Help overcoming pain early, a brief person-centred intervention for adolescents with chronic pain in a school setting, may improve symptoms of insomnia.

Introduction and aims: Chronic pain and symptoms of insomnia affect large numbers of adolescents and early interventions are prioritized. The aim of the current study was to evaluate potential secondary effects of the intervention, Help Overcoming Pain Early (HOPE), on symptoms of insomnia and self-rated health. Methods: The study included non-randomized aggregated data from the active and control conditions in a previously conducted randomized controlled trial evaluating the efficacy of HOPE, after the participants in the control condition also had received the intervention. Symptoms of insomnia were assessed with the Minimal Insomnia Symptom Scale and self-rated health was assessed with one item, at the start of the intervention, post intervention, and at a six-month follow-up. Baseline variables included age, gender, pain localization, pain impact, school absence and symptoms of depression (assessed with the Center for Epidemiological Studies Depression Scale for Children). Inferential analyzes were performed using Linear Mixed Models (LMM). Effect sizes were evaluated by calculating Cohen's d. Results: There were statistically significant improvements in symptoms of insomnia at the six-month follow-up, and statistically significant improvements in self-rated health at the end of the intervention and at the six-month follow-up. Effect sizes were small across outcomes and assessments. Discussion and conclusion: Results illustrated significant but small improvements in symptoms of insomnia and self-rated health in adolescents with chronic pain following the HOPE intervention. Although caution is needed when assessing the findings, results illustrate the potential utility of an accessible brief early intervention in a school context.

Pain acceptance and psychological inflexibility predict pain interference outcomes for persons with chronic pain receiving pain psychology.

OBJECTIVES: Awareness (being present), acceptance, and engagement (committed action) are three dimensions of psychological flexibility. Understanding these in the context of chronic pain may identify treatment targets to help refine individual treatment. Our objective was to test the predictive capacity of three dimensions within the psychological flexibility model on the longitudinal trajectory of pain interference. METHODS: Patients receiving pain psychology treatment at a pain management center participated in this pragmatic clinical longitudinal study (n=86 with at least three assessments; Mean age=51 years; Gender=60 females, 26 males). Measures included the Five Facet Mindfulness Questionnaire (FFMQ-SF); Chronic Pain Acceptance Questionnaire (CPAQ-8); Psychological Inflexibility in Pain Scale (PIPS-12); and Committed Action Questionnaire (CAQ-8). The dependent variable was the Patient Reported Outcomes Information System (PROMIS) Pain Interference (PI). We used latent growth modelling to analyze scores assessed within 180 days of patient care. RESULTS: Psychological inflexibility (PIPS-12) and pain acceptance (CPAQ-8) measured at baseline predicted PI outcomes (n=86). PIPS-12 showed a direct relationship with pain interference (PI), where higher PIPS-12 scores predicted significantly higher PI mean scores on average across the study period (ρ=0.422, r2=0.382) but also predicted significantly greater decreases in PI across time (ρ=-0.489, r2=0.123). Higher CPAQ-8 scores predicted significantly lower PI mean scores on average across the study period (ρ=-0.478, r2=0.453) but also significantly smaller decreases in PI across time (ρ=0.495, r2=0.076). Awareness (FFMQ-SF) and engagement (CAQ-8) were not predictive of PI outcomes. CONCLUSIONS: Patients who entered pain psychology treatment with lower pain acceptance and higher psychological inflexibility showed the largest reductions in pain interference across time. These results contribute towards a novel prognostic understanding of the predictive roles of an enhancing dimension and limiting dimension of psychological flexibility.

Baseline Pro-Inflammatory Cytokine Levels Moderate Psychological Inflexibility in Behavioral Treatment for Chronic Pain.

