findings point toward people who may and who may not benefit fully from the 3 psychosocial treatments studied here, and so may guide future research on matching people to these kinds of psychosocial approaches or to other (eg, forced-based interventions) non-psychosocial approaches. TRIAL REGISTRATION: The ClinicalTrials.gov Identifier is NCT02133976. PERSPECTIVE: This article examines potential predictors/moderators of response to psychosocial treatments for chronic pain. Results could guide efforts to match people to the most effective treatment type or kind.

Treating a common comorbidity: Pain outcomes following a 3-week cognitive processing therapy-based intensive treatment for posttraumatic stress disorder address.

Posttraumatic stress disorder (PTSD) commonly co-occurs with pain and has been implicated in the maintenance of chronic pain. However, limited research has examined whether intervening for PTSD can hinder or optimize treatment outcomes for co-occurring pain and PTSD. In the present study, we examined changes in pain, PTSD, and depressive symptoms among 125 veterans completing a 3-week cognitive processing therapy (CPT)-based intensive treatment program (ITP) for PTSD. We also explored whether pretreatment pain interference predicted changes in PTSD and depressive symptom severity and whether larger changes in pain interference over the course of treatment were associated with larger changes in PTSD and depressive symptom severity. Linear mixed models revealed that participants' pain interference decreased throughout treatment, d = 0.15, p = .039. Higher levels of pretreatment pain interference were associated with higher PTSD, p = .001, and depressive symptom severity, p = .014, over time. Larger reductions in pain interference corresponded to more improvement in PTSD symptoms, ß = -.03; p < .001, but not depressive symptoms. These findings indicate that ITPs for PTSD can reduce pain interferences, albeit to a small degree, and that reductions in pain interference can contribute to reductions in PTSD symptom severity. Future studies should examine which treatment components contribute to larger changes in symptom severity for veterans with co-occurring pain and PTSD.

Cognitive therapy, mindfulness-based stress reduction, and behavior therapy for people with chronic low back pain: A comparative mechanisms study.

OBJECTIVE: Cognitive therapy (CT), mindfulness-based stress reduction (MBSR), and behavior therapy (BT) for chronic pain treatment produce outcome improvements. Evidence also suggests that changes in putative therapeutic mechanisms are associated with changes in outcomes. Nonetheless, methodological limitations preclude clear understanding of how psychosocial chronic pain treatments work. In this comparative mechanism study, we examined evidence for specific and shared mechanism effects across the three treatments. METHOD: CT, MBSR, BT, and treatment as usual (TAU) were compared in people with chronic low back pain (N = 521). Eight individual sessions were administered with weekly assessments of "specific" mechanisms (pain catastrophizing, mindfulness, behavior activation) and outcomes. RESULTS: CT, MBSR, and BT produced similar pre- to posttreatment effects on all mechanism variables, and all three active treatments produced greater improvements than TAU. Participant ratings of expectations of benefit and working alliance were similar across treatments. Lagged and cross-lagged analyses revealed that prior week changes in both mechanism and outcome factors predicted next week changes in their counterparts. Analyses of variance contributions suggested that changes in pain catastrophizing and pain self-efficacy were consistent unique predictors of subsequent outcome changes. CONCLUSIONS: Findings support the operation of shared mechanisms over specific ones. Given significant lagged and cross-lagged effects, unidirectional conceptualizations-mechanism to outcome-need to be expanded to include reciprocal effects. Thus, prior week changes in pain-related cognitions could predict next week changes in pain interference which in turn could predict next week changes in pain-related cognitions, in what may be an upward spiral of improvement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain.

Seriously ill patients often experience persistent pain. As a part of a comprehensive repertoire of pain interventions, palliative care clinicians can help by using behavioral pain management. Behavioral pain management refers to evidence-based psychosocial interventions to reduce pain intensity and enhance functional outcomes and quality of life. Conceptualized using the biopsychosocial model, techniques involve promoting helpful behaviors (e.g., activity pacing, stretching, and relaxation exercises) and modifying underlying patterns of thinking, feeling, and communicating that can exacerbate pain. The authors have expertise in pain management, clinical health psychology, geropsychology, behavioral science, and palliative medicine. The article reviews the current evidence for behavioral interventions for persistent pain and provides 10 recommendations for behavioral pain management.

A 4-week morning light treatment with stable sleep timing for individuals with fibromyalgia: a randomized controlled trial.

