Prospective Comparison of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and MMPI-2-Restructured Form (MMPI-2-RF) in Predicting Treatment Outcomes Among Patients with Chronic Low Back Pain.

The purpose of the current study was to examine the relative utility of the most updated MMPI adult instrument, the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF), which was designed to address psychometric limitations of the MMPI-2. To this end, we compared mean scores and correlates of emotional distress treatment outcomes using the Depression Anxiety Stress Scales in a sample of 230 patients (73 males, 157 females) who had completed an interdisciplinary chronic pain rehabilitation program. Structural equation modeling analyses indicated that higher scale scores from all the MMPI-2-RF substantive domains were meaningfully associated with worse emotional distress outcomes, whereas the MMPI-2 Clinical Scales generally did not have any meaningful associations. Similar results were found in additional analyses using a clinically significant change framework with more direct clinical implications. The results of this study provide preliminary support for the use of the MMPI-2-RF among patients with chronic low back pain.

Pain Psychology: A Global Needs Assessment and National Call to Action.

OBJECTIVE: The Institute of Medicine and the draft National Pain Strategy recently called for better training for health care clinicians. This was the first high-level needs assessment for pain psychology services and resources in the United States. DESIGN: Prospective, observational, cross-sectional. METHODS: Brief surveys were administered online to six stakeholder groups (psychologists/therapists, individuals with chronic pain, pain physicians, primary care physicians/physician assistants, nurse practitioners, and the directors of graduate and postgraduate psychology training programs). RESULTS: 1,991 responses were received. Results revealed low confidence and low perceived competency to address physical pain among psychologists/therapists, and high levels of interest and need for pain education. We found broad support for pain psychology across stakeholder groups, and global support for a national initiative to increase pain training and competency in U.S. therapists. Among directors of graduate and postgraduate psychology training programs, we found unanimous interest for a no-cost pain psychology curriculum that could be integrated into existing programs. Primary barriers to pain psychology include lack of a system to identify qualified therapists, paucity of therapists with pain training, limited awareness of the psychological treatment modality, and poor insurance coverage. CONCLUSIONS: This report calls for transformation within psychology predoctoral and postdoctoral education and training and psychology continuing education to include and emphasize pain and pain management. A system for certification is needed to facilitate quality control and appropriate reimbursement. There is a need for systems to facilitate identification and access to practicing psychologists and therapists skilled in the treatment of pain.

Retrospective outcome analyses for headaches in a pain rehabilitation interdisciplinary program.

BACKGROUND: Incapacitating chronic migraine and other severe headaches can have significant impact on peoples' lives, including family and occupational functioning. Although a number of reports have investigated the prevalence and medical treatment of chronic headache, few have reported on the efficacy of treating these disorders within a comprehensive, intensive chronic pain rehabilitation program (CPRP), instead of a headache-specific program. CPRPs provide treatment of headache by focusing not only on physical pain, but also its association with impaired mood and function. METHODS: We examined the efficacy of CPRP in patients with chronic headache via a retrospective analysis of 123 patients (76.4% female), ages 21 to 85, who completed the CPRP at the Cleveland Clinic between January 2007 and December 2011, and were diagnosed using International Classification of Headache Disorders, 2nd edition and International Classification of Headache Disorders, 2nd edition revision, with migraine or headache as a major complaint. Outcome measures included: pain intensity scores present at the moment of questioning where 10 is the maximal (0-10/10), Depression Anxiety Stress Scale (DASS) scores, (measuring mood), and Pain Disability Index scores (measuring function). Repeated measures t-tests were used. RESULTS: Average pain score on admission was 6.4, and 3.4 upon discharge. Average function on admission was moderately impaired, and normalized on discharge. The average depression score was in the moderate range, and had normalized on discharge. The average anxiety score on admission was in the severe range and was in the mild range on discharge. CONCLUSIONS: Results indicate that individuals had statistically and clinically meaningful improvement in pain, mood, and function. Data suggest that an interdisciplinary CPRP approach for patients diagnosed with headache can be effective in helping to decrease pain, as well as normalize mood and function. Thus, CPRPs serve as an alternative treatment to multidisciplinary headache programs, interventional pain techniques, and primary care standard headache care.

Variability in the relationship between sleep and pain in patients undergoing interdisciplinary rehabilitation for chronic pain.

