Chronic Pain Rehabilitation Research Articles

Chronic pain and the interpersonal theory of suicide.

Chronic pain is a known risk factor for suicide. To date, however, few studies of people with chronic pain have tested specific predictions about suicidal ideation that are derived from theory. The interpersonal theory of suicide proposes that the psychological constructs of thwarted belongingness and perceived burdensomeness are unique and independent precursors to suicidal ideation. We tested this hypothesis in a clinical sample of patients with chronic pain. A total of 303 patients of a chronic pain rehabilitation program completed measures of pain severity, duration, and disability; cognitive-affective measures of depression and catastrophizing; and interpersonal measures of relationship distress and self-perceived burden to others. The latter measures were included as indices of the belongingness and burdensomeness constructs. Participants also rated two items pertaining to suicidal ideation. In a multiple regression analysis, both distress in interpersonal relations (β = 0.12, p = .037) and self-perceived burden to others (β = 0.25, p < .001) were significant predictors of suicidal ideation, even after adjusting statistically for demographic characteristics, pain severity and duration, functional limitations, catastrophizing, and depression. These findings suggest that the interpersonal theory is relevant to understanding elevated rates of suicidal ideation among people with chronic pain, and may have broader applicability to other populations with chronic illness or disability.

A Smartphone-Based Intervention With Diaries and Therapist-Feedback to Reduce Catastrophizing and Increase Functioning in Women With Chronic Widespread Pain: Randomized Controlled Trial

BackgroundInternet-based interventions using cognitive behavioral approaches can be effective in promoting self-management of chronic pain conditions. Web-based programs delivered via smartphones are increasingly used to support the self-management of various health disorders, but research on smartphone interventions for persons with chronic pain is limited.ObjectiveThe aim of this trial was to study the efficacy of a 4-week smartphone-delivered intervention with written diaries and therapist feedback following an inpatient chronic pain rehabilitation program.MethodsA total of 140 women with chronic widespread pain who participated in a 4-week inpatient rehabilitation program were randomized into 2 groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of 1 face-to-face session and 4 weeks of written communication via a smartphone. Participants received 3 smartphone diary entries daily to support their awareness of and reflection on pain-related thoughts, feelings, and activities. The registered diaries were immediately available to a therapist who submitted personalized written feedback daily based on cognitive behavioral principles. Both groups were given access to a noninteractive website after discharge to promote constructive self-management. Outcomes were measured with self-reported questionnaires. The primary outcome measure of catastrophizing was determined using the pain catastrophizing scale (score range 0-52). Secondary outcomes included acceptance of pain, emotional distress, functioning, and symptom levels.ResultsOf the 140 participants, 112 completed the study: 48 in the intervention group and 64 in the control group. Immediately after the intervention period, the intervention group reported less catastrophizing (mean 9.20, SD 5.85) than the control group (mean 15.71, SD 9.11, P<.001), yielding a large effect size (Cohen’s d=0.87) for study completers. At 5-month follow-up, the between-group effect sizes remained moderate for catastrophizing (Cohen’s d=0.74, P=.003), acceptance of pain (Cohen’s d=0.54, P=.02), and functioning and symptom levels (Cohen’s d=0.75, P=.001).ConclusionsThe results suggest that a smartphone-delivered intervention with diaries and personalized feedback can reduce catastrophizing and prevent increases in functional impairment and symptom levels in women with chronic widespread pain following inpatient rehabilitation.Trial RegistrationClinicaltrials.gov NCT01236209; http://www.clinicaltrials.gov/ct2/show/NCT01236209 (Archived by WebCite at http://www.webcitation.org/6DUejLpPY)

A Randomized-controlled Trial of Using a Book of Metaphors to Reconceptualize Pain and Decrease Catastrophizing in People With Chronic Pain