OBJECTIVES: Fibromyalgia is characterized by chronic widespread pain, mood, and sleep disturbance. Pharmacological treatments have modest efficacy and are associated with negative side effects, and alternative approaches are needed. Morning bright light treatment may assist in the management of fibromyalgia as it can reduce depressive symptoms, improve sleep, and advance circadian timing. METHODS: Sixty people with fibromyalgia (58 women, mean age 41.8 ± 13.3 years) were enrolled in a study comparing 4 weeks of a 1-hour daily morning bright light treatment (active treatment) to a morning dim light treatment (comparison treatment). Both light treatments included behavioral procedures to stabilize sleep timing. The morning bright light treatment was expected to produce larger improvements in pain and function than the dim light treatment and larger improvements in potential mediators (mood, sleep, and circadian timing). RESULTS: Both the bright and dim light treatment groups achieved significant but similar levels of improvement in pain intensity, pain interference, physical function, depressive symptoms, and sleep disturbance. Overall, the sample on average displayed a clinically meaningful improvement in the Fibromyalgia Impact Questionnaire-Revised score (mean reduction of 11.2 points), comparable to that reported following physical exercise treatments. Minimal side effects were observed. CONCLUSIONS: Findings indicate that the effects of a morning bright light treatment did not exceed those of a comparison dim light treatment; yet the changes on average in both conditions revealed clinically meaningful improvements. Future research is warranted to identify what elements of this trial may have contributed to the observed effects.

Cognitive therapy, mindfulness-based stress reduction, and behavior therapy for the treatment of chronic pain: randomized controlled trial.

ABSTRACT: Trials of cognitive therapy (CT), mindfulness-based stress reduction (MBSR), and behavior therapy (BT) suggest that all 3 treatments produce reductions in pain and improvements in physical function, mood, and sleep disturbance in people with chronic pain conditions. Fewer studies have compared the relative efficacies of these treatments. In this randomized controlled study, we compared CT, MBSR, BT, and treatment as usual (TAU) in a sample of people with chronic low back pain (N = 521). Eight individual sessions were administered with weekly assessments of outcomes. Consistent with the prior work, we found that CT, MBSR, and BT produced similar pretreatment to posttreatment effects on all outcomes and revealed similar levels of maintenance of treatment gains at 6-month follow-up. All 3 active treatments produced greater improvements than TAU. Weekly assessments allowed us to assess rates of change; ie, how quickly a given treatment produced significant differences, compared with TAU, on a given outcome. The 3 treatments differed significantly from TAU on average by session 6, and this rate of treatment effect was consistent across all treatments. Results suggest the possibility that the specific techniques included in CT, MBSR, and BT may be less important for producing benefits than people participating in any techniques rooted in these evidence-based psychosocial treatments for chronic pain.

A Dyadic Investigation of Depressed Affect and Interspousal Behavior in Couples With Chronic Back Pain.

BACKGROUND: Depression and marital discord are characteristic not only of individuals with chronic low back pain (ICPs) but also of their spouses. PURPOSE: We examined actor-partner interdependence models to evaluate associations among depressed affect and criticism and support of partners at the same time point (concurrent effects) and 3 hr later (lagged effects). Fully dyadic models were used to account for both within-person and cross-spouse associations among depressed affect, criticism, and support for ICPs and spouses. We also examined the direction of the relationships (depressed affect predicting behavior and behavior predicting depressed affect) all while controlling for pain intensity, pain behavior, and the prior dependent variable. METHODS: ICPs (n = 105) and their spouses completed electronic diary measures of depressed affect and behavior (criticism and support) five times a day for 2 weeks. Hierarchical linear modeling with person-mean centering was used for data analysis. RESULTS: Within the same 3 hr epoch, more depressed affect was related to higher criticism and generally less support. Lagged analyses suggested bidirectional relationships between spouse's own depressed affect and spouse's own criticism of ICPs. Spouse depressed affect was also associated with decreased support received from ICPs. Pain behavior and pain intensity were also related to depressed affect, criticism, and support especially concurrently. CONCLUSIONS: Theories and interventions need to address not only ICP depressed affect but also spouse depressed affect, as spouse depressed affect may be a stress generating precursor to criticism and support.

Examination of mechanism effects in cognitive behavioral therapy and pain education: analyses of weekly assessments.

