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

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

Pain referents used to respond to the pain catastrophizing scale.

BACKGROUND: Pain catastrophizing has emerged as a highly important construct in pain research. The Pain Catastrophizing Scale (PCS) is a widely used self-report measure used to determine a person's level of pain catastrophizing, assumed to be associated with an ongoing, recalled or anticipated pain experience. In practice, instructions for self-reporting catastrophizing typically do not provide a specific pain referent, even when assessing patients with chronic pain. Researchers have noted that it is not known what type of pain participants are referring to when responding to a catastrophizing questionnaire. METHOD: In the current study, 182 presumably healthy undergraduate students completed the PCS followed by a query regarding the pain referent used to complete the scale. In addition, they were asked if they have ever experienced chronic pain and to list their worst pain experience. RESULTS: The most commonly used primary referents included pain due to acute injury (26.4%), headache (18.0%) and general physical pain (11.5%). The type of primary referent and the number of referents did not influence the catastrophizing scores. However, the catastrophizing scores were influenced by the context of the primary pain referent, i.e., whether the primary pain referent was non-chronic worst pain, both chronic and worst pain, chronic pain or unrelated to either chronic or worst pain. Notably, a larger than expected proportion of participants reported having experienced chronic pain (44.5%; n = 81). CONCLUSION: The examination of pain referents while responding to a catastrophizing measure would add to our understanding of a person's pain experience and related catastrophic cognitions.

The relation between pain beliefs, negative thoughts, and psychosocial functioning in chronic pain patients.

Cognitions and beliefs appear important in predicting adjustment to chronic pain. The current study examines how cognitions and beliefs are related to psychosocial functioning. One hundred and sixty-three chronic pain out-patients were assessed. Regression analyses were performed using scores on the Pain Beliefs and Perceptions Inventory and the Inventory of Negative Thoughts in Response to Pain as predictor variables and responses to the West Haven Yale Multidimensional Pain Inventory as criterion variables. Pain cognitions and pain beliefs were correlated. After controlling for demographics, employment status and pain severity, pain beliefs and cognitions accounted for a significant amount of the variance in general activity, pain interference, and affective distress. Negative cognitions, particularly negative self-statements, were more predictive of outcome than pain beliefs. Although these data are correlational, they provide additional support for a biopsychosocial model of adjustment to chronic pain.

The effect of pain on memory for affective words.

Memory is a key cognitive variable in pain management, but lacks extensive research. This study is a replication and extension of Seltzer and Yarczower's investigation of pain's influence on memory for affective words, which found fewer positive words and more negative words recalled if subjects were in acute pain (versus no pain). In the present study, two experiments were conducted: one with a recall memory test and one with a recognition memory test. One hundred sixty undergraduate subjects were randomly placed in one of four groups: two groups had the same condition (pain or no pain) for both the encoding task and memory test, and two groups had mixed conditions (pain at encoding-no pain at memory test or no pain at encoding-pain at memory test). Pain was induced by 0 degrees-2 degrees C water immersion. At encoding, subjects categorized words by judging them as either positive or negative. Results of both experiments show that pain impairs memory. In neither experiment were differences found on memory for positive and negative words. These results do not support Seltzer and Yarczower's discriminative effects of pain on word category, but they are consistent with other research using acute pain manipulations and chronic pain populations, suggesting that pain interferes with memory. It is hypothesized that pain depletes scarce attentional resources, thereby interfering with concurrent cognitive tasks such as thinking, reasoning, and remembering.

Sexual misconduct in psychotherapy: reactions to a consumer-oriented brochure.

Reactions of subjects to a brochure addressing the topic of sexual intimacy in psychotherapy was assessed. Fifty-four psychotherapy clients and 52 licensed psychologists responded favorably to the brochure, with the majority indicating that the brochure should be made available before therapy begins or during the first session. Potential clients (120 college students) read either the brochure on sexual misconduct or a control brochure containing general information about psychology. Subjects who read the sexual misconduct brochure showed increased ability to understand what is appropriate and inappropriate therapist behavior, see unwanted touch as nontherapeutic, regard a therapist talking a lot about his or her own sex life as inappropriate, view sex in the therapeutic relationship as inappropriate, and intend to behave assertively within the session if their therapist's behavior should make them feel uncomfortable. Subjects who read the control brochure showed no such changes.

Goals for coping with pain mitigate time distortion.

The cold pressor test was used to investigate the effect of specific versus nonspecific time-oriented goals on perception of time by a person experiencing pain. Headache pain has been shown to attenuate the retrospective estimates of time passage. In the present study, laboratory-induced (cold pressor) pain produced results congruent with those of a previous clinical report on headache. In addition, results indicated that giving a specific time goal for coping with pain minimized the time distortion. Time estimations of subjects in pain with a specified goal were found to be significantly longer (and more accurate) than time estimations of subjects who were in pain but not given a time-specific goal.