Reconceptualization of pain and reduction of pain-related catastrophizing are primary objectives in chronic pain rehabilitation. Teaching people about the underlying biology of pain has been shown to facilitate these objectives. The objective of this study was to investigate whether written metaphor and story can be used to increase knowledge of the biology of pain and reduce pain-related catastrophizing. In this randomized single-blind partial cross-over controlled trial, 79 people with chronic pain received either a booklet of metaphors and stories conveying key pain biology concepts or a booklet containing advice on how to manage chronic pain according to established cognitive-behavioral principles. The primary outcome variables, pain biology knowledge and catastrophizing, were measured before randomization, at 3 weeks and at 3 months, at which time the control group was crossed over to receive the metaphors and stories booklet. Pain and disability were secondary outcome variables. The Metaphors group showed larger changes in both variables (time × group interactions: P < 0.01, effect size Cohen d = 0.7 for catastrophizing and 1.7 for pain biology knowledge). Gains were maintained for at least 3 months. Changes were replicated in the Advice group when crossed over. There was no change in pain or self-reported disability in either group. We conclude that providing educational material through metaphor and story can assist patients to reconceptualize pain and reduce catastrophizing. Metaphor and story could be used as a precurser to other interventions that target functional capacity.

The Effects of Interdisciplinary Team Assessment and a Rehabilitation Program for Patients with Chronic Pain

The aim of this study was to evaluate the effects of interdisciplinary team assessment and a 4-wk rehabilitation program in chronic pain patients. This was a longitudinal cohort study evaluating interdisciplinary pain rehabilitation measures in a specialist care setting. A total of 93 women (42.2 ± 9.5 yrs) with chronic musculoskeletal pain (median pain duration, 8 yrs) were evaluated at assessment and at the start and end of the rehabilitation program. Pain intensity measured with a visual analog scale, pain dimensions measured with the Multidimensional Pain Inventory, and anxiety and depression measured with the Hospital Anxiety and Depression Scale were registered. The participants exhibited significantly improved results of pain and pain-related measures. The results were seen both after the short-term intervention in the form of the interdisciplinary assessment and after the 4-wk rehabilitation program. The improvements seen after the assessment were not related to specific interventions, such as change of medication, and therefore seem to be a result of the interdisciplinary assessment concept as such. Both interdisciplinary assessment and rehabilitation program seem to be effective in chronic pain rehabilitation, at least for women. Further studies are needed to investigate potential sex differences, as well as content and duration for optimal pain rehabilitation programs.

Low Back Pain Rehabilitation Using Motor Imagery

Background: The “neuromatrix “ theory of Melzack and the studies of Decety about the motor imagery (MI) open the way to new insights in the treatment of chronic pain rehabilitation. In the chronic pain genesis we have a perceptive dis-coherency and MI could remake a coherence of these afferences. Aim: The aim of the study, referring to Melzak theory and Decety studies, is to evaluate the effectiveness of MI in the rehabilitation of chronic non-specific low back pain. Design: case reports. Setting: Outpatient academic hospital. Population: Were included in the study three women with diagnosis of chronic non-specific low back pain. Materials and Methods: Pain was assessed using the Visual Analogue Scale and the McGill Pain Questionnaire. Disability was evaluated using the Roland and Morris Disability Questionnaire. Rehabilitation Program: the rehabilitation treatment was centered on the fragmentation-perceived segments of the body with a neurocognitive approach. Ten sessions were performed, two times per week, lasting one hour. Results: A reduction of pain and disability scores was observed at the end of rehabilitation treatment. Conclusion: The exercise based on MI is a valid modality in a cognitive-perceptive therapeutic concept for nonspecific chronic low back pain. The exercise is then considered an individually planned experience, who therapeutic value must emphasizes patient’s skills which will enter become a stable behavioral repertoire, so they must be memorized and automated. The evocation of the correct MI, would allow a greater capacity to acquire the proper somesthesic information, generating a greater coherence in the body self and remission, if not disappearance, of the chronic pain.