ABSTRACT: Psychosocial treatments for chronic pain produce favorable outcomes. However, we still do not know precisely by what mechanisms or techniques these outcomes are wrought. In secondary analyses of a 10-week group intervention study comparing the effects of literacy-adapted cognitive behavioral therapy (CBT) with literacy-adapted pain education (EDU) among patients with chronic pain, low-socioeconomic status, and low literacy, the Learning About My Pain trial, we examined whether pain catastrophizing was a mechanism specific to CBT. Participants (N = 168) completed mechanism and outcome measures weekly for the 10 weeks of group treatment. Analyses revealed that (1) pain catastrophizing was reduced similary across CBT and EDU; (2) lagged analyses indicated that previous week reductions in pain catastrophizing predicted next week reductions in pain intensity and pain interference; (3) cross-lagged analyses indicated that previous week reductions in pain intensity and interference predicted next week reductions in pain catastrophizing; and (4) the relationships between pain catastrophizing and pain intensity and interference were moderated by session progression such that these links were strong and significant in the first third of treatment, but weakened over time and became nonsignificant by the last third of treatment. Results suggest the existence of reciprocal influences whereby cognitive changes may produce outcome improvements and vice versa. At the same time, results from analyses of changes in slopes between pain catastrophizing and outcomes indicated that CBT and EDU were successful in decoupling pain catastrophizing and subsequent pain intensity and interference as treatment progressed. Results provide further insights into how psychosocial treatments for chronic pain may work.

Preoperative cognitive-behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial.

INTRODUCTION: Cognitive-behavioral therapy (CBT) can reduce preoperative pain catastrophizing and may improve postsurgical pain outcomes. We hypothesized that CBT would reduce pain catastrophizing more than no-CBT controls and result in improved pain outcomes. METHODS: The study was a randomized controlled trial of patients undergoing elective total knee arthroplasty between January 2013 and March 2020. In phase 1, the change in pain catastrophizing scores (PCS) among 4-week or 8-week telehealth, 4-week in person and no-CBT sessions was compared in 80 patients with a PCS >16. In phase 2, the proportion of subjects that achieved a 3-month decrease in Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain subscale >4 following 4-week telehealth CBT with no-CBT controls were compared in 80 subjects. RESULTS: In phase 1, 4-week telehealth CBT had the highest completion rate 17/20 (85%), demonstrated an adjusted median reduction in PCS of -9 (95% CI -1 to -14, p<0.01) compared with no-CBT and was non-inferior to 8-week telehealth CBT at a margin of 2 (p=0.02). In phase 2, 29 of 35 (83%) in the 4-week telehealth CBT and 26 of 33 (79%) subjects in the no-CBT demonstrated a decrease in the WOMAC pain subscale >4 at 3 months, difference 4% (95% CI -18% to 26%, p=0.48), despite a median decrease in the PCS for the 4-week CBT and no-CBT group of -6 (-10 to -2, p=0.02). CONCLUSIONS: Our findings demonstrate that CBT interventions delivered prior to surgery in person or via telehealth can reduced PCS scores; however, this reduction did not lead to improved 3-month pain outcomes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT01772329, registration date 21 January 2013).

Does aerobic exercise training alter responses to opioid analgesics in individuals with chronic low back pain? A randomized controlled trial.

ABSTRACT: We tested whether aerobic exercise training altered morphine analgesic responses or reduced morphine dosages necessary for adequate analgesia. Patients with chronic back pain were randomized to an 18-session aerobic exercise intervention (n = 38) or usual activity control (n = 45). Before and after the intervention, participants underwent 3 laboratory sessions (double-blinded, crossover) to assess effects of saline placebo, i.v. morphine (0.09 mg/kg), and i.v. naloxone (12 mg) on low back pain and evoked heat pain responses. Differences in evoked and back pain measures between the placebo and morphine conditions indexed morphine analgesia, with pre-post intervention changes the primary outcome. Endogenous opioid analgesia was indexed by differences in evoked and low back pain measures between the naloxone and placebo conditions. A Sex X Intervention interaction on the analgesic effects of morphine on visual analogue scale back pain intensity was observed (P = 0.046), with a similar trend for evoked pain threshold (P = 0.093). Male exercisers showed reduced morphine analgesia pre-post intervention, whereas male controls showed increased analgesia (with no differences in females). Of clinical significance were findings that relative to the control group, aerobic exercise produced analgesia more similar to that observed after receiving ≈7 mg morphine preintervention (P < 0.045). Greater pre-post intervention increases in endogenous opioid function (from any source) were significantly associated with larger pre-post intervention decreases in morphine analgesia (P < 0.046). The overall pattern of findings suggests that regular aerobic exercise has limited direct effects on morphine responsiveness, reducing morphine analgesia in males only.

