The Activity Management Inventory for Pain (AMI-P): Initial Development and Validation of a Questionnaire Based on Operant Learning and Energy Conservation Models of Activity Management.

OBJECTIVES: Activity management is an important treatment component in chronic pain programs. However, there are shortcomings in measures of this construct, leading to inconsistencies in research findings. Here, we describe the development of the Activity Management Inventory for Pain (AMI-P). MATERIALS AND METHODS: The AMI-P was developed by a group of international researchers with extensive expertise in both chronic pain and activity management. The initial evaluation of the AMI-P items included 2 studies that were both conducted in Canadian tertiary pain care centers. RESULTS: The resulting 20-item measure has 3 behavior scales (Rest, Alternating Activity, and Planned Activity), and 4 goal scales (Feel Less Pain, Get More Done, Complete the Task, and Save Energy). The behavior scales evidenced marginal to good internal consistency and test-retest reliability, and a moderate positive association with an existing pacing measure. The Rest and Alternating Activity scales were associated with greater pain interference, the Alternating Activity and Planned Activity scales were associated with less satisfaction with social roles, and the Planned Activity scale was associated with fewer depressive symptoms. The Alternating Activity scale increased significantly from pretreatment to posttreatment. All goal scales were positively associated with all behavior scales. The Feel Less Pain goal scale was positively associated with measures of avoidance and pain interference, while the Get More Done goal scale was negatively associated with measures of depressive symptoms and overdoing. DISCUSSION: The findings support the reliability and validity of the AMI-P scales, while also highlighting the complexity and multidimensional aspects of activity management.

Development and Initial Evaluation of the Patterns of Activity Measure-Pain Short Form.

OBJECTIVES: There has been growing interest in examining pain-related activity patterns and their relationships to psychosocial functioning. The Patterns of Activity Measure-Pain (POAM-P) is frequently used to measure 3 pain-related activity patterns: avoidance, overdoing, and pacing. Although the POAM-P possesses excellent psychometric properties, its length may limit its utility where multiple measures of functioning are required or the time available for assessment is limited. The present studies describe the development and evaluation of a short-form version of this measure. MATERIALS AND METHODS: In Study 1, 775 individuals with ongoing pain completed the original POAM-P at the start of a treatment program. Item analyses were conducted to construct a short-form of the POAM-P. In Study 2, a separate sample of 171 individuals completed the original and short-form of the POAM-P, and measures of psychosocial functioning. Correlations between the short-form and original, and between the short-form and measures of psychosocial functioning were examined to evaluate the reliability and validity of the short-form. RESULTS: The 3 scales of the short-form were found to have excellent internal consistency and correlated well with corresponding scales on the original POAM-P. Correlations between scales on the short-form and measures of psychosocial functioning supported the construct validity of the measure. DISCUSSION: The short-form of the POAM-P possesses good psychometric properties and correlates well with the long-form of the measure. It appears to be a promising addition to existing measures of pain-related activity. It may be useful as an addition to questionnaire batteries that comprehensively assess the psychosocial functioning of individuals with ongoing pain.

Threat Prediction from Schemas as a Source of Bias in Pain Perception.

Our sensory impressions of pain are generally thought to represent the noxious properties of an agent but can be influenced by the predicted level of threat. Predictions can be sourced from higher-order cognitive processes, such as schemas, but the extent to which schemas can influence pain perception relative to bottom-up sensory inputs and the underlying neural underpinnings of such a phenomenon are unclear. Here, we investigate how threat predictions generated from learning a cognitive schema lead to inaccurate sensory impressions of the pain stimulus. Healthy male and female participants first detected a linear association between cue values and stimulus intensity and rated pain to reflect the linear schema when compared with uncued heat stimuli. The effect of bias on pain ratings was reduced when prediction errors (PEs) increased, but pain perception was only partially updated when measured against stepped increases in PEs. Cognitive, striatal, and sensory regions graded their responses to changes in predicted threat despite the PEs (p < 0.05, corrected). Individuals with more catastrophic thinking about pain and with low mindfulness were significantly more reliant on the schema than on the sensory evidence from the pain stimulus. These behavioral differences mapped to variability in responses of the striatum and ventromedial prefrontal cortex. Thus, this study demonstrates a significant role of higher-order schemas in pain perception and indicates that pain perception is biased more toward predictions and less toward nociceptive inputs in individuals who report less mindfulness and more fear of pain.SIGNIFICANCE STATEMENT This study demonstrates that threat predictions generated from cognitive schemas continue to influence pain perception despite increasing prediction errors arising in pain pathways. Individuals first formed a cognitive schema of linearity in the relationship between the cued threat value and the stimulus intensity. Subsequently, the linearity was reduced gradually, and participants partially updated their evaluations of pain in relation to the stepped increases in prediction errors. Individuals who continued to rate pain based more on the predicted threat than on changes in nociceptive inputs reported high pain catastrophizing and less mindful-awareness scores. These two affects mapped to activity in the ventral and dorsal striatum, respectively. These findings direct us to a significant role of top-down processes in pain perception.

An Evaluation of Sex Differences in Patients With Chronic Pain Undergoing an Interdisciplinary Pain Treatment Program.