Trauma system development

The word 'trauma' describes the disease entity resulting from physical injury. Trauma is one of the leading causes of death worldwide and deaths due to injury look set to increase. As early as the 1970s, it became evident that centralisation of resources and expertise could reduce the mortality rate from serious injury and that organisation of trauma care delivery into formal systems could improve outcome further. Internationally, trauma systems have evolved in various forms, with widespread reports of mortality and functional outcome benefits when major trauma management is delivered in this way. The management of major trauma in England is currently undergoing significant change. The London Trauma System began operating in April 2010 and others throughout England became operational this year. Similar systems exist internationally and continue to be developed. Anaesthetists have been and continue to be involved with all levels of trauma care delivery, from the provision of pre-hospital trauma and retrieval teams, through to chronic pain management and rehabilitation of patients back into society. This review examines the international development of major trauma care delivery and the components of a modern trauma system.

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.

Editorial

As we close out another busy year in caring for patients with multiple sclerosis (MS), the current issue of IJMSC offers another set of articles covering a broad range of topics relevant to MS clinicians and researchers.One important article deals with the initial diagnosis of MS, which is a critical step in defining subsequent treatment approaches, whether these are pharmacologic, rehabilitative, or a mixture of the two. Dr. Lalan and colleagues of the University of Mississippi Medical Center in Jackson contribute to our understanding of how to differentiate neuromyelitis optica (NMO) from MS using magnetic resonance imaging. Given that NMO is treated differently than more standard forms of MS, and that NMO patients may even worsen if given standard disease-modifying agents used in MS, this differentiation between the two entities is critical. The authors offer guidelines that are helpful to all MS clinicians, but especially to those who may not have seen this rarer form of demyelinating disease on a regular basis.Once the diagnosis of MS is established, the next step for an MS clinician is generally to consider whether a disease-modifying agent is appropriate and, if so, which one. An important subsequent step is to make sure that the patient is compliant with this agent. Dr. Dhib-Jalbut of the UMDNJ–Robert Wood Johnson Medical School in New Brunswick, New Jersey, and colleagues describe the effect of a focused training and education program using specialized nurses on compliance with interferon beta-1b in patients with early-onset MS. The program seemed to be effective in increasing patients' adherence to disease-modifying therapy.We have two contributions on specific areas of symptom management in this issue, one being a discussion of the use of a comprehensive pain management program in MS, and the other being a listing of poster presentations at a recent symposium on gait and balance in MS. While some clinicians continue to believe that MS does not cause pain, MS patients clearly experience pain from the disease as well as from multiple other causes, and most MS clinicians feel ill-equipped to effectively help patients with their pain. Dr. Sullivan and colleagues at the Cleveland Clinic in Cleveland, Ohio, describe the experience of MS patients who have chronic pain and have been enrolled in a comprehensive chronic pain rehabilitation program at the Cleveland Clinic. The authors demonstrate that MS patients can have significant improvements in pain, depression, and functioning, with results similar to those experienced by non-MS patients. Dr. Zackowski of the Johns Hopkins University School of Medicine in Baltimore, Maryland, and colleagues have organized a symposium on gait and balance in MS for a couple of years now, and we have the pleasure of including a list of the poster abstract titles from the most recent conference in the print issue, with the full abstracts published in our online edition at IJMSC.org. We are glad to help achieve a wider audience for their excellent work on this important topic.We are particularly pleased to have a contribution from a colleague in Jordan, Dr. Hamed of the University of Jordan in Amman, which discusses the real-life experience of MS patients and how environmental factors hinder their attempts to integrate into the wider community. Dr. Hamed also discusses the potential role for occupational therapists as well as others in planning intervention programs for patients with MS. Although the study involved Jordanian MS patients, the findings are equally applicable to other countries.Closing out this issue are two helpful contributions regarding caregivers of people with MS. Ms. Gupta of Kantar Health in Princeton, New Jersey, along with colleagues at EMD Serono and Pfizer, compares the reported burden of caregiving for MS patients and Alzheimer's disease patients, finding that MS caregivers have a much heavier load in some areas. This interesting study has important implications for policymaking as well as raising our awareness of caregiving issues. Ms. Preissner and colleagues of the University of Illinois at Chicago discuss the difficulty of doing research involving MS caregivers and how to get around these issues in order to advance such research and then develop educational programs to assist the caregivers, who are so crucial to the lives of our MS patients.We also want to remind you that the deadline for submitting abstracts for the Fifth Cooperative Meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis, to be held in the spring of 2013, is December 31, 2012. Enjoy the rest of 2012, and we at IJMSC wish you all a very happy New Year!