Greater Conditioned Pain Modulation Is Associated With Enhanced Morphine Analgesia in Healthy Individuals and Patients With Chronic Low Back Pain.

OBJECTIVES: Conditioned pain modulation (CPM) protocols index magnitude of descending pain inhibition. This study evaluated whether the degree of CPM, controlling for CPM expectancy confounds, was associated with analgesic and subjective responses to morphine and whether chronic pain status or sex moderated these effects. MATERIALS AND METHODS: Participants included 92 individuals with chronic low back pain and 99 healthy controls, none using daily opioid analgesics. In a cross-over design, participants attended 2 identical laboratory sessions during which they received either intravenous morphine (0.08 mg/kg) or saline placebo before undergoing evoked pain assessment. In each session, participants engaged in ischemic forearm and heat pain tasks, and a CPM protocol combining ischemic pain (conditioning stimulus) and heat pain (test stimulus). Placebo-controlled morphine outcomes were derived as differences in pain and subjective effects across drug conditions. RESULTS: In hierarchical regressions controlling for CPM expectancies, greater placebo-condition CPM was associated with less subjective morphine unpleasantness (P=0.001) and greater morphine analgesia (P's<0.05) on both the ischemic pain task (Visual Analog Scale Pain Intensity and Unpleasantness) and heat pain task (Visual Analog Scale Pain Intensity, McGill Pain Questionnaire-Sensory, and Present Pain Intensity subscales). There was no moderation by sex or chronic low back pain status, except for the ischemic Present Pain Intensity outcome for which a significant 2-way interaction (P<0.05) was noted, with men showing a stronger positive relationship between CPM and morphine analgesia than women. DISCUSSION: Results suggest that CPM might predict analgesic and subjective responses to opioid administration. Further evaluation of CPM as an element of precision pain medicine algorithms may be warranted.

Cognitive behavioral therapy (CBT) and pain education for people with chronic pain: Tests of treatment mechanisms.

OBJECTIVES: The goals of the study were to determine to what degree changes in pain-related cognition during cognitive behavioral treatment (CBT) and pain education (EDU) represented treatment mechanisms and whether these cognitive changes worked to a larger extent to produce favorable outcomes in CBT than in EDU. METHOD: Reported here are secondary analyses of a randomized control trial (N = 290) comparing CBT, EDU, and treatment as usual for low-literacy, low-socioeconomic-status people with chronic pain. We excluded the treatment as usual condition from these analyses and included measures collected at a midtreatment epoch. Treatment was 10 weekly group sessions. RESULTS: Linear mixed models revealed nonsignificant differences in pre- to mid- to posttreatment changes in pain catastrophizing and pain self-efficacy between CBT and EDU. The same was true for outcome measures. Cross-lagged analyses revealed significant relationships between pre- to midtreatment changes in catastrophizing and self-efficacy and mid- to posttreatment changes in outcomes. However, relationships between pre- to midtreatment changes in outcomes and mid- to posttreatment changes in catastrophizing and self-efficacy were also significant. CONCLUSIONS: Results suggest a complex set of mechanistic relationships. Instead of a unidirectional path from designated mechanism to designated outcome, our results suggest reciprocal influences whereby cognitive changes may beget outcome improvements and vice versa. Results also suggest that cognitive changes do not occur solely in a treatment that uses cognitive restructuring to foster such changes but may occur as a function of providing people with detailed information regarding the biopsychosocial nature of chronic pain. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Psychosocial Correlates of Objective, Performance-Based, and Patient-Reported Physical Function Among Patients with Heterogeneous Chronic Pain.