Background: The medical and scientific communities struggle to understand chronic pain and find effective treatments. Multimodal approaches are encouraging but show significant individual differences. Methods: Seventy-eight persons (56 women) with chronic pain received Acceptance and Commitment Therapy and provided blood samples before and after treatment. The participants completed surveys with the blood sampling. Blood plasma was analyzed for IL-6 and TNF-α levels with the Olink Inflammation Panel (Olink Bioscience Uppsala, Sweden). The treatment effects and moderating effects of low-grade inflammation on changes in outcomes were analyzed using linear mixed models. Results: Pain interference (p < 0.001) and psychological inflexibility (p < 0.001) improved significantly during treatment, but pain intensity did not (p = 0.078). Cytokine levels did not change over the course of the treatment (IL-6/TNF-α p = 0.086/0.672). Mean baseline levels of IL-6 and TNF-α moderated improvement in psychological inflexibility during the course of treatment (p = 0.044), but cytokine levels did not moderate changes in pain interference (p = 0.205) or pain intensity (p = 0.536). Conclusions: Higher baseline inflammation levels were related to less improvement in psychological inflexibility. Low-grade inflammation may be one factor underlying the variability in behavioral treatment in chronic pain.

Evaluating the construct validity and internal consistency of the Sickness Questionnaire in a Swedish sample of adults with longstanding pain.

OBJECTIVES: Low-grade inflammation is a possible contributing factor in the development and persistence of chronic primary pain syndromes. Related to inflammatory activity is sickness behavior, a set of behavioral responses including increased pain sensitivity, fatigue, malaise, fever, loss of appetite, as well as depressive behavior and anhedonia. To capture these behavioral responses and their relation to longstanding pain, psychometrically sound self-report questionnaires are needed. The Sickness Questionnaire (SicknessQ) was developed to assess self-reported sickness behavior based on studies on acute immune activation while maintaining relevance for persistent conditions. The aim of the current study was to evaluate aspects of the validity and reliability of the SicknessQ in a Swedish sample of persons with longstanding pain. METHODS: Aspects of construct validity were evaluated by means of performing a confirmatory factor analysis (CFA) (testing structural validity) and by relevant hypothesis testing i.e., that ratings of sickness behavior in combination with other related factors (e.g., depression and anxiety) would be significantly related to ratings of avoidance. Reliability was evaluated by means of analyzing the internal consistency of items. RESULTS: Following the CFA, a non-significant Chi-Square test (χ2 [32, N=190] = 42.95, p=0.094) indicated perfect model fit. Also, the relative fit indices supported adequate model fit (CFI = 0.978; TLI = 0.969; RMSEA = 0.0430). Sickness behavior (p<0.0001), depression (p<0.05) and pain duration (p<0.05) significantly contributed to the regression model, explaining 45% of the total variance in avoidance. Internal consistency was adequate, as indicated by a Cronbach's α value of 0.82 for the entire questionnaire. CONCLUSIONS: Results indicate that the SicknessQ has adequate structural validity as well as adequate internal consistency, and is significantly associated with avoidance. The SicknessQ appears to have utility as a self-report questionnaire to assess symptoms of sickness behavior for adults with longstanding pain.

Psychological Flexibility and Its Relationship to Distress and Work Engagement Among Intensive Care Medical Staff.

Intensive care settings place specific work-related demands on health care professionals that may elicit stress and negatively influence occupational health and work engagement. Psychological flexibility has emerged as a promising construct that could help explain variation in reported health. Understanding the role of psychological flexibility in occupational psychological health among intensive care medical staff may potentially guide the development of effective interventions. Thus, the present study evaluated the relationships between psychological flexibility (Work-related Acceptance and Action Questionnaire), distress (Perceived Stress Scale, General Health Questionnaire) and work engagement (Utrecht Work Engagement Scale) in a sample of 144 health care professionals from one adult (ICU, N = 98) and one pediatric (PICU, N = 46) intensive care unit. In addition to cross-sectional analyses, a subset of data (PICU, N = 46) was analyzed using a longitudinal design. Results illustrated that higher levels of distress were associated with lower levels of work engagement. Furthermore, psychological flexibility was related to greater work engagement, and psychological flexibility had a significant indirect effect on the relationship between distress and work engagement. Lastly, increased psychological flexibility over time corresponded with increased work engagement. Although tentative, the results suggest the importance of psychological flexibility for work engagement in health care professionals within intensive care settings.

Effects of a person-centred approach in a school setting for adolescents with chronic pain-The HOPE randomized controlled trial.

BACKGROUND: Chronic pain among adolescents is common but effective interventions applicable in a school setting are rare. Person-centred care (PCC) is a key factor in improving health by engaging persons as partners in their own care. METHODS: In this randomized controlled trial, a total of 98 adolescents in secondary school or upper secondary school (aged 14 - 21 years) with chronic pain were randomly assigned to a PCC intervention or standard school healthcare. In the intervention group a pain management programme, based on a PCC approach, comprising four face-to-face sessions with a school nurse over a period of 5 weeks was added to standard school healthcare. The main outcome measure was self-efficacy in daily activities (SEDA scale) and rating scales for pain intensity and pain impact were used as secondary outcome measures. RESULTS: At the follow-up, no significant differences were found between the groups in the SEDA scale (p = .608) or in the rating scales for pain intensity (p = .261) and pain impact (p = .836). In the sub-group analysis, a significant improvement in the SEDA scale was detected at the secondary school in favour of the PCC intervention group (p = .021). CONCLUSION: In this pain management programme based on a PCC approach, we found no effect in the total sample, but the programme showed promising results to improve self-efficacy in daily activities among adolescents at secondary school. SIGNIFICANCE: This study evaluates the effects of a pain management programme based on a PCC approach in a school setting addressing adolescents at upper secondary and secondary schools with chronic pain. No overall effects were shown, but results illustrate that the intervention improved self-efficacy in adolescents at secondary school. Implementation of a PCC approach in a school setting may have the potential to improve self-efficacy in daily activities for adolescents with chronic pain at secondary school.

Fear of Movement Is Related to Low Back Disability During a Two-Year Period in Patients Who Have Undergone Elective Lumbar Spine Surgery.

OBJECTIVE: To evaluate change in fear of movement and the relationship of fear of movement and pain intensity to low back disability and general health-related quality of life over a 2-year period. METHODS: Consecutive patients scheduled for lumbar spine surgery were included. In addition to clinical background variables, back pain intensity, fear of movement, low back disability, and general health-related quality of life were assessed at baseline, 1 year, and 2 years after surgery. Linear mixed-effects models were used to analyze data. RESULTS: In total, 348 patients were included in the final analyses. There was a significant reduction in fear of movement and a significant interaction between fear of movement and low back disability across assessments, showing that greater levels of fear of movement were related to greater levels of disability over the 2-year period. Similarly, greater levels of back pain intensity were related to lower levels of general health-related quality of life during this period. CONCLUSIONS: We found that greater levels of fear of movement were related to greater levels of low back disability, following lumbar spine surgery, in a longitudinal study. This shows the need to address fear of movement in prehabilitation/rehabilitation pre- or postsurgically to improve health outcomes for patients who undergo lumbar spine surgery.

Evaluation of a Novel Psychological Intervention Tailored for Patients With Early Cognitive Impairment (PIPCI): Study Protocol of a Randomized Controlled Trial.

BACKGROUND: Individuals with early phase cognitive impairment are frequently affected by existential distress, social avoidance and associated health issues (including symptoms of stress, anxiety, and depression). The demand for efficient psychological support is crucial from both an individual and a societal perspective. We have developed a novel psychological intervention (Psychological Intervention tailored for Patients with Cognitive Impairment, PIPCI) manual for providing a non-medical path to enhanced psychological health in the cognitively impaired population. The current article provides specific information on the randomized controlled trial (RCT)-design and methods. The main hypothesis is that participants receiving PIPCI will increase their psychological flexibility (the ability to notice and accept interfering thoughts, emotions, and bodily sensations without acting on them, when this serves action in line with personal values) compared to participants in the active control (cognitive training) group and the waiting list control group. The secondary hypotheses are that participants receiving PIPCI will improve psychological health (stress measures, quality of life, depression, and general health) compared to participants in the active control group and the waiting list control group. MATERIALS AND METHODS: This three-arm RCT will recruit participants from the cognitive centers at Karolinska University Hospital in Stockholm and randomize approximately 120 individuals in the early phase of cognitive impairment to either an experimental group (psychological intervention once a week for 10 weeks), an active control group (cognitive training once a week for 10 weeks) or a waiting list control group. Intervention outcome will be evaluated with self-report questionnaires on physical and psychological aspects of health, cognitive assessment, biological markers (obtained from blood and saliva) and health care costs. Assessments will be performed at pre- (1 week before the interventions) and post-intervention (1 week after the interventions), as well as at a 6-month follow-up. DISCUSSION: The development of a potentially feasible and effective psychological intervention tailored for early phase cognitive impairment (PIPCI) has the potential to advance the non-pharmacological intervention field. This is especially important given the extensive burden for many affected individuals and their families and the current lack of effective treatments. If the psychological intervention discussed here shows feasibility and efficacy, there is potential for far-reaching healthcare implications for patients with early cognitive impairment at risk of developing dementia. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT04356924. Date of registration: April 22, 2020. URL: https://clinicaltrials.gov/ct2/show/NCT04356924.