An "open-transformed scale" for correcting ceiling effects and enhancing retest reliability: the example of pain.

The use of closed scales (with anchors at each end) to measure pain was found to produce ceiling effects characterized by a deceleration of ratings toward the upper end of the scale. This was consistent with previous research. Apart from producing nonlinear functions, the closed scale also limited test-retest reliability because of subjects' tendencies to correct their distorted ratings in subsequent trials. However, an open-ended scale coupled with transformation of reported ratings into a decile scale virtually eliminated the ceiling effect, thus producing consistently linear functions and maximizing test-retest reliability. This finding may have implications for the measurement of other sensory and psychological phenomena, especially those in which the property evaluated varies in a continuous fashion.

Stimulation-produced analgesia and its cross-tolerance between dorsal and ventral PAG loci.

This study explored the development of tolerance to brain stimulation-produced analgesia in both dorsal and ventral periaqueductal gray (PAG) sites and the development of cross-tolerance between naloxone-reversible and non-reversible sites. Cross-tolerance was produced from non-naloxone-reversible sites to naloxone-reversible sites (NNR-NR) and from naloxone-reversible sites to non-naloxone-reversible sites (NR-NNR). The following conclusions can be drawn from the present study: (1) the descending pain inhibitory systems within the PAG do not operate in isolation of each other since cross-tolerance to chronic stimulation can be produced between systems; (2) the interaction between the two systems is apparently bi-directional in that cross-tolerance was produced from naloxone-reversible to non-reversible sites and vice versa; and (3) the interaction may be the result of a co-activation of opioid and non-opioid systems produced by electrical stimulation or by a co-utilization of a common neuronal substrate. It is speculated that serotonin is a neurotransmitter involved in the mechanism of convergence.

The relative efficacy of monopolar vs. bipolar electrodes in stimulation-produced analgesia.

Focal brain stimulation (FBS) of the periaqueductal gray (PAG) produces reliable antinociception. The use of different electrode configurations alters the distribution of excitation as well as the locus of cells being stimulated, making it difficult to compare results across laboratories. This study compared the analgesic properties of bipolar electrodes delivering biphasic current and monopolar electrodes delivering either a biphasic or a monophasic current to the ventral PAG. Naloxone reversibility of the analgesia was also tested. Results indicate that biphasic current with either monopolar or bipolar electrodes is more likely to elicit analgesia than monophasic current using monopolar electrodes. Naloxone reversed the analgesia produced by the monopolar/monophasic model, but only attenuated the monopolar/biphasic FBS and did not affect the analgesia produced by the bipolar/biphasic configuration. Biphasic current delivered through bipolar electrodes results in the sequential activation of different cell populations. Use of bipolar electrodes may widen the distribution of excitation beyond that of either monopolar configuration. Thus, a wider neural field of excitation may cause a bleedover of the field of stimulation into two systems (one opiate and one nonopiate).

Ability of periaqueductal gray subdivisions and adjacent loci to elicit analgesia and ability of naloxone to reverse analgesia.

This study is an investigation of the effects of stimulation of regions within and adjacent to the periaqueductal gray (PAG) matter. Eighty-five rats were implanted with 1 monopolar stimulating electrode into 1 of 5 loci. Potency of analgesia was evaluated by relative increases in tailflick latencies after brain stimulation, and threshold current intensity was used to elicit analgesia. The ability of naloxone to reverse the stimulation-induced analgesia was also evaluated. Results replicate the previous finding of differential naloxone reversibility of ventral vs. dorsal PAG sites, but they do not support a regional distinction in the potency of analgesia induced. The results suggest that dorsal PAG sites are involved in a separate nonopiate pain-inhibitory system, whereas ventral sites are involved in an opiate system. These systems, however, do not respect the cytoarchitectural boundaries of the PAG because sites adjacent to the PAG elicit similar effects with a corresponding dorsal-ventral distinction.

Cognitive behavioral treatment of chronic headache: group versus individual treatment format.

Two hypotheses were tested in this study: (1) that a short course of cognitive behavioral therapy (CBT) is effective in the treatment of chronic headache; and (2) that group CT is as effective as individually administered CBT. Twenty-two chronic headache sufferers were randomly assigned to one of three treatment conditions: group administered CBT, individually administered CBT, or no treatment (wait list) control. Wait list subjects ultimately received treatment identical to that offered to subjects in the group treatment condition. Treatment outcome measures included the Brief Symptom Inventory, the McGill Pain Questionnaire, and several measures calculated from self-monitoring data. Tentative support was found for the hypothesis that CBT as provided in this study is effective in the treatment of chronic headache. There was no evidence that group versus individually treated subjects differed significantly on any of the measures used, although the small N and large variance among subjects limit us to preliminary conclusions for our findings. Clinical implications and suggestions for future research are discussed.