OBJECTIVES: To determine if there are sex differences in a sample of patients participating in a 4-week interdisciplinary pain treatment program in (1) pretreatment pain intensity, physical function, psychological function, pain beliefs, kinesiophobia, pain catastrophizing, and activity management patterns; and (2) treatment response. METHODS: Seventy-two men and 130 women with chronic pain completed study measures. Analyses of covariance (ANCOVAs) were performed to compare men and women on pretreatment measures. Repeated-measures ANCOVAs were used to compare both sexes on 3 treatment outcomes (pain intensity, physical function, and depressive symptoms). RESULTS: Before treatment, compared to women, men reported higher levels of kinesiophobia, were more likely to view their pain as being harmful, and used more activity pacing when doing daily activities. Women were more likely to use an overdoing activity pattern than men. No sex differences emerged for pretreatment pain intensity, physical function, psychological function, catastrophizing, activity avoidance, or measures of other pain-related beliefs. At posttreatment, women reported more improvements in pain intensity and physical function compared to men, while both sexes reported similar reductions in depressive symptoms. All effect sizes for statistically significant findings were of small to moderate magnitude. DISCUSSION: The results of this study suggest that men and women have a comparable profile with respect to the overall burden of chronic pain. Nevertheless, sex differences were found for certain pain beliefs and coping styles. Women appear to reap more benefits from the interdisciplinary pain management program than men. These findings indicate that further research to develop sex-specific assessment procedures and tailored pain treatments may be warranted.

The Role of Sleep Quality and Fatigue on the Benefits of an Interdisciplinary Treatment for Adults With Chronic Pain.

BACKGROUND: Interdisciplinary chronic pain treatment is effective for reducing pain intensity and pain-related disability, and for improving psychological function. However, the mechanisms that underlie these treatment-related benefits are not yet well understood. Sleep problems and fatigue are modifiable factors often comorbid with chronic pain. The goal of this study was to evaluate the role that changes in sleep quality and fatigue might have on the benefits of an interdisciplinary chronic pain treatment. METHODS: A total of 125 adults with chronic pain participated in a 4-week interdisciplinary pain management program. Measures of depression, sleep disturbance, fatigue, pain intensity, and physical function were administered at pre- and post-treatment. Three regression analyses were conducted to evaluate the contribution of pre- to post-treatment improvements in fatigue and sleep disturbance to the pre- to post-treatment improvements in pain intensity, disability, and depression, while controlling for demographic characteristics (age and sex) and pain intensity. RESULTS: Changes in fatigue and sleep disturbance made independent and significant contributions to the prediction of treatment-related benefits in pain intensity; improvements in depressive symptoms were predicted by improvements in fatigue, and improvements in disability were only predicted by pre-treatment and pre- to post-treatment decreases in pain intensity (one of the control variables). CONCLUSIONS: In addition to sleep, fatigue emerged as a key potential mechanism of multidisciplinary chronic pain treatment-related improvements, suggesting that interventions including elements that effectively target sleep and fatigue may enhance the efficacy of interdisciplinary chronic pain programs. This possibility should be evaluated in future research.

Patterns of pain-related activity: replicability, treatment-related changes, and relationship to functioning.

Changes in activity patterns frequently accompany the experience of chronic pain. Two activity patterns, avoidance and overdoing, are hypothesized to contribute to the development of ongoing pain and pain-related disability, while activity pacing is frequently introduced to enhance pain management and functioning. Two studies were conducted to assess whether reliable subgroups with differing activity patterns could be identified in different pain populations and to evaluate changes in these subgroups after a group format, pain management program. In study 1, individuals with ongoing pain being assessed for treatment at 2 different tertiary care pain centres completed a measure of pain-related activity. Separate cluster analyses of these samples produced highly similar cluster solutions. For each sample, a 2-cluster solution was obtained with clusters corresponding to the activity patterns described by the avoidance-endurance model of pain. In study 2, a subset of individuals completing a 12-session, group format, pain management program completed measures of pain-related activity, pain intensity, and physical and psychological functioning at the beginning and end of the program. At the conclusion of the program, 4 clusters of pain-related activity were identified. Individuals who used high levels of activity pacing and low levels of avoidance consistently reported significantly better functioning relative to all other individuals. Observed changes in activity patterns from pre-treatment to post-treatment suggested that decreasing the association between activity pacing and avoidance was associated with better functioning. These results have implications for both the assessment of activity pacing and for its use as an intervention in the management of ongoing pain.

Pain catastrophizing, activity engagement and pain willingness as predictors of the benefits of multidisciplinary cognitive behaviorally-based chronic pain treatment.