Adolescent and Parent Experiences of Acceptance and Commitment Therapy for Pediatric Chronic Pain: An Interpretative Phenomenological Analysis.

Pediatric chronic pain is common and can be related to reduced functioning in many domains for the young person and their parents. Existing psychological treatments such as Acceptance and Commitment Therapy (ACT) have shown to be effective, but improvements are needed. Qualitative approaches can help improve our understanding of treatment processes and outcomes. The aim of the present qualitative interview study was to explore the lived experiences of young people and parents who had participated in ACT for pediatric chronic pain. Four young persons and four parents were interviewed, and data was analyzed using Interpretative Phenomenological Analysis (IPA). Three themes were generated, each comprising two subthemes: (1) 'Warning system', which included experiences from being offered this psychological intervention, and the alternative explanations provided for pain; (2) 'Change and challenges', which suggested the importance of the values-based work, and of individual adaptation; and (3) 'A common language' in which the interaction with others and new ways to communicate around the pain experience were described. Findings highlight the importance of pain education, formulating and acting in line with personal values, and communication around the pain experience, as well as the need for developmental and individual adaptations of interventions.

Factor structure and internal consistency of a Swedish version of the Pain Catastrophizing Scale.

BACKGROUND: Pain catastrophizing is highly relevant to assess in the context of long-standing pain. The Pain Catastrophizing Scale (PCS) is a well-established questionnaire used to measure catastrophizing in individuals with long-standing pain. So far, no Swedish translation has been evaluated in regard to validity and reliability. The aims of this study were to translate the PCS questionnaire from English to Swedish, and to investigate its construct validity (face, content, and structural validity) and reliability (internal consistency). METHODS: We translated the original English version of the PCS to Swedish and collected item responses from 194 persons suffering from primarily long-standing musculoskeletal pain. We used confirmatory factor analysis to evaluate structural validity, and tested the model fit of a one-factor model, an oblique two-factor model, and an oblique three-factor model. We evaluated the measure's reliability in regard to internal consistency calculated with Cronbach's alpha. RESULTS: A three-factor model comprising a four-item rumination factor, a three-item magnification factor, and a six-item helplessness factor provided the best fit to the data. Internal consistency was adequate and Cronbach's α was 0.92 for the entire scale, 0.84 for the rumination subscale; 0.69 for the magnification subscale, and 0.89 for the helplessness subscale. CONCLUSIONS: The results indicated adequacy of a three-factor solution and the questionnaire's internal consistency, and provide initial support for the structural validity and internal consistency of a Swedish version of the PCS. Future studies should replicate the study in larger samples and extend the current evaluation in regard to validity and reliability.

Evaluation of an Intensive Interdisciplinary Pain Treatment Based on Acceptance and Commitment Therapy for Adolescents With Chronic Pain and Their Parents: A Nonrandomized Clinical Trial.