OBJECTIVE: Chronic pain and sleep disturbance frequently coexist and often complicate the course of treatment. Despite the well-established comorbidity, there are no studies that have investigated concurrent changes in sleep and pain among patients participating in an interdisciplinary chronic pain rehabilitation program (ICPRP). The goal of this study was to investigate the daily changes in sleep and pain among patients participating in an ICPRP. METHODS: Multilevel modeling techniques were used to evaluate the daily changes in total sleep time (TST) and pain among a sample of 50 patients with chronic noncancer pain participating in the ICPRP. RESULTS: Increases in TST were predictive of less pain the following treatment day, although daily pain ratings were not predictive of that night's TST. Time in treatment was a significant predictor of both TST and pain reduction, even while controlling for age, gender, anxiety, and depression. Additional analyses revealed significant individual variability in the relationship between TST and next day pain. Individuals with stronger associations between previous night's TST and next day pain were found to experience the greatest treatment benefits overall, in terms of pain reduction and TST. CONCLUSIONS: Our results provide compelling support for individual variability of the pain-sleep relationship in patients with intractable pain conditions participating in an ICPRP. Importantly, these findings suggest that when pain and sleep are comorbid, both must be addressed to reap the maximum response to treatment programs such as an ICPRP. PERSPECTIVE STATEMENT: This study demonstrates the utility of treating sleep problems in patients participating in an interdisciplinary chronic pain rehabilitation program. Results highlight the benefits of accounting for individual variability in the pain-sleep relationship in a clinical setting and targeting sleep interventions for those individuals whose pain and sleep problems are comorbid.

Opioid use 12 months following interdisciplinary pain rehabilitation with weaning.

OBJECTIVES: To examine the frequency of and factors predicting opioid resumption among patients with chronic non-cancer pain (CNCP) and therapeutic opioid addiction (TOA) treated in an interdisciplinary chronic pain rehabilitation program (CPRP) incorporating opioid weaning. DESIGN: Longitudinal retrospective treatment outcome study. Only those with addiction were counseled to avoid opioids for non-acute pain. SETTING: Large academic medical center. PARTICIPANTS: One hundred twenty patients, 32.5% with TOA. Participants were predominately married (77.5%), females (66.7%). Mean age was 49.5 (±13.7). 29.2% had lifetime histories of non-opioid substance use disorders. METHODS: TOA was diagnosed using consensus definitions developed by American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine to supplement Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) criteria. Non-opioid substance use disorders were diagnosed using DSM-IV-TR. Data, including pain severity, depression and anxiety, were collected at admission, discharge and 12 months. Opioid use during treatment was based on medical records and use at 12 months was based on self-report. RESULTS: Only 22.5% reported resuming use at 12 months. Neither patients with TOA nor patients with non-opioid substance use disorders were more likely to resume use than those without substance use disorders. Only posttreatment depression increased the probability of resumption. CONCLUSIONS: CNCP and co-occurring TOA can be successfully treated within a CPRP. Patients report low rates of resumption regardless of addiction status. This is in marked contrast to reported outcomes of non-medically induced opioid addictions. Prolonged abstinence may depend upon the successful treatment of depression.

The role of exercise and types of exercise in the rehabilitation of chronic pain: specific or nonspecific benefits.

Chronic pain is one of the most common complaints seen in general practitioners' offices, and it contributes to social, emotional, physical, and economical losses. The management of this problem poses challenges for health care providers when the current treatment of choice for chronic pain is pharmacological management, which may not be a sufficient and/or holistic approach to the management of chronic pain. Our goal is to increase awareness of the significance of physical activity, as well as examine additional cost-effective, integrated approaches to help manage the complex and debilitating effects of this condition. This article summarizes the types of exercise in the rehabilitation of chronic pain patients and provides practical recommendations for the clinician based on empirical and clinical experience. This safe, cost-free, nonpharmacologic way of managing pain has been found to reduce anxiety and depression, improve physical capacity, increase functioning and independence, and reduce morbidity and mortality.

Effect of pre-operative opioid exposure on surgical outcomes in elective laparoscopic cholecystectomy.