Pain catastrophizing and pain acceptance have been shown to be associated with improvements after participation in cognitive behaviorally-based treatment (CBT) for chronic pain. However, it is not yet clear how important each of these factors is relative to the other. Furthermore, it is also not clear if multidisciplinary pain treatment has the same impact on the two primary dimensions of pain acceptance (activity engagement and pain willingness), and whether their role in explaining treatment outcome differs as a function of the outcomes under study. The aim of this study was to examine the relative importance of changes in pain catastrophizing, activity engagement and pain willingness as predictors of the benefits of a multidisciplinary CBT for chronic pain. 186 adults with chronic pain participated. Pain catastrophizing and activity engagement, but not pain willingness, were significantly associated with treatment outcome. Moreover, each one evidenced different patterns of associations with outcomes. Specifically, while changes in both were associated with improvements in depressive symptoms, only catastrophizing was associated with improvements in pain intensity and only activity engagement was associated with improvements in pain-related disability.

Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain.

BACKGROUND AND AIMS: Trait behavioral inhibition represents a tendency to react with negative emotions - primarily worry - to cues which signal potential threats. This tendency has been hypothesized by a two-factor model of chronic pain to have direct effects on psychological and physical function in individuals with chronic pain, as well as to influence the associations between pain-related maladaptive cognitions and function. Our aim was to test these hypothesized associations in a sample of individuals who were being screened for possible interdisciplinary chronic pain treatment. METHODS: Eighty-eight patients referred to an interdisciplinary chronic pain management program were administered measures of average pain intensity, trait behavioral inhibition, kinesiophobia, pain catastrophizing, depressive symptoms, and pain interference. We then performed two linear regression analyses to evaluate the direct effects of trait behavioral inhibition on depressive symptoms and pain interference and the extent to which behavioral inhibition moderated the associations between kinesiophobia and pain catastrophizing, and the criterion variables. RESULTS: In partial support of the study hypotheses, the results showed significant (and independent) direct effects of trait behavioral inhibition on depressive symptoms, and behavioral inhibition moderated the association between kinesiophobia and depression, such that there were stronger associations between kinesiophobia and depressive symptoms in those with higher dispositional sensitivity to fear-inducing stimuli. However, neither direct nor moderating effects of behavioral inhibition emerged in the prediction of pain interference. CONCLUSIONS: If replicated in additional studies, the findings would indicate that chronic pain treatments which target both reductions in maladaptive cognitions (to decrease the direct negative effects of these on depressive symptoms) and the individual's tendency to respond to pain with worry (as a way to buffer the potential effects of maladaptive cognitions on depressive symptoms) might be more effective than treatments that targeted only one of these factors. IMPLICATIONS: Additional research is needed to further evaluate the direct and moderating effects of pain-related behavioral inhibition on function, as well as the extent to which treatments which target behavioral inhibition responses provide benefits to individuals with chronic pain.

Obstacles to activity pacing: assessment, relationship to activity and functioning.

Activity pacing is frequently included among the strategies provided to individuals with chronic pain to manage pain and improve functioning. Individuals with chronic pain may, however, limit their use of activity pacing because they perceive significant obstacles to its use. This study describes the development of a measure to assess obstacles to activity pacing and examines the relationship of this measure to activity patterns and functioning. A sample of 637 individuals with chronic pain completed items describing potential obstacles to activity pacing as part of their pretreatment assessment. Item analyses were used to construct a 14-item measure of obstacles to activity pacing. A subset of these individuals completed the measure again after completion of a group treatment program. The resulting measure demonstrated excellent internal consistency and was minimally affected by social desirability. Correlations with measures of activity and psychosocial functioning provided initial construct validity for the measure. Sex differences were found with women initially identifying more obstacles to activity pacing. Fewer obstacles were identified by both men and women after treatment, and these changes were related to modest changes in activity patterns and functioning. The present results identify a number of obstacles that may limit the use of activity pacing by individuals with chronic pain. Treatment may result in a decrease in the number of obstacles identified, and this change is related to changes in the individual's activity pattern and psychosocial functioning.

Pain-related activity patterns: measurement, interrelationships, and associations with psychosocial functioning.

OBJECTIVES: Changes in activity frequently occur as a consequence of ongoing pain. Three activity patterns commonly observed among individuals with ongoing pain are avoidance, overdoing, and pacing. We conducted 2 studies investigating these activity patterns, their interrelationships, and their associations with key psychosocial factors. Study 1 describes the development of a measure, the Patterns of Activity-Pain (POAM-P), to assess these activity patterns; Study 2 examines the psychosocial correlates of these activity patterns. METHODS: In study 1, a sample of 393 individuals with chronic pain responded to a pool of 51 items assessing activity as part of their pretreatment assessment. Item analyses were conducted to create a 30-item measure with 3, 10-item scales assessing avoidance, overdoing, and pacing. In study 2, a sample of 164 individuals attending a follow-up program 3 months after treatment completed the POAM-P along with measures of affect, pain control, and disability. RESULTS: scales demonstrated excellent internal consistency and correlations with other measures provided initial support for construct validity. Avoidance and overdoing were associated with negative psychosocial outcomes whereas pacing was associated with positive outcomes. In contrast to previous studies, pacing and avoidance were unrelated. DISCUSSION: The POAM-P has excellent psychometric properties and may be useful in clinical practice to identify activity patterns associated with poorer functioning and to evaluate interventions intended to modify these activity patterns. The present results support previous findings linking avoidance and various negative outcomes. These results also provide evidence that pacing may be related to positive outcomes after treatment.