BACKGROUND: Improving all aspects of physical function is an important goal of chronic pain management. Few studies follow recent guidelines to comprehensively assess physical function via patient-reported, performance-based, and objective/ambulatory measures. PURPOSE: To test 1) the interrelation between the 3 types of physical function measurement and 2) the association between psychosocial factors and each type of physical function measurement. METHODS: Patients with chronic pain (N=79) completed measures of: 1) physical function (patient-reported disability; performance-based 6-minute walk-test; objective accelerometer step count); 2) pain and non-adaptive coping (pain during rest and activity, pain-catastrophizing, kinesiophobia); 3) adaptive coping (mindfulness, general coping, pain-resilience); and 4) social-emotional dysfunction (anxiety, depression, social isolation and emotional support). First, we tested the interrelation among the 3 aspects of physical function. Second, we used structural equation modeling to test associations between psychosocial factors (pain and non-adaptive coping, adaptive coping, and social-emotional dysfunction) and each measurement of physical function. RESULTS: Performance-based and objective physical function were significantly interrelated (r=0.48, p<0.001) but did not correlate with patient-reported disability. Pain and non-adaptive coping (ß=0.68, p<0.001), adaptive coping (ß=-0.65, p<0.001) and social-emotional dysfunction (ß=0.65, p<0.001) were associated with patient-reported disability but not to performance-based or objective physical function (ps>0.1). CONCLUSION: Results suggest that patient-reported physical function may provide limited information about patients' physical capacity or ambulatory activity. While pain and non-adaptive reactions to it, adaptive coping, and social-emotional dysfunction may potentially improve patient-reported physical function, additional targets may be needed to improve functional capacity and ambulatory activity. TRIAL REGISTRATION: ClinicalTrials.gov NCT03412916.

Usability and Acceptability of a Smartphone App to Assess Partner Communication, Closeness, Mood, and Relationship Satisfaction: Mixed Methods Study.

BACKGROUND: Interpersonal communication is critical for a healthy romantic relationship. Emotional disclosure, coupled with perceived partner responsiveness, fosters closeness and adjustment (better mood and relationship satisfaction). On the contrary, holding back from disclosure is associated with increased distress and decreased relationship satisfaction. Prior studies assessing these constructs have been cross-sectional and have utilized global retrospective reports of communication. In addition, studies assessing holding back or perceived partner responsiveness have not taken advantage of smartphone ownership for data collection and have instead required website access or use of a study-provided device. OBJECTIVE: This study aimed to examine the (1) usability and acceptability of a smartphone app designed to assess partner communication, closeness, mood, and relationship satisfaction over 14 days and (2) between-person versus within-person variability of key constructs to inform the utility of their capture via ecological momentary assessment using the participants' own handheld devices. METHODS: Adult community volunteers in a married or cohabiting partnered relationship received 2 smartphone prompts per day, one in the afternoon and one in the evening, for 14 days. In each prompt, participants were asked whether they had conversed with their partner either since awakening (afternoon prompt) or since the last assessment (evening prompt). If yes, a series of items assessed enacted communication, perceived partner communication, closeness, mood, and relationship satisfaction (evening only). Participants were interviewed by phone, 1 week after the end of the 14-day phase, to assess perceptions of the app. Content analysis was employed to identify key themes. RESULTS: Participants (N=27; mean age 36, SD 12 years; 24/27, 89% female; 25/27, 93% white and 2/27, 7% Hispanic) responded to 79.2% (555/701) of the total prompts sent and completed 553 (78.9%) of those assessments. Of the responded prompts, 79.3% (440/555) were characterized by a report of having conversed with one's partner. The app was seen as highly convenient (mean 4.15, SD 0.78, scale: 1-5) and easy to use (mean 4.39, SD 0.70, scale: 1-5). Qualitative analyses indicated that participants found the app generally easy to navigate, but the response window too short (45 min) and the random nature of receiving notifications vexing. With regard to the variability of the app-delivered items, intraclass correlation coefficients were generally <0.40, indicating that the majority of the variability in each measure was at the within-person level. Notable exceptions were enacted disclosure and relationship satisfaction. CONCLUSIONS: The findings of this study support the usability and acceptability of the app, with valuable user input to modify timing windows in future work. The findings also underscore the utility of an intensive repeated-measures approach, given the meaningful day-to-day variation (greater within-person vs between-person variability) in communication and mood.

Are endogenous opioid mechanisms involved in the effects of aerobic exercise training on chronic low back pain? A randomized controlled trial.