The relationship between acceptance, catastrophizing and illness representations in chronic pain

Cognitive- and acceptance-based approaches are used to help people live with chronic pain. Little is known about how these constructs relate to each other. In this study, we examined how cognitive representations of chronic pain relate to interpersonal styles such as catastrophizing and the behavioural process of acceptance of chronic pain. This study further examined how these processes relate to emotional and physical functioning in chronic pain. A cross-sectional design, employing validated questionnaires, was used to measure pain, emotional and physical dysfunction, illness representations, catastrophizing and acceptance in a heterogeneous sample of 150 chronic pain sufferers. The psychological variables significantly mediated the impact of pain severity on both emotional and physical dysfunction. In addition, a distinct pattern of mediation was observed. The relationship between pain and emotional dysfunction was mediated by representations of pain as a highly emotive experience and by catastrophizing; acceptance did not mediate this relationship. By contrast, the relationship between pain and physical dysfunction was mediated by acceptance and representations of high consequences of chronic pain, but not by catastrophizing. Pain severity itself is a relatively poor predictor of emotional and physical dysfunction in chronic pain states. These relationships are significantly mediated by psychological variables. Different approaches to chronic pain rehabilitation emphasize different targets (changing illness representations and reducing catastrophizing vs. acceptance and behavioural activation). This cross-sectional study suggests that these processes may differentially influence outcomes, but that they are complex and overlapping. Theoretical and clinical implications are discussed.

Cognitive treatment of illness perceptions, a theory-driven approach to chronic low back pain rehabilitation.

Cognitive treatment of illness perceptions, a theory-driven approach to chronic low back pain rehabilitation.

What does coping mean to the worker with pain-related disability? A qualitative study

Purpose: Pain coping is important in health outcomes. In the current literature, pain coping usually means those goal-directed strategies to manage pain. The study goal was to explore what personal meaning “coping” has for work-disabled individuals in pain. Method: Qualitative, in depth interviews with follow-up verification interviews were conducted with 13 volunteers who were off work and in rehabilitation for chronic pain from a musculoskeletal injury. The two main questions were: (1) How did participants understand the term “coping with pain”; and (2) how did they come to this understanding of coping. The theoretical approach was social phenomenology and data were analyzed using thematic analysis. Results: The dominant theme was that pain coping is an intrinsic and life-defining attitude and belief. This understanding primarily arose through early modeling by parents and significant others. Secondary theme was that coping is practical strategies to manage or eliminate pain. This arose through more current interactions with health care providers and others in the social network. Conclusions: Researchers’ and clinicians’ view of coping may not always match the views held by individuals with chronic pain. This might impact on the effectiveness of interventions designed to modify coping behaviors, and alternative ways of intervening may be needed.Implications for RehabilitationCoping has an important impact on health recovery after musculoskeletal injuries but interventions to modify pain coping strategies in those with chronic pain have met with modest success.The dominant model for coping in the research literature defines coping as a behavioral and/or cognitive response to a stressful situation.A qualitative study to examine what personal meaning “coping” holds for work-disabled persons with chronic pain suggests that coping is primarily conceptualized as an intrinsic and life-defining attitude/belief learned early in life.The above incongruence between the dominant research model of coping and the views of workers with chronic pain might impact on the effectiveness of interventions designed to modify coping behaviors for this population, and alternative ways of intervening may be needed.

Reliability and validity study of the Finnish version of the Chronic Pain Acceptance Questionnaire (CPAQ)

Purpose: Acceptance has been discovered to be successful in improving quality of life when adjusting to chronic pain. Instead of avoiding and controlling the pain, the goal is to confront the pain and to live a value directed life. Thus far, there has not been an instrument in Finnish to assess the acceptance of chronic pain. This study aimed at translating the Chronic Pain Acceptance Questionnaire-(CPAQ)-into Finnish and assessing its reliability and validity. Method: Eighty-one persons with different types of chronic pain responded to the CPAQ, the Beck Depression Inventory (BDI), RAND-36 and questions of sociodemographic and pain-related variables. Results: The responders’ ages varied from 16 to 83 years (mean = 48.5 years) and 63% of them were women. For 55% of the participants, the pain had lasted more than 4 years and 63% from the sample had chronic pain in the low back or lower extremities. In test-retest analysis, the interclass correlation coefficient (ICC ) values were good, 0.81–0.87. Internal consistency was very good (α = 0.86). There was no floor-ceiling effect in the Finnish version of CPAQ. Correlation was found between both subscales of the CPAQ and every domain of the RAND-36 (r = 0.23; 0.68) and the BDI (r = −0.24; −0.62). Education, age, pain avoidance, social support and pain intensity correlated with either one of the subscales or total CPAQ. CPAQ revealed no association between fear of pain and pain duration. Conclusions: In conclusion, the Finnish version of the CPAQ is a reliable and valid method for measuring chronic pain acceptance.Implications for RehabilitationChronic Pain Acceptance QuestionnaireThere has not been an instrument in Finnish to assess the acceptance of chronic pain.The Finnish version of the Chronic Pain Acceptance Questionnaire (CPAQ) is a reliable and valid method for measuring chronic pain acceptance.In physiotherapy, CPAQ can be a useful instrument collecting background information of the chronic pain patient and assessing when to consult a psychologist. In addition in long therapies assessing the enhanced acceptance can be monitored with CPAQ.

Patient outcomes: patients with chronic headache treated in a chronic pain rehabilitation program

Incapacitating chronic migraine and other severe headaches can have a 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.) CPRPs provide treatment of headache by focusing not only on physical pain, but also its association with impaired mood and function.

Resumption of opioids and sedative hypnotics amongst chemically dependent patients at 12 months post discharge from a chronic pain rehabilitation program

Resumption of opioids and sedative hypnotics amongst chemically dependent patients at 12 months post discharge from a chronic pain rehabilitation program

Successful treatment of post-stroke pain in a chronic pain rehabilitation program

Persistent pain following stroke is most commonly associated with central post-stroke pain, post-stroke headache, or pain that persists in the affected sites in the periphery. Little has been written regarding treatment of patients with any post-stroke pain in a comprehensive pain rehabilitation program. This multiple case study examined the outcomes of 10 patients with post-stroke pain who participated in the Cleveland Clinic Chronic Pain Rehabilitation Program from 1999-2011. Sixty percent were female, and their mean age was 52 years; the range of duration of pain was 3-37 years.

Effects of the withdrawal of opioids and benzodiazepines on cognitive functioning in the context of an interdisciplinary chronic pain rehabilitation program

Effects of the withdrawal of opioids and benzodiazepines on cognitive functioning in the context of an interdisciplinary chronic pain rehabilitation program

Health Economics of Interdisciplinary Rehabilitation for Chronic Pain: Does it Support or Invalidate the Outcomes Research of These Programs?

Interdisciplinary rehabilitation has been shown to be effective for treatment of patients suffering from chronic nonmalignant pain with respect to activity level, pain intensity, function, or days of sick leave. However, effects in clinical outcome do not necessarily imply a superiority of the intervention from an economic point of view. Despite an increasing number of cost-utility and cost-effectiveness studies, systematic reviews outline the methodological heterogeneity of studies, which makes it impossible to perform meta-analyses and to draw conclusions from the studies. Recent publications add interesting information to the current discussion; these studies cover the long-term development of sickness absence post-intervention and the cost effectiveness of workplace interventions, as well as a collaborative intervention in primary care. Much research has been done, and tendencies of effectiveness are visible, but there is still a long way to go to understand the economic implications of interdisciplinary rehabilitation from the perspectives of society, the health insurers, and the patients.

The dual faces of service user participation: Implications for empowerment processes in interprofessional practice

• Summary: This article reports on an empirical research study exploring and describing variations in how front-line practitioners perceive service user participation (SUP), specifically in interprofessional practice. The settings comprised three Swedish health and social care organizations where the professionals worked in interprofessional teams: a program for chronic pain rehabilitation, a program for surgical treatment of obesity, and a short-term municipal home for older adults. The qualitative study design was informed by a phenomenographic approach and conducted as semi-structured individual interviews with 15 professionals representing nine professions, including social work. • Findings: The main findings show seven qualitative variations in understanding of SUP: 1) inclusion in activities and social events, 2) obtaining guidance, 3) having self-determination and choice, 4) getting confirmation from and contact with professionals, 5) negotiating for adjustment, 6) personal responsibility through insight, and 7) circumstance surrounding SUP. • Applications: The interprofessional dimensions discerned in the meaning attributed to SUP are mainly described in terms of amplified opportunities for participation. An interesting aspect of the findings is that in all the variations of perceptions of SUP, there are potentials to reverse to their opposites, that is, paradoxes that can be termed ‘the dual faces of service user participation’. These aspects stress the need for continuing reflection on practices among both front-line practitioners and managers in empowering and paternalistic processes and on constantly improving organizational and policy conditions to facilitate SUP.

Operant Learning Theory in Pain and Chronic Pain Rehabilitation

The application of operant learning theory on chronic pain by Fordyce has had a huge impact on chronic pain research and management. The operant model focuses on pain behaviors as a major component of the pain problem, and postulates that they are subject to environmental contingencies. The role of operant learning in pain behaviors generally has been supported by experimental studies, which are reviewed in the present article. Subsequently, the rationale, goals, and methods of operant behavioral treatment of chronic pain are outlined. Special attention is paid to three therapeutic techniques (graded activity, activity pacing, and time-contingent medication management), which are discussed in detail with regard to their operationalization, effectiveness, and (possible) mechanisms of action. Criticisms of the operant model are presented, as are suggestions for the optimization of (operant) behavioral treatment efficacy.

Self-Reported Issues With Driving in Patients With Chronic Pain

To assess the driving habits, driving patterns, and barriers to driving reported by patients with chronic pain. Cross-sectional mail survey with self-administered questionnaires. University-affiliated hospital. A sample of 223 patients seen in consultation by a physiatrist through the Chronic Pain Rehabilitation Service. Not applicable. Percentage of subjects who were current drivers, percentage of subjects experiencing difficulty with driving, and driving characteristics. Response rate was 48.9%. Of the subjects, 79% were current drivers; of the nondrivers, 56% reported stopping driving because of chronic pain. A significantly greater percentage of nondrivers (80%) than drivers (62.9%) were women (P = .039). Nondrivers reported greater levels of pain than drivers (P = .027). The mean Pain Disability Index total score was significantly lower for drivers (42.3) than for nondrivers (48.7; P = .006). Of all subjects, 70% indicated that pain limited their driving in some manner; 41% of this group indicated that they experienced quite a bit or a great deal of difficulty driving. Factors that limited driving included pain (88.9%), fatigue (50.6%), limited joint mobility/stiffness (48.3%), and weakness (19.4%). The most frequently reported difficulties related to driving were sitting for any length of time (79.6%) and getting into the driver's seat (66.5%). Only 2.4% of current drivers had been referred for a driving assessment. Most people with chronic pain continue to drive and overall appear to have better functioning than those who cannot continue driving because of chronic pain. Despