Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial.

BACKGROUND: Low back pain is the leading cause of years lived with disability globally, but most interventions have only short-lasting, small to moderate effects. Cognitive functional therapy (CFT) is an individualised approach that targets unhelpful pain-related cognitions, emotions, and behaviours that contribute to pain and disability. Movement sensor biofeedback might enhance treatment effects. We aimed to compare the effectiveness and economic efficiency of CFT, delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling low back pain. METHODS: RESTORE was a randomised, controlled, three-arm, parallel group, phase 3 trial, done in 20 primary care physiotherapy clinics in Australia. We recruited adults (aged ≥18 years) with low back pain lasting more than 3 months with at least moderate pain-related physical activity limitation. Exclusion criteria were serious spinal pathology (eg, fracture, infection, or cancer), any medical condition that prevented being physically active, being pregnant or having given birth within the previous 3 months, inadequate English literacy for the study's questionnaires and instructions, a skin allergy to hypoallergenic tape adhesives, surgery scheduled within 3 months, or an unwillingness to travel to trial sites. Participants were randomly assigned (1:1:1) via a centralised adaptive schedule to usual care, CFT only, or CFT plus biofeedback. The primary clinical outcome was activity limitation at 13 weeks, self-reported by participants using the 24-point Roland Morris Disability Questionnaire. The primary economic outcome was quality-adjusted life-years (QALYs). Participants in both interventions received up to seven treatment sessions over 12 weeks plus a booster session at 26 weeks. Physiotherapists and patients were not masked. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001396213. FINDINGS: Between Oct 23, 2018 and Aug 3, 2020, we assessed 1011 patients for eligibility. After excluding 519 (51·3%) ineligible patients, we randomly assigned 492 (48·7%) participants; 164 (33%) to CFT only, 163 (33%) to CFT plus biofeedback, and 165 (34%) to usual care. Both interventions were more effective than usual care (CFT only mean difference -4·6 [95% CI -5·9 to -3·4] and CFT plus biofeedback mean difference -4·6 [-5·8 to -3·3]) for activity limitation at 13 weeks (primary endpoint). Effect sizes were similar at 52 weeks. Both interventions were also more effective than usual care for QALYs, and much less costly in terms of societal costs (direct and indirect costs and productivity losses; -AU$5276 [-10 529 to -24) and -8211 (-12 923 to -3500). INTERPRETATION: CFT can produce large and sustained improvements for people with chronic disabling low back pain at considerably lower societal cost than that of usual care. FUNDING: Australian National Health and Medical Research Council and Curtin University.

Becoming confidently competent: a qualitative investigation of training in cognitive functional therapy for persistent low back pain.

BACKGROUND: Physiotherapists trained to deliver biopsychosocial interventions for complex musculoskeletal pain problems often report difficulties in confidence and competency at the end of training. Cognitive Functional Therapy (CFT) is an individualized biopsychosocial intervention and understanding the facilitators and barriers to training in CFT will help inform future training programs. This study aimed to explore physiotherapists' and trainers' perceptions of the process of developing competency in CFT. METHODS: A cross-sectional qualitative design using interviews of 18 physiotherapists and two trainers investigated training in CFT for persistent LBP via reflexive thematic analysis. RESULTS: Physiotherapists reported undergoing a complex behavior change process during training. Four themes emerged: 1) Pre-training factors; 2) Behavior change process; 3) Physiotherapy culture and context; and 4) Confident competence and beyond. Key components included graduated practice exposure linked to experiential learning with feedback and clear competency guidelines. Pre-training and contextual factors were facilitators or barriers depending on the individual. Physiotherapists supported ongoing learning, even after competency was achieved. CONCLUSIONS: This study provides insight into the processes of change during progress toward competency in CFT. It highlights facilitators and barriers to competency including physiotherapy culture and the clinical environment. The study also describes important educational components, including experiential learning and clinical integration, which may be used to inform future post-graduate training.

"Listen to me, learn from me": a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care.

ABSTRACT: What are the care-seeking priorities of people living with chronic pain and carers and how can these shape interdisciplinary workforce training to improve high-value pain care? Phase 1: Australian people living with chronic pain (n = 206; 90% female) and carers (n = 10; 40% female) described their pain care priorities (eDelphi, round 1). A coding framework was inductively derived from 842 pain care priorities (9 categories, 52 priorities), including validation; communication; multidisciplinary approaches; holistic care; partnerships; practitioner knowledge; self-management; medicines; and diagnosis. Phase 2: In eDelphi round 2, panellists (n = 170; valid responses) rated the importance (1 = less important; 9 = more important) of the represented framework. In parallel, cross-discipline health professionals (n = 267; 75% female) rated the importance of these same priorities. Applying the RAND-UCLA method (panel medians: 1-3: "not important," 4-6: "equivocal," or 7-9: "important"), "important" items were retained where the panel median score was >7 with panel agreement ≥70%, with 44 items (84.6%) retained. Specific workforce training targets included the following: empathic validation; effective, respectful, safe communication; and ensuring genuine partnerships in coplanning personalised care. Panellists and health professionals agreed or strongly agreed (95.7% and 95.2%, respectively) that this framework meaningfully reflected the importance in care seeking for pain. More than 74% of health professionals were fairly or extremely confident in their ability to support care priorities for 6 of 9 categories (66.7%). Phase 3: An interdisciplinary panel (n = 5) mapped an existing foundation-level workforce training program against the framework, identifying gaps and training targets. Recommendations were determined for framework adoption to genuinely shape, from a partnership perspective, Australian interdisciplinary pain training.

Psychological distress in early childhood and the risk of adolescent spinal pain with impact.

BACKGROUND: Spinal pain (SP), including neck and back pain, is common and often associated with poor mental health and reduced quality of life of adolescents. Contemporary understanding of SP favours a biopsychosocial approach, and emerging evidence suggests the stronger influence of psychological rather than other factors. OBJECTIVES: We aimed to investigate if experiencing psychological distress in early childhood increases the risk of spinal pain with impact during adolescence. METHODS: 1175 adolescents from a prospective cohort study (Raine Study Gen2) were included. Psychological distress was assessed at ages 2, 5, 8 and 10 using Child Behaviour Check List (CBCL). CBCL total and subscale scores (internalizing and externalizing symptoms) were converted to age-standardized scores and dichotomized according to t-scores (>60=high distress). Life-time spinal pain, including low back, mid back, or neck/shoulder, was measured at age 17. We were interested in adolescent SP with impact (care seeking, medication use, school absenteeism, daily activity interference, leisure activity interference) and defined cases as SP with impact (one or more) or greater impact (two or more) impacts. We investigated the longitudinal associations between childhood psychological distress and adolescent SP using univariate and multivariable logistic regression models. RESULTS: Psychological distress in childhood increased the odds of adolescent SP with impact by 33% (OR 1.33; 95% CI 1.01-1.76), but not spinal pain with greater impact (OR 1.22; 95% 0.83-1.80). Internalizing symptoms were associated with SP with greater impact and externalizing symptoms with SP with impact after adjusting for a range of potential child and family confounders. CONCLUSION: Psychological distress in childhood increases the risk of SP with impact in adolescence and may be a promising prevention target. SIGNIFICANCE: Our findings provide evidence that psychological distress early in life is an independent risk factor for spinal pain with impact during adolescence. As psychological distress during childhood is potentially modifiable, it may be a promising target for research on the prevention of consequential spinal pain in adolescence. Identifying and addressing psychological distress in children may be an important component of best practice to reduce consequential spinal pain in adolescents.

The anticipatory response to stress and symptoms of depression and anxiety in early adulthood.

BACKGROUND: Whilst cortisol reactivity has been associated with depression and anxiety disorders, research examining cortisol reactivity with early symptoms of these conditions in males and females is limited. METHODS: At age 18, 748 males and females from Gen2 of the Raine Study were assessed for their salivary cortisol response to a psychosocial stressor using the Trier Social Stress Test (TSST). Participants later completed the Depression Anxiety Stress Scale (DASS-21) at age 20 which was used as the outcome measure in regression models. RESULTS: We found differences in DASS-21 across TSST responder categories in females but not males. Female reactive-responders (RR) and non-responders (NR) had increased symptoms of depression and anxiety compared to anticipatory-responders (AR). AR were associated with the lowest symptomology in females. We found limited evidence for an association between salivary cortisol summary measures (CBL, CMAX, CMIN, CRANGE, AUCG and AUCR) and depression/anxiety symptoms at age 20. CONCLUSIONS: This study sheds new light on adaptive and maladaptive physiological responses to psychosocial stress in terms of depression and anxiety symptoms. These preliminary findings indicate the pattern of response to a psychosocial stressor may contribute to individual vulnerability for stress-related diseases in a sex-specific manner.

What influences patient satisfaction after total knee replacement? A qualitative long-term follow-up study.

OBJECTIVES: To explore whether a conceptual model of patient satisfaction previously developed 1-2 years post-total knee replacement (TKR) is still relevant 3-4 years post-TKR. Specifically, (i) what is the stability in satisfaction levels 3-4 years post-TKR? and (ii) does the existing conceptual model of patient satisfaction after TKR apply at this later follow-up? DESIGN: A constructivist grounded theory qualitative follow-up study. The present study was theoretically governed by the findings of the initial qualitative inquiry. One-on-one semi-structured interviews were used to test the assumptions of the model developed from the findings of the previous study. SETTING: An urban Australian public hospital PARTICIPANTS: From 40 people who participated in the original study, 11 participants were purposively sampled based on their level of satisfaction and factors driving satisfaction as reported in their first interview. There were six women and five men, the average time since TKR was 3 years and 5 months, and the average age at time of interview was 77 years. RESULTS: Satisfaction levels were mostly stable with the exception of three participants; two transitioned in a positive direction; one in a negative direction. The meaning of satisfaction and the factors that influenced satisfaction were consistent with the original findings. However, beliefs relating to the influence of ageing on persistent knee symptoms and functional limitations were more dominant in the present study. CONCLUSIONS: The findings provide support for patient satisfaction being a multifactorial construct that is potentially modifiable over time. Clinicians may apply the conceptual model we have described to optimise satisfaction in patients up to 3-4 years post-TKR.

Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review.

OBJECTIVE: Current guidelines recommend management of musculoskeletal pain conditions from a biopsychosocial approach; however, biopsychosocial interventions delivered by physical therapists vary considerably in effectiveness. It is unknown whether the differences are explained by the intervention itself, the training and/or competency of physical therapists delivering the intervention, or fidelity of the intervention. The aim was to investigate and map the training, competency assessments, and fidelity checking of individualized biopsychosocial interventions delivered by physical therapists to treat musculoskeletal pain conditions. METHODS: A scoping review methodology was employed, using Arksey and O'Malley's framework. Seven electronic databases were searched between January and March 2019, with a bridge search completed in January 2020. Full-text peer-reviewed articles, with an individualized biopsychosocial intervention were considered, and 35 studies were included. RESULTS: Reporting overall was sparse and highly variable. There was a broad spectrum of training. More sophisticated training involved workshops combining didactic and experiential learning over longer durations with supervision and feedback. Less sophisticated training was brief, involving lectures or seminars, with no supervision or feedback. Competency assessments and fidelity testing were underperformed. CONCLUSIONS: Training in some interventions might not have facilitated the implementation of skills or techniques to enable the paradigm shift and behavior change required for physical therapists to effectively deliver a biopsychosocial intervention. Lack of competency assessments and fidelity checking could have impacted the methodological quality of biopsychosocial interventions. IMPACT: This study highlighted problematic reporting, training, assessment of competency, and fidelity checking of physical therapist-delivered individualized biopsychosocial interventions. Findings here highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions. These findings can help inform future research and facilitate more widespread implementation of physical therapist-delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life.

A randomised controlled trial to test the feasibility of online mindfulness programs for people with multiple sclerosis.

BACKGROUND: Practicing mindfulness may improve mental health and reduce pain in people with multiple sclerosis (MS). Since participating in face-to-face mindfulness programs can be challenging for people with MS, exploring alternative ways of delivering these programs is necessary. The objective of this trial was to assess feasibility of two different eight-week online mindfulness programs across five domains: recruitment, practicality, acceptability, integration of mindfulness practice, and limited efficacy testing on mental health, quality of life and pain. METHODS: In a three-arm randomised controlled mixed-method trial, participants were assigned to: 1) Mindfulness for Multiple Sclerosis (M4MS) (n=18); 2) Chair Yoga (n=18); or 3) wait-list control group (n=19) for eight weeks. Daily home practice diaries and weekly reflective journals were collected along with online questionnaires at baseline and post-intervention. Feasibility was assessed using descriptive statistics, multilevel mixed-effects regression, and content analysis. RESULTS: Online recruitment, online program delivery and online data collection were all found to be feasible. The sign up rate was 65% and overall, 87% of the participant completed the eight-week online programs. The programs were perceived as practical and acceptable by the participants. Integration of mindfulness practice into daily life varied, with time and fatigue reported as common barriers to practice. No statistically significant differences in efficacy measures were found among groups (p>0.05). CONCLUSION: Online mindfulness programs are feasible and acceptable for people with MS. This study provides useful insights for future trials when designing online mindfulness programs for people with MS.

Prenatal and childhood stress exposure and the sex specific response to psychosocial stress in adulthood.

BACKGROUND: Early life stress exposures may cause dysregulation of the Hypothalamic Pituitary Adrenal (HPA)-axis and cortisol production, with timing and sex-specific effects. Studies examining the impact of early life stress on cortisol responses to stress have focused on severe trauma and have produced inconsistent results. The aim of this study was to investigate whether common early life stressors, experienced prenatally or throughout childhood and adolescence, play a role in the dysregulation of the HPA-axis in early adulthood. METHODS: Exposures to common life stress events were examined prenatally and as longitudinal trajectories of stress exposure from birth to age 17 in males and females from Gen2 of the Raine Study. At age 18 years, 986 participants were assessed for their salivary cortisol response to a psychosocial stressor - the Trier Social Stress Test (TSST). RESULTS: In males there was an association between high prenatal stress exposure at 18 weeks gestation and a heightened TSST response. We found evidence for sex-specific associations with increasing stress exposure during adolescence (the ascending trajectory) whereby males were more likely to be non-responders to the TSST and females were more likely to be responders. CONCLUSION: Our results point to sex differences in how stress exposure in-utero and exposure increasing during adolescence may affect regulation of the HPA-axis later in life. However, overall common life stress events experienced in-utero, during childhood and adolescence show limited impact on the HPA-axis stress response in early adulthood.

What Influences Patient Satisfaction after TKA? A Qualitative Investigation.

BACKGROUND: Patient satisfaction is a common measure of the success of an orthopaedic intervention. However, there is poor understanding of what satisfaction means to patients or what influences it. QUESTIONS/PURPOSES: Using qualitative study methodology in patients undergoing TKA, we asked: (1) What does it mean to be satisfied after TKA? (2) What factors influence satisfaction levels after TKA? METHODS: People in a hospital registry who had completed 12-month follow-up questionnaires and were not more than 18 months post-TKA at the time of sampling were eligible (n = 121). To recruit a sample that provided insight into a range of TKA experiences, we divided eligible candidates on the registry into quadrants based on their responder status and satisfaction level. A responder was an individual who experienced a clinically meaningful change in pain and/or function on the WOMAC according to the Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria. Individuals were considered satisfied unless they indicated somewhat dissatisfied or very dissatisfied for one or more of the four items on the Self-Administered Patient Satisfaction Scale. From the resulting quadrants: responder satisfied, nonresponder satisfied, nonresponder dissatisfied, responder dissatisfied, we identified men and women with a range of ages and invited them to participate (n = 85). The final sample (n = 40), consisted of 10 responder satisfied, nine nonresponder satisfied, eight nonresponder dissatisfied, and 13 responder dissatisfied; 71% were women, with a mean age of 71 ± 7 years and a mean time since TKA surgery of 17 ± 2 months (range 13 to 25 months). Interview transcripts were analyzed by looking for factors in the participants' narrative that appeared to underscore their level of satisfaction and attaching inductive (data-derived, rather than a priori derived) codes to relevant sections of text. Coded data from participants who reported high and low levels of satisfaction were compared/contrasted and emerging patterns were mapped into a conceptual model. Recruitment continued until no new information was uncovered in data analysis of subsequent interviews, signalling to the researchers that further interviews would not change the key themes identified and data collection could cease. RESULTS: In those with high satisfaction levels, satisfaction was conceptualized as an improvement in pain and function. In those with low satisfaction levels, rather than an improvement, satisfaction was conceptualized as completely resolving all symptoms and functional limitations. In addition, we identified three pathways through which participants reached different levels of low and high satisfaction: (1) The full-glass pathway, characterized by no or minimal ongoing symptoms and functional deficits, which consistently led to high levels of satisfaction; (2) the glass-half-full pathway, characterized by ongoing symptoms and functional limitations, which led to high satisfaction; and (3) the glass-half-empty pathway, also characterized by ongoing symptoms and functional limitations, which led to low satisfaction levels. The latter two pathways were mediated by three core mechanisms (recalibration, reframing valued activities, and reconceptualization) influenced either positively or negatively by (1) a persons' thoughts and feelings such as optimism, self-efficacy, pain catastrophizing, external locus of control; and (2) social and contextual factors such as fulfilment of social roles, therapeutic alliance, lack of family/social support. CONCLUSIONS: This qualitative study suggests that for preoperative patients in whom unrealistically high hopes for complete symptom resolution and restoration of functional capacity persists, it may be appropriate to direct them away from TKA due to the risk of low satisfaction. For postoperative patients troubled by ongoing symptoms or functional limitations, clinicians may improve levels of satisfaction by targeting the three core mechanisms (recalibration, reframing valued activities, and reconceptualization) through addressing modifiable negative thoughts and feelings in interventions such as psychology or psychotherapy; and negative social and contextual factors by promoting a strong therapeutic alliance and engagement in community activities. Given that these factors may be identifiable preoperatively, future research is needed to explore if and how addressing them preoperatively may improve satisfaction post-TKA. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Metacognition, perseverative thinking, and pain catastrophizing: A moderated-mediation analysis.

BACKGROUND: Pain catastrophizing is linked to a range of negative health and treatment outcomes, although debate continues about how best to define and treat it, since most interventions produce only modest benefit. This study aimed to contribute to theory-driven development of these treatments by exploring the role of perseverative thinking in pain catastrophizing, along with the higher order beliefs, called metacognitions that might shape it. METHODS: An Internet sample of 510 people with chronic pain (≥3 months), who mostly (54.9%) had clinical levels of catastrophizing, completed self-report measures of pain intensity, disability, perseverative thinking, pain catastrophizing, depression, anxiety, and pain metacognition. Regression-based moderated mediation analysis tested the conditional indirect effect of pain intensity on pain catastrophizing via perseverative thinking at varying levels of unhelpful pain metacognition. RESULTS: Perseverative thinking partially mediated the effect of pain intensity on pain catastrophizing, accounting for 20% of the total effect. This indirect effect was conditional on both positive and negative metacognition. Higher levels of both forms of unhelpful metacognition strengthened the indirect effect, which was not significant below the 50th percentile for positive metacognitions or below the 60th percentile for negative metacognitions. CONCLUSIONS: Strongly believing that thinking about pain helps you solve problems or cope with pain (positive metacognition), or that it is harmful and uncontrollable (negative metacognition), can increase the amount you worry or ruminate as pain increases. This is associated with increased pain catastrophizing. Identifying and modifying these unhelpful pain metacognitions may improve treatments for pain catastrophizing and thereby chronic pain generally. SIGNIFICANCE: This study shows that perseverative thinking (worry and rumination) mediates the relationship between pain intensity and catastrophizing. Consistent with metacognitive theory, this association is also moderated by unhelpful beliefs about worry and rumination. Pain metacognitions could become new therapeutic targets to help improve psychological treatments for pain-related distress, which are currently only modestly effective.

RESTORE-Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain: study protocol for a randomised controlled trial.

INTRODUCTION: Low back pain (LBP) is the leading cause of disability globally and its costs exceed those of cancer and diabetes combined. Recent evidence suggests that individualised cognitive and movement rehabilitation combined with lifestyle advice (cognitive functional therapy (CFT)) may produce larger and more sustained effects than traditional approaches, and movement sensor biofeedback may enhance outcomes. Therefore, this three-arm randomised controlled trial (RCT) aims to compare the clinical effectiveness and economic efficiency of individualised CFT delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling LBP. METHODS AND ANALYSIS: Pragmatic, three-arm, randomised, parallel group, superiority RCT comparing usual care (n=164) with CFT (n=164) and CFT-plus-movement-sensor-biofeedback (n=164). Inclusion criteria include: adults with a current episode of LBP >3 months; sought primary care ≥6 weeks ago for this episode of LBP; average LBP intensity of ≥4 (0-10 scale); at least moderate pain-related interference with work or daily activities. The CFT-only and CFT-plus-movement-sensor-biofeedback participants will receive seven treatment sessions over 12 weeks plus a 'booster' session at 26 weeks. All participants will be assessed at baseline, 3, 6, 13, 26, 40 and 52 weeks. The primary outcome is pain-related physical activity limitation (Roland Morris Disability Questionnaire). Linear mixed models will be used to assess the effect of treatment on physical activity limitation across all time points, with the primary comparison being a formal test of adjusted mean differences between groups at 13 weeks. For the economic (cost-utility) analysis, the primary outcome of clinical effect will be quality-adjusted life years measured across the 12-month follow-up using the EuroQol EQ-5D-5L . ETHICS AND DISSEMINATION: Approved by Curtin University Human Research Ethics Committee (HRE2018-0062, 6 Feb 2018). Study findings will be disseminated through publication in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12618001396213).

Assessing Beliefs Underlying Rumination About Pain: Development and Validation of the Pain Metacognitions Questionnaire.

Metacognitions, which are beliefs about our own thinking processes, can modulate worry and rumination and thereby influence emotional distress. This study aimed to develop a self-report measure of unhelpful pain-related metacognitions which might serve as a clinical and research tool to better understand pain catastrophizing, a significant risk factor for adverse pain outcomes. Two phases of validation are presented. Phase 1 reports on how the Pain Metacognitions Questionnaire (PMQ) was empirically developed through a qualitative study of 20 people with chronic back (n = 15) or knee (n = 5) pain in secondary or tertiary care and then validated in a large internet sample of people experiencing pain (N = 864). Rasch analysis yielded a 21-item scale with two dimensions (positive and negative metacognition) assessing how useful and problematic people believe rumination about pain to be, respectively. In Phase 2, further validation using a new sample (N = 510) replicated initial findings. Both PMQ subscales have good retest reliability (r = 0.76, r = 0.72) and internal consistency (0.86, 0.87). They correlate negatively with mindfulness and positively with pain intensity, disability, anxiety, depression, catastrophizing, rumination, and metacognition. The PMQ also predicts unique variance in catastrophizing when other variables are controlled and predicts 'patient' status for pain catastrophizing. Sensitivity analysis yielded preliminary suggestions for clinically meaningful cut-offs. Unhelpful pain metacognitions can be validly and reliably measured using a self-report instrument. Future studies using the PMQ might shed new light on pain-related thinking processes to develop better interventions for people prone to worry and rumination about their pain.

Modified Mindfulness-Based Cognitive Therapy for Depressive Symptoms in Parkinson's Disease: a Pilot Trial.

BACKGROUND: Mindfulness-based cognitive therapy (MBCT) has evidence of efficacy in a range of populations, but few studies to date have reported on MBCT for treatment of anxious and depressive symptoms in Parkinson's disease (PD). AIMS: The aim of this study was to examine the efficacy of modified MBCT in reducing symptoms of anxiety and depression and improving quality of life in PD. METHOD: Thirty-six individuals with PD were randomly assigned to either modified MBCT or a waitlist control. Changes in symptoms of anxiety, depression and quality of life were compared at group level using generalized linear mixed models and at individual level using reliable change analysis. RESULTS: At post-treatment, there was a significant reduction in depressive symptoms for people undertaking modified MBCT at both group and individual levels compared with controls. There was no significant effect on anxiety or quality of life at the group level, although significantly more people had reliable improvement in anxiety after modified MBCT than after waitlist. Significantly more waitlist participants had reliable deterioration in symptoms of anxiety and depression than those completing modified MBCT. Most participants stayed engaged in modified MBCT, with only three drop-outs. DISCUSSION: This proof-of-concept study demonstrates the potential efficacy of modified MBCT as a treatment for depressive symptoms in Parkinson's disease and suggests further research is warranted.

Mindfulness and avoidance mediate the relationship between yoga practice and anxiety.

OBJECTIVES: There is accumulating evidence that yoga and mindfulness meditation can alleviate symptoms of anxiety, although the mechanisms by which this occurs remain unclear. The purpose of this study was to examine the relationship between yoga practice and self-reported anxiety as well as the potential mediating roles of mindfulness and emotional avoidance. METHODS: Using a cross-sectional design, 367 participants were recruited online and completed measures of anxiety, avoidance, and mindfulness. RESULTS: Results showed that length of yoga practice was significantly correlated with lower anxiety in yoga practitioners. Avoidance and mindfulness mediated the relationship between length of yoga practice and anxiety, shedding light on possible mechanisms by which these practices reduce anxiety. CONCLUSIONS: Future experimental and longitudinal research is needed to examine the causal role of mindfulness and avoidance in the relationship between yoga practice and anxiety, and whether yoga is a useful adjunct to cognitive behaviour therapy for anxiety disorders.

How Can We Best Reduce Pain Catastrophizing in Adults With Chronic Noncancer Pain? A Systematic Review and Meta-Analysis.

Pain catastrophizing (PC), defined as an exaggerated negative cognitive-affective orientation toward pain, is one of the strongest psychological predictors of pain outcomes. Although regularly included as a process variable in clinical trials, there have been no comprehensive reviews of how it can be modified. Using a registered protocol (PROSPERO 2016 CRD42016042761), we searched MEDLINE, PsychINFO, EMBASE, CINAHL, and CENTRAL up to November 2016 for all randomized controlled trials measuring PC in adults with chronic noncancer pain. Two authors independently screened studies and assessed bias risk using the Cochrane tool. Quality of evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation criteria. We included 79 studies (n = 9,914), which mostly recruited participants with musculoskeletal pain and had low risk of bias. Meta-analyses (standardized mean difference) showed 9 interventions had efficacy compared with waitlist/usual care or active control, although evidence quality was often low. The best evidence (moderate-high quality) was found for cognitive-behavioral therapy, multimodal treatment, and acceptance and commitment therapy. Effects were generally of medium strength and had questionable clinical significance. When only the 8 studies targeting people with high PC were included, effects were larger and more consistent. Multimodal treatment showed the strongest effects when all studies were considered, whereas cognitive-behavioral therapy had the best evidence among targeted studies. PERSPECTIVE: PC is a modifiable characteristic but most interventions produce only modest benefit unless targeted to people with high PC. More research into theory-driven interventions matched to specific patient profiles is required to improve treatment efficacy and efficiency.

Making Sense of Low Back Pain and Pain-Related Fear.

Synopsis Pain-related fear is implicated in the transition from acute to chronic low back pain and the persistence of disabling low back pain, making it a key target for physical therapy intervention. The current understanding of pain-related fear is that it is a psychopathological problem, whereby people who catastrophize about the meaning of pain become trapped in a vicious cycle of avoidance behavior, pain, and disability, as recognized in the fear-avoidance model. However, there is evidence that pain-related fear can also be seen as a common-sense response to deal with low back pain, for example, when one is told that one's back is vulnerable, degenerating, or damaged. In this instance, avoidance is a common-sense response to protect a "damaged" back. While the fear-avoidance model proposes that when someone first develops low back pain, the confrontation of normal activity in the absence of catastrophizing leads to recovery, the pathway to recovery for individuals trapped in the fear-avoidance cycle is less clear. Understanding pain-related fear from a common-sense perspective enables physical therapists to offer individuals with low back pain and high fear a pathway to recovery by altering how they make sense of their pain. Drawing on a body of published work exploring the lived experience of pain-related fear in people with low back pain, this clinical commentary illustrates how Leventhal's common-sense model may assist physical therapists to understand the broader sense-making processes involved in the fear-avoidance cycle, and how they can be altered to facilitate fear reduction by applying strategies established in the behavioral medicine literature. J Orthop Sports Phys Ther 2017;47(9):628-636. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7434.

'I call it stinkin' thinkin'': A qualitative analysis of metacognition in people with chronic low back pain and elevated catastrophizing.

OBJECTIVES: Pain catastrophizing is widely studied in quantitative pain research because of its strong link with poor pain outcomes, although the exact nature of this construct remains unclear. Focusing on its ruminative dimension, the present qualitative study aimed to explore a nascent aspect of pain catastrophizing - metacognition - by documenting people's attitudes towards rumination and examining how these metacognitions might influence the course it takes. DESIGN: Qualitative interview study. METHODS: Semi-structured interviews were conducted in a tertiary care setting with 15 adults experiencing chronic (≥6 months) low back pain who scored highly (≥30) on the Pain Catastrophising Scale. Transcripts were analysed using interpretative phenomenological analysis. RESULTS: The first aim of documenting pain metacognitions revealed both positive (e.g., 'thinking helps me to cope') and negative (e.g., 'rumination is uncontrollable') attitudes towards pain rumination. These were often held simultaneously, creating internal conflict. The second aim of exploring the influence of metacognition on rumination showed that both negative and positive metacognitions could fuel perseverative thinking. However, more nuanced negative metacognitions (e.g., 'worry is pointless') could help to end episodes of rumination by motivating the use of concrete problem-solving or active coping behaviours. CONCLUSIONS: While most participants described pain rumination as uncontrollable and harmful, dwelling on pain could be helpful when focused on tangible and solvable problems, thereby translating into adaptive coping behaviours that eventually interrupt rumination. Future treatments may be more effective if they are based on individualized formulations of pain catastrophizing that focus on its perseverative nature and implicit function. Statement of contribution What is already known on this subject? Chronic pain affects one in five people, and psychological coping responses are key targets within gold standard biopsychosocial interventions. People who have elevated pain catastrophizing tend to have worse pain outcomes, including increased pain, disability, and emotional distress. What people believe about their own thinking (i.e., their metacognitions) influences how much they worry or ruminate. What does this study add? This is the first qualitative study exploring metacognitions in people with chronic pain and the first to target a purposive sample of people with elevated pain catastrophizing. People with elevated pain catastrophizing often see rumination as uncontrollable and harmful but may simultaneously believe it helps them to solve problems or feel prepared for future threats. Pain catastrophizing is not a stable and enduring trait but fluctuates both within and across individuals in response to pain, context, metacognitive beliefs about rumination, and coping behaviours.

Young people's experiences of persistent musculoskeletal pain, needs, gaps and perceptions about the role of digital technologies to support their co-care: a qualitative study.

OBJECTIVE: To investigate young people's experiences of persistent musculoskeletal pain, including care needs and current service gaps as well as perceptions about the role of digital technologies to support their co-care. METHODS: A qualitative study employing two independent data collection modes: in-depth individual semistructured interviews and focus groups. SETTING: Community settings throughout Australia. PARTICIPANTS: Participants were included if they had experienced persistent musculoskeletal pain of >3-month duration with an average of ≥3 on the visual analogue scale over the preceding 3 months, including non-specific conditions (eg, low back pain) and specific conditions (eg, juvenile idiopathic arthritis and other systemic arthritides), with/without pre-existing or current diagnosed mental health conditions. 23 young people (87.0% women; mean (SD) age: 20.8 (2.4) years) from across 6 Australian jurisdictions participated. Almost two-thirds of participants with persistent musculoskeletal pain reported comorbid mental health conditions. MAIN OUTCOME MEASURES: Inductive and deductive approaches to analyse and derive key themes from verbatim transcripts. RESULTS: Participants described their daily experiences of living with persistent musculoskeletal pain, their fears and the challenges imposed by the invisibility of pain, and the two-way relationship between their pain and mental well-being. A lack of relevant and accessible information and resources tailored to young people's unique needs, integrated and youth-relevant healthcare services and adequately skilled healthcare practitioners were identified as key care gaps. Participants strongly advocated for the use of digital technologies to improve access to age-appropriate resources and support for co-care. CONCLUSIONS: Young people living with persistent musculoskeletal pain described the absence of age-appropriate pain services and clearly articulated their perceptions on the role of, and opportunities provided by, digital technologies to connect with and support improved pain healthcare. Innovative and digitally-enabled models of pain care are likely to be helpful for this group.

Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear.

OBJECTIVES: The fear-avoidance model describes how the belief that pain is a sign of damage leads to pain-related fear and avoidance. But other beliefs may also trigger the fear and avoidance responses described by the model. Experts have called for the next generation of fear avoidance research to explore what beliefs underlie pain-related fear and how they evolve. We have previously described damage beliefs and suffering/functional loss beliefs underlying high pain-related fear in a sample of individuals with chronic back pain. The aim of this study is to identify common and differential factors associated with the beliefs in this sample. DESIGN: A qualitative study employing semistructured interviews. SETTING: Musculoskeletal clinics in Western Australia. PARTICIPANTS: 36 individuals with chronic back pain and high scores on the Tampa Scale (mean 47/68). RESULTS: The overarching theme was a pain experience that did not make sense to the participants. The experience of pain as unpredictable, uncontrollable and intense made it threatening. Attempting to make sense of the threatening pain, participants with damage beliefs drew on past personal experiences of pain, societal beliefs, and sought diagnostic certainty. Met with diagnostic uncertainty, or diagnoses of an underlying pathology that could not be fixed, they were left fearful of damage and confused about how to 'fix' it. Participants with suffering/functional loss beliefs drew on past personal experiences of pain and sought help from healthcare professionals to control their pain. Failed treatments and the repeated failure to achieve functional goals left them unable to make 'sensible' decisions of what to do about their pain. CONCLUSIONS: The findings raise the suggestion that sense-making processes may be implicated in the fear-avoidance model. Future research is needed to explore whether fear reduction may be enhanced by considering beliefs underlying fear and providing targeted intervention to help individuals make sense of their pain.