Aerobic exercise is believed to be an effective chronic low back pain (CLBP) intervention, although its mechanisms remain largely untested. This study evaluated whether endogenous opioid (EO) mechanisms contributed to the analgesic effects of an aerobic exercise intervention for CLBP. Individuals with CLBP were randomized to a 6-week, 18-session aerobic exercise intervention (n = 38) or usual activity control (n = 44). Before and after the intervention, participants underwent separate laboratory sessions to assess responses to evoked heat pain after receiving saline placebo or intravenous naloxone (opioid antagonist) in a double-blinded, crossover fashion. Chronic pain intensity and interference were assessed before and after the intervention. Endogenous opioid analgesia was indexed by naloxone-placebo condition differences in evoked pain responses (blockade effects). Relative to controls, exercise participants reported significantly greater pre-post intervention decreases in chronic pain intensity and interference (Ps < 0.04) and larger reductions in placebo condition evoked pain responsiveness (McGill Pain Questionnaire-Short Form [MPQ]-Total). At the group level, EO analgesia (MPQ-Total blockade effects) increased significantly pre-post intervention only among female exercisers (P = 0.03). Dose-response effects were suggested by a significant positive association in the exercise group between exercise intensity (based on meeting heart rate targets) and EO increases (MPQ-Present Pain Intensity; P = 0.04). Enhanced EO analgesia (MPQ-Total) was associated with a significantly greater improvement in average chronic pain intensity (P = 0.009). Aerobic exercise training in the absence of other interventions appears effective for CLBP management. Aerobic exercise-related enhancements in endogenous pain inhibition, in part EO-related, likely contribute to these benefits.

The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department.

Posttraumatic stress disorder (PTSD) symptoms and other negative psychosocial factors have been implicated in the transition from acute to persistent pain. Women (N = 375) who presented to an inner-city emergency department (ED) with complaints of acute pain were followed up for 3 months. They completed a comprehensive battery of questionnaires at an initial visit and provided ratings of pain intensity at the site of pain presented in the ED during 3 monthly phone calls. Latent class growth analyses were used to detect possible trajectories of change in pain intensity from the initial visit to 3 months later. A 3-trajectory solution was found, which identified 3 groups of participants. One group (early recovery; n = 93) had recovered to virtually no pain by the initial visit, whereas a second group (delayed recovery; n = 120) recovered to no pain only after 1 month. A third group (no recovery; n = 162) still reported elevated pain at 3 months after the ED visit. The no recovery group reported significantly greater PTSD symptoms, anger, sleep disturbance, and lower social support at the initial visit than both the early recovery and delayed recovery groups. Results suggest that women with high levels of PTSD symptoms, anger, sleep disturbance, and low social support who experience an acute pain episode serious enough to prompt an ED visit may maintain elevated pain at this pain site for at least 3 months. Such an array of factors may place women at an increased risk of developing persistent pain following acute pain.

Moderators of Mindfulness Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain: A Test of the Limit, Activate, and Enhance Model.

This study examined psychosocial pain treatment moderation in a secondary analysis of a trial that compared cognitive therapy (CT), mindfulness-meditation (MM), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP). The Limit, Activate, and Enhance (LA&E) model of moderation provided a framework for testing a priori hypotheses. Adult participants (N = 69) with CLBP completed a pretreatment assessment of hypothesized moderators: pain catastrophizing, brain state as assessed by electroencephalogram, mindful observing, and nonreactivity. Outcomes were pain interference, characteristic pain intensity, physical function, and depression, assessed at pre- and post-treatment. Moderation analyses found significant interaction effects, specifically: 1) higher and lower baseline pain catastrophizing was associated with greater improvement in pain intensity in MM and MBCT, respectively; 2) higher baseline theta power was associated with greater improvement in depression in MBCT and interfered with response to CT; 3) lower baseline nonreactivity was associated with greater improvement in physical function in MM while higher nonreactivity was associated with greater improvement in MBCT. The findings support the possibility that different patients are more or less likely to benefit from various treatments. Theory-driven moderation research has the capacity to inform the development of patient-treatment matching algorithms to optimize outcome. PERSPECTIVE: This study presents preliminary findings from theory-driven tests of the moderators of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain. The results of such analyses may inform the understanding of for whom various evidence-based psychosocial pain treatments may engender the most meaningful benefits.

Social support, social undermining, and acute clinical pain in women: Mediational pathways of negative cognitive appraisal and emotion.

Women may be disproportionately vulnerable to acute pain, potentially due to their social landscape. We examined whether positive and negative social processes (social support and social undermining) are associated with acute pain and if the processes are linked to pain via negative cognitive appraisal and emotion (pain catastrophizing, hyperarousal, anger). Psychosocial variables were assessed in inner-city women (N = 375) presenting to an Emergency Department with acute pain. The latent cognitive-emotion variable fully mediated social undermining and support effects on pain, with undermining showing greater impact. Pain may be alleviated by limiting negative social interactions, mitigating risks of alternative pharmacological interventions.