BACKGROUND: The effects of varying levels of pre-operative opioids on post-operative outcomes following elective laparoscopic cholecystectomy is largely unknown. METHODS: Patients who underwent elective laparoscopic cholecystectomy from 2012 to 2019 were reviewed and categorized by the number of outpatient opioid prescriptions received in the 90 days preceding surgery: none (Naïve), one (1 Rx), two (2 Rx), or three or more (Chronic). Operative time, hospital length of stay, and 30-day readmission rate were analyzed. RESULTS: Of the 11911 patients identified, 2958 (24.8%) used opioids pre-operatively. Among patients with an overnight admission, the Naïve, 1 Rx, and 2 Rx cohorts had a shorter length of stay compared to the Chronic cohort. The Naïve group had the lowest 30-day readmission rate (5.0%) followed by the 1 Rx (5.9%), 2 Rx and Chronic groups (9.1% and 8.7%, respectively) (p < 0.001). CONCLUSIONS: Prevalence of pre-operative opioid use is high and warrants surgeon assessment to minimize adverse post-operative outcomes.

Immediate benefits of a brief 10-minute exercise protocol in a chronic pain population: a pilot study.

OBJECTIVE: Determining the acute effects of a brief, 10-minute exercise protocol on pain, mood, and perceived exertion. PATIENTS: Twenty-eight subjects who were admitted to the Cleveland Clinic Chronic Pain Rehabilitation Program (CPRP), and who were capable of completing an experimenter-designed and controlled treadmill protocol were included in this pilot study. METHODS: A within-group repeated measure analysis was used to compare 28 subjects admitted to the Cleveland Clinic CPRP. Measures of heart rate were obtained using the Nellcor Oximax, pulse oximeter; measures of mood and pain were obtained using a 0-10 Likert scale, and perceived exertion measured with a visual analog scale. Each measure was taken pre- and post-10-minute exercise protocol. RESULTS: The brief exercise protocol was associated with self-report of immediate antidepressant and anxiolytic effects. Additionally, after the 3-week CPRP, self-reports in perceived exertion decreased. Brief exercise was not found to have an acute analgesic effect. CONCLUSION: This preliminary research revealed a temporal association of improvement in self-rated anxiety and depression, following a brief exercise protocol, and over the course of 3 weeks leads to decreased perceived exertion. Therefore suggesting that brief exercise is a safe, nonpharmacologic strategy for immediately improving mood, and has further implications for mortality risk.

The Impact of Preoperative Chronic Opioid Therapy in Patients Undergoing Decompression Laminectomy of the Lumbar Spine.

STUDY DESIGN: Retrospective review of electronic medical records (EMR). OBJECTIVE: This study aims to (1) characterize the pattern of opioid utilization in patients undergoing spine surgery and (2) compare the postoperative course between patients with and without chronic preoperative opioid prescriptions. SUMMARY OF BACKGROUND DATA: Postoperative pain management for patients with a history of opioid usage remains a challenge for spine surgeons. Opioids are controversial in this setting due to side effects and potential for abuse and addiction. Given the increasing rate of opioid prescriptions for spine-related pain, more studies are needed to evaluate patterns and risks of preoperative opioid usage in surgical patients. METHODS: EMR were reviewed for patients (age > 18) with lumbar spinal stenosis undergoing lumbar laminectomy in 2011 at our institution. Data regarding patient demographics, levels operated, pre/postoperative medications, and in-hospital length of stay were collected. Primary outcomes were length of stay and duration of postoperative opioid usage. RESULTS: One hundred patients were reviewed. Fifty-five patients had a chronic opioid prescription documented at least 3 months before surgery. Forty-five patients were not on chronic opioid therapy preoperatively. The preoperative opioid group compared with the non-opioid group had a greater proportion of females (53% vs. 40%), younger mean age (63 yrs vs. 65 yrs), higher frequency of preoperative benzodiazepine prescription (20% vs. 11%), longer average in-hospital length of stay (3.7 d vs. 3.2 d), and longer duration on postoperative opioids (211 d vs. 79 d). CONCLUSION: Patients on chronic opioids prior to spine surgery are more likely to have a longer hospital stay and continue on opioids for a longer time after surgery, compared with patients not on chronic opioid therapy. Spine surgeons and pain specialists should seek to identify patients on chronic opioids before surgery and evaluate strategies to optimize pain management in the pre- and postoperative course. LEVEL OF EVIDENCE: 3.

Prevalence of posttraumatic stress disorder (PTSD) in patients with an incisional hernia.

BACKGROUND: We investigate the prevalence of PTSD in patients with an incisional hernia presenting for evaluation at our institution. METHODS: Study patients were screened for PTSD using the PCL-5 checklist for DSM-5. Patient-reported quality of life and pain scores were assessed using validated tools (HerQLes and PROMIS Pain Intensity 3a survey). RESULTS: The prevalence of PTSD in 131 patients was 32.1% [95% CI 24%-40%]. Patients screening positive (PTSD+) reported lower quality of life scores on HerQles (17.3 ± 14.3 vs. 47.7 ± 29.6, P < 0.001), and higher pain scores on the PROMIS scale (54.2 ± 9.1 vs. 44.2 ± 10, p < 0.001). PTSD + patients also reported significantly higher numbers of previous hernia repairs and abdominal operations, as well as a higher rate of a history of an open abdomen. CONCLUSION: Our study found a significant prevalence of positive screening for PTSD in patients seeking consultation regarding an incisional hernia. We have begun routine preoperative evaluations by a behavioral medicine specialist to address some of these complex issues in high-risk patients. Other high volume hernia programs caring for this challenging patient population should consider such assessments.

Sustained improvements in pain, mood, function and opioid use post interdisciplinary pain rehabilitation in patients weaned from high and low dose chronic opioid therapy.

Increased prescribing of opioids for chronic noncancer pain is associated with significant social costs, including overdose and addiction. In this context, there is interest in interdisciplinary chronic pain rehabilitation programs focusing on self-management and minimizing opioid use. This study examined outcomes of patients weaned from opioids in an ICPRP from 2007 to 2012. Participants included 413 patients on high dose chronic opioid therapy (COT; >100 mg), 528 on low dose COT, and 516 not on opioids (NO). Outcomes were assessed at discharge, 6, and 12 months posttreatment through self-report and chart review. One thousand one hundred ninety-four participants completed treatment (81.95%); 86.74% of those on opioids were weaned. High doses were less likely to complete (78.45%) than NO participants (85.27%; P < 0.05). Results showed immediate (P < 0.01) and sustained improvements (P < 0.05) in pain severity, depression, anxiety, and functional impairment with no group differences. Effect sizes ranged from medium to large (Cohen d values 0.57-1.96). Longitudinal medication use data were available for 319 no dose and 417 weaned participants; opioid resumption rates were 10.51% and 30.70% respectively. There were no differences in resumption between the high dose and low dose groups. Logistic regression analyses determined that opioid dose predicted neither treatment completion nor opioid resumption. Anxiety predicted completion, and functional impairment predicted opioid resumption within 1 year of discharge. Results suggest that patients on COT can be successfully weaned with long-term benefits in pain, mood, and function. Targeting anxiety and functional restoration may increase success rates.

A multilevel path model analysis of the relations between sleep, pain, and pain catastrophizing in chronic pain rehabilitation patients.

BACKGROUND AND AIM: Pain catastrophizing is linked to heightened pain and poorer coping among individuals with chronic pain, yet little is known about how pain catastrophizing associates with sleep and pain over the course of treatment for chronic pain. Previous research employing a cross-sectional design suggests that sleep mediates the association between pain catstrophizing and pain, but there have been no longitudinal studies examining the directionality of these associations. Thus, the aim of this study was to test two competing theoretical models. The first model specified that pain catastrophizing leads to increased pain via poor sleep. The second model specified that poor sleep leads to increased pain catastrophizing via increased pain. METHODS: This study examined the relations between pain catastrophizing, sleep, and pain among 50 consecutive patients (36 female, 14 male) ages 20-80 (M=45.96, SD=13.94) with chronic, non-malignant pain who were admitted to the Cleveland Clinic, Chronic Pain Rehabilitation Programme (CPRP). The CPRP, within the Neurological Centre for Restoration, Neurologic Institute at the Cleveland Clinic, is a comprehensive, interdisciplinary programme designed to treat patients with disabling chronic pain. As part of their daily, morning update with their case manager, patients completed self-report ratings of their previous night's sleep time (TST), and their current pain, anxiety, and depression. Pain catastrophizing was assessed at admission and discharge. RESULTS: Over the course of treatment, daily TST increased from approximately 5h and 20min per night to nearly 6h and 30min per night, and average daily pain, daily depression, and daily anxiety decreased over the course of treatment. As the data in this study has a multilevel structure, with daily reports nested with in patients, we conducted multilevel path models to examine the longitudinal relations between pain catastrophizing, sleep, and pain. Multilevel path analysis permits the analysis of interdependent data without violating the assumptions of standard multiple regression. Models were conducted for pain catastrophizing and each of its subscales: rumination, magnification and helplessness. The findings were uniform across the composite pain catastrophizing scale and its subscales. There was an indirect path from sleep to pain catastrophizing (post-treatment) via pain, but not from pain catastrophizing (pre-treatment) to pain via sleep. There were also direct effects of sleep on pain and from pain to pain catastrophizing (post-treatment). Additionally, decreases in pain over the course of treatment were related to lower pain catastrophizing post-treatment. CONCLUSION AND IMPLICATIONS: These results call into question previous evidence that pain catastrophizing indirectly affects pain by way of its impact on sleep. Rather, our findings suggest that pain mediates the relationship between sleep and levels of pain catastrophizing. These results therefore underscore importance and value in collecting longitudinal data and potential influence on the conclusions gained with regards to sleep, pain and psychological variables. These findings may be of clinical importance when tailoring interventions for individuals with chronic pain and perhaps even more so for those with comorbid pain and sleep disturbance; prioritizing the treatment of sleep difficulties could result in improvements to pain-related outcomes.

The Impact of Preoperative Depression and Health State on Quality-of-Life Outcomes after Anterior Cervical Diskectomy and Fusion.

Study Design Retrospective cohort study. Objective We sought to assess the predictive value of preoperative depression and health state on 1-year quality-of-life outcomes after anterior cervical diskectomy and fusion (ACDF). Methods We analyzed 106 patients who underwent ACDF. All patients had either bilateral or unilateral cervical radiculopathy. Preoperative and 1-year postoperative health outcomes were assessed based on the visual analog scale, Pain Disability Questionnaire (PDQ), Patient Health Questionnaire (PHQ-9), and EuroQol-5 Dimensions (EQ-5D) questionnaire. Univariable and multivariate regression analyses were performed to assess for preoperative predictors of 1-year change in health status according to the EQ-5D. Results Compared with preoperative health states, the ACDF cohort showed statistically significant improved PDQ (78.5 versus 57.9), PHQ-9 (9.7 versus 5.3), and EQ-5D (0.55 versus 0.68) scores at 1 year postoperatively and surpassed the minimum clinically important difference for the EQ-5D of 0.1 units (all p ≤ 0.01). Multivariate linear regression indicated that anxiolytic use and higher EQ-5D preoperative scores were associated with less 1-year postoperative improvement in health status. Although not statistically significant, clinically important effects of preoperative depression, as measured by the PHQ-9, were observed on postoperative QOL outcome (-0.006, 95% confidence interval -0.014 to 0.001). Conclusions Of patients who undergo ACDF with similar preoperative QOL health states, those with a greater degree of depression may have lower improvements in postoperative QOL compared with those with less depression. Patients with anxiety and better preoperative health states also attain less 1-year QOL improvements.

Reliability and validity of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in evaluations of chronic low back pain patients.

The purpose of the current study was to investigate the reliability and concurrent validity of Minnesota Multiphasic Personality Inventory (MMPI)-2-Restructured Form (2-RF) (Ben-Porath & Tellegen, 2008/2011) scores in a sample of 811 chronic low back pain patients (346 males, 529 females) beginning treatment in a short-term interdisciplinary pain rehabilitation program. We calculated internal consistency coefficients, mean-item correlations, and SEM for all substantive scales, as well as zero-order correlations with collateral medical record information and self-report testing. Results indicated reliability and validity for most of the MMPI-2-RF substantive scales. Implications of these findings and limitations of this study are discussed.

Nonopioid substance use disorders and opioid dose predict therapeutic opioid addiction.

UNLABELLED: Limited research examines the risk of therapeutic opioid addiction (TOA) in patients with chronic noncancer pain. This study examined TOA among 199 patients undergoing long-term opioid therapy at the time of admission to a pain rehabilitation program. It was hypothesized that nonopioid substance use disorders and opioid dosage would predict TOA. Daily mean opioid dose was 132.85 mg ± 175.39. Patients with nonopioid substance use disorders had 28 times the odds (odds ratio [OR] = 28.58; 95% confidence interval [CI] = 10.86, 75.27) of having TOA. Each 50-mg increase in opioid dose nearly doubled the odds of TOA (OR = 1.73; 95% CI = 1.29, 2.32). A 100-mg increase was associated with a 3-fold increase in odds (OR = 3.00; 95% CI = 1.67, 5.41). Receiver operating characteristic analysis revealed that opioid dose was a moderately accurate predictor (area under the curve = .75; 95% CI = .68, .82) of TOA. The sensitivity (.70) and specificity (.68) of opioid dose in predicting TOA was maximized at 76.10 mg; in addition, 46.00 mg yielded 80% sensitivity in identifying TOA. These results underscore the importance of obtaining a substance use history prior to prescribing and suggest a low screening threshold for TOA in patients who use opioids in the absence of improvement in pain or functional impairment. PERSPECTIVE: This article examines TOA in patients with chronic noncancer pain undergoing long-term opioid therapy. Results suggest that patients should be screened for nonopioid substance use disorders prior to prescribing. In the absence of improvement in pain or function, there is a low threshold (∼50 mg daily opioid dose) for addiction screening.

The impact of preoperative depression on quality of life outcomes after posterior cervical fusion.

BACKGROUND CONTEXT: Posterior cervical fusion (PCF) has been shown to be an effective treatment for cervical spondylosis, but is associated with a 9% complication rate and high costs. To limit such complications and costs, it is imperative that proper selection of surgical candidates occur for those most likely to do well with the surgery. Affective disorders, such as depression, are associated with worsened outcomes after lumbar surgery; however, this effect has not been evaluated in patients undergoing cervical spine surgery. PURPOSE: To assess the predictive value of preoperative depression and the health state on 1-year quality of life (QOL) outcomes after PCF. STUDY DESIGN: A retrospective cohort analysis. PATIENT SAMPLE: Eighty-eight patients who underwent PCF for cervical spondylosis were reviewed. OUTCOME MEASURES: Preoperative and 1-year postoperative health outcomes were assessed based on the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire-9 (PHQ-9), and the EuroQol five-dimensions (EQ-5D) questionnaire. METHODS: Univariable and multivariable regression analyses were performed to assess for preoperative predictors of 1-year change in health status. RESULTS: Compared with preoperative health states, the PCF cohort showed statistically significant improved PDQ (87.8 vs. 73.6), PHQ-9 (7.7 vs. 6.6), and EQ-5D (0.50 vs. 0.60) scores at 1 year postoperatively. Only 10/88 (11%) patients achieved or surpassed the minimum clinically important difference for the PHQ-9 (5). Multiple linear and logistic regression analyses showed that increasing PHQ-9 and EQ-5D preoperative scores were associated with reduced 1-year postoperative improvement in health status (EQ-5D index). CONCLUSIONS: Of patients who undergo PCF, those with a greater degree of preoperative depression have lower improvements in postoperative QOL compared with those with less depression. Additionally, patients with better preoperative health states also attain lower 1-year QOL improvements.

Interdisciplinary treatment of patients with multiple sclerosis and chronic pain: a descriptive study.

The objective of this study was to examine the efficacy of an interdisciplinary pain rehabilitation program in a multiple sclerosis (MS) population by evaluating changes in mood, pain, and functioning. This descriptive study examined 20 patients with chronic pain and MS who were admitted to the Cleveland Clinic's Chronic Pain Rehabilitation Program (CPRP) between 2000 and 2009. At both admission to and discharge from the CPRP, measures of pain, depression, and functioning were obtained using a pain visual analogue scale (VAS), the Beck Depression Inventory (BDI), the Depression Anxiety Stress Scale (DASS), and the Pain Disability Index (PDI). Outcomes for the MS patients were compared with those of patients without MS who had participated in the same program. The results showed that MS patients who completed the CPRP reported dramatic decreases in pain and depression and an increase in daily functioning. The benefits received by MS patients from the program were similar to those received by patients without MS. Thus programs like the CPRP can result in significant improvements in pain, depression, and functioning among people with MS.