Objective: Parental factors are central in the development and maintenance of chronic pain in youths. Only a handful of studies have investigated the impact of psychological treatments for pediatric chronic pain on parental factors, and the relationships between changes in parental and adolescent factors. In the current study, we evaluated the effects of an intensive interdisciplinary pain treatment (IIPT) program based on Acceptance and Commitment Therapy (ACT) for adolescents with chronic pain, on adolescent and parental variables, and the relationship between parental psychological flexibility and adolescent pain acceptance. Methods: Adolescents (N = 164) with chronic pain were included, with a mean age of 15.5 years, and completed the 3-week treatment with an accompanying parent (N = 164). Linear mixed-effects models were used to analyze change over time (from pretreatment to 3-month follow-up) on parent (depression, health-related quality of life and parent psychological flexibility) and adolescent (physical, social and emotional functioning, and adolescent pain acceptance) variables. Additionally, linear mixed-effects models were used to analyze the relationship between parent psychological flexibility and adolescent pain acceptance. Results: Results illustrated significant improvements over time in depressive symptoms and levels of psychological flexibility in parents. Excluding social development, adolescents improved significantly in all assessed aspects of functioning and pain acceptance. Additionally, changes in parent psychological flexibility were significantly associated with changes in adolescent pain acceptance. Conclusions: Results indicated that treatment had positive effects for parents and adolescents, and a significant positive relationship between changes in parent psychological flexibility and adolescent pain acceptance was found.

Low-grade inflammation may moderate the effect of behavioral treatment for chronic pain in adults.

The purpose of the present pilot study was to explore the moderating role of basal inflammation on the effects of behavioral pain treatment in 41 patients with long-standing pain. Baseline pro-inflammatory status moderated behavioral treatment outcomes: higher pre-treatment levels of Tumor Necrosis Factor (TNF)-α and Interleukin (IL)-6 were related to less improvement in pain intensity, psychological inflexibility and in mental health-related quality of life. The treatment outcomes improved in the subgroup that had low levels of pro-inflammatory cytokines at baseline, while the subjects with higher pro-inflammatory status did not. Altogether, results indicate that low-grade inflammation may influence the behavioral treatment outcomes and provide a possible explanation of the heterogeneity in treatment response.

Pain Interference Mediates the Relationship between Pain and Functioning in Pediatric Chronic Pain.

Pediatric chronic pain is a major health problem commonly associated with impaired functioning. There is a great need for more knowledge regarding the complex interplay between demographic variables such as age and gender, pain, and functioning in pediatric chronic pain. Objective: The objective of the study was to investigate if; (1) pediatric chronic pain patients with high and low levels of functioning differ in demographic variables, pain, and pain interference; (2) explore the mediating function of pain interference in the relationship between pain and functioning (i.e., depression and functional disability). Method: The study includes a consecutive sample of children and adolescents referred to a tertiary pain clinic due to chronic pain (n = 163). Cross-sectional data was analyzed to investigate the interrelationships between variables. Analyses of indirect effects were used to assess the impact of pain interference on the relation between pain and depression. Results: Findings illustrate high levels of depression, school absence and pain interference in this sample. Furthermore, pain interference mediated the relationship between pain and depression. Conclusion: Thus, this study adds to the growing support of findings suggesting that functioning and pain interference should be routinely assessed in pediatric chronic pain and a central target in treatment. Particularly, these findings imply a need for interventions specifically aimed at improved functioning for patients with chronic debilitating pain.

Exploring Changes in Valued Action in the Presence of Chronic Debilitating Pain in Acceptance and Commitment Therapy for Youth - A Single-Subject Design Study.

Objective: The objective of the study was to improve the understanding of processes of change in Acceptance and Commitment Therapy for youth with chronic debilitating pain by exploring the relation between individual change patterns in pain intensity and valued activities. Method: A single-subject design across three adolescents suffering from longstanding debilitating pain was utilized. Pain intensity and participation in valued activities were rated daily. Visual analysis of the graphed data was performed to evaluate the effects of the intervention, and the relationship between pain intensity and values-based activity. Results: The graphed data illustrated that pain levels did not decrease from the baseline period to the follow-up period. In contrast, compared to baseline ratings values oriented behaviors increased from the start of treatment to the follow-up period. Conclusion: Results illustrate that increases in values-based behavior may occur without corresponding decreases in pain, and warrant further research on change processes in ACT for youth suffering from chronic pain.

Evaluating the Statistical Properties of the Pain Interference Index in Children and Adolescents with Chronic Pain.

UNLABELLED: The high prevalence of chronic debilitating pain in pediatric populations calls for more knowledge regarding the impact of pain on functioning or pain interference. This in turn requires valid and reliable instruments to adequately assess the impact of pain on functioning. Also, adequate measures of pain interference are important in evaluations of behavioral interventions aimed at improving functioning. OBJECTIVE: The objectives of this study were to evaluate the statistical properties of the Pain Interference Index (PII), including the factor structure, internal consistency, and concurrent criteria validity of the instrument. METHOD: Data were collected from a consecutive sample of children and adolescents referred to a tertiary pain clinic due to chronic pain (n = 163). A principal component analysis was used to investigate the latent factor structure of items. The internal consistency was assessed by Cronbach's alpha. A set of hierarchical regression analyses was conducted to evaluate the ability of instruments to predict levels of depression and functional disability. RESULTS: Analyses indicated the adequacy of a 1-factor solution with a total of 6 items. The intercorrelation between items and the scale's reliability was satisfactory. Furthermore, bivariate correlations and hierarchical regression analyses illustrate the concurrent criteria validity of the instrument. CONCLUSION: Results support the use of PII as an adequate instrument to assess pain interference in children and adolescents with chronic pain.

Efficacy and Cost-effectiveness of Acceptance and Commitment Therapy and Applied Relaxation for Longstanding Pain: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: To date, few studies have compared Acceptance and Commitment Therapy (ACT) for longstanding pain with established treatments. Only 1 study has evaluated the cost-effectiveness of ACT. The aim of the current study was to evaluate the efficacy and cost-effectiveness of ACT and applied relaxation (AR) for adults with unspecific, longstanding pain. MATERIALS AND METHODS: On the basis of the inclusion criteria 60 consecutive patients received 12 weekly group sessions of ACT or AR. Data were collected pretreatment, midtreatment, and posttreatment, as well as at 3- and 6-month follow-up. Growth curve modeling was used to analyze treatment effects on pain disability, pain intensity, health-related quality of life (physical domain), anxiety, depression, and acceptance. RESULTS: Significant improvements were seen across conditions (pretreatment to follow-up assessment) on all outcome measures. Pain disability decreased significantly in ACT relative to AR from preassessment to postassessment. A corresponding decrease in pain disability was seen in AR between postassessment and 6-month follow-up. Pain acceptance increased only in ACT, and this effect was maintained at 6-month follow-up. Approximately 20% of the participants achieved clinically significant change after treatment. Health economic analyses showed that ACT was more cost-effective than AR at post and 3-month follow-up assessment, but not at 6-month follow-up. DISCUSSION: More studies investigating moderators and mediators of change are needed. The present study is one of few that have evaluated the cost-effectiveness of ACT and AR and compared ACT with an established behavioral intervention, and the results provide additional support for behavioral interventions for longstanding pain.

A case study: Acceptance and commitment therapy for pediatric sickle cell disease.

OBJECTIVE: Sickle cell disease (SCD) negatively impacts patients' functioning and quality of life. Acceptance and Commitment Therapy (ACT) promotes acceptance of difficult sensations, emotions, and thoughts when doing so facilitates living a values-based life. This study describes ACT for improving functioning and quality of life for an adolescent with SCD and his parents. METHODS: A 16-year old with SCD and his parents attended an eight-session ACT program. Process (adolescent psychological flexibility, parent acceptance) and outcome (adolescent social anxiety, pain, functioning, quality of life; parent distress) measures were conducted prior to and following treatment and at 3-month follow-up. RESULTS AND CONCLUSIONS: Improvements were evident, especially at follow-up. Process measures suggest adolescent psychological flexibility and parent acceptance might explain positive effects. Anecdotal comments support these findings and provide additional evidence that ACT might effectively promote functioning and quality of life in adolescents with chronic diseases.