Opiate and serotonergic mechanisms of stimulation-produced analgesia within the periaqueductal gray.

These studies investigated the distribution of analgesia-producing sites within the periaqueductal gray (PAG), and their potential reversal by naloxone and methysergide. The PAG is not differentiable in its ability to elicit stimulation-produced analgesia (SPA) until the point of stimulation is caudal to the dorsal raphe nucleus, where analgesia was not obtained. Naloxone, however, was found to have a differential effect at specific loci, significantly reducing SPA from ventral but not dorsal sites. In contrast, methysergide was effective in reversing analgesia both at ventral and dorsal sites. The site of stimulation was critical to whether motor effects were elicited: Motor effects accompanied by analgesia were most often produced rostrally, while motor effects without analgesia were most frequently produced in the middle PAG. Null effects for both motor activity and analgesia were obtained from caudal PAG sites.

Focal brain stimulation attenuates morphine withdrawal behaviors.

Male albino rats were stereotaxically implanted with a bipolar stimulating electrode in the periaqueductal gray and also received a subcutaneous surgical implantation of a 72-mg morphine or a placebo pellet. Seventy-two hours following pellet implantation, naloxone-precipitated withdrawal was induced. Opiate withdrawal behaviors were observed and quantified. Animals then received focal brain stimulation for 30 min after which they were again observed for opiate withdrawal behaviors. The data suggest that focal brain stimulation attenuates morphine withdrawal behaviors, specifically the recessive behaviors associated with autonomic changes. These findings are consistent with those of other studies, from which it is speculated that more than one system is involved in the mediation of opioid dependence and analgesia.

Adrenalectomy attenuates stimulation-produced analgesia.

Ablation of the adrenal glands potentiates analgesia induced by morphine and attenuates an opioid form of stress-induced analgesia. the adrenal cortex has been implicated in analgesia induced by morphine and enkephalin-like peptides in the adrenal medulla have been suggested to modulate stress-induced analgesia. The effect of adrenalectomy upon analgesia produced by stimulation of the brain has not been investigated. The present investigations demonstrated that antinociception (measured with the tail-flick test) from focal stimulation of the periaqueductal grey was attenuated or abolished after adrenal ablation. These results implicate adrenal hormones in the regulation of the endogenous pain inhibitory system in the brain.

Locus of control and effects of perceptual tasks on heart rate.

The hypothesis was tested that the relationship found in prior research between heart rate changes produced in biofeedback settings and locus of control scores derives from the heart-brain relationship described by the Laceys in 1967, as well as from "expectancies for control." 48 subjects were tested on two perceptual tasks known to elicit changes in heart rate. Significant heart rate changes were observed in response to both tasks, but those changes did not correlate with locus of control as measured by scores on the Rotter I-E Scale and the Multidimensional Health Locus of Control Scale. Explanations for these results are offered.

Effects of stress on methyltransferase synthesis: an important DNA repair enzyme.

The enhancement of tumor development following acute stress has been demonstrated in some animal studies. This study was designed to explore mechanisms that would account in part for the relationship between stress and tumor development at the level of DNA repair, using a rat model. Forty-four rats were given the carcinogen dimethylnitrosamine in their drinking water, and half were randomly assigned to a rotational stress condition. The levels of methyltransferase, a DNA repair enzyme induced in response to carcinogen damage, were significantly lower in spleens from the stressed animals. These data suggest that stress may impair DNA repair.

Opiate withdrawal behavior after focal brain stimulation.

Electrical stimulation of the brainstem abolishes pain, while continued stimulation induces tolerance to the analgesic effect. Analgesic drugs producing tolerance also induce physical dependence, suggesting that the phenomenon of tolerance is associated with addiction. There is evidence that the neural mechanism for stimulation-produced analgesia is related to the release of opiate substances within the brain. We therefore propose that repeated or protracted brain stimulation elicits dependence upon the endorphins released by electrical stimulation of the neurons themselves. To investigate this possibility, rats were given repetitive bursts of analgesic electrical brain stimulation for two hours. Immediately thereafter, they were injected with the opiate antagonist, naloxone. Behaviors associated with low grade opiate withdrawal were observed. These data suggest that prolonged analgesic stimulation can result in naloxone-precipitated behaviors similar to the behaviors exhibited during opiate withdrawal.

Marketing therapeutic recreation services.

The use of marketing strategies can enhance the delivery of therapeutic recreation services. This article discusses how agencies can adapt marketing techniques and use them to identify potential markets, improve image, evaluate external pressures, and maximize internal strengths. Four variables that can be controlled and manipulated in a proposed marketing plan are product, price, place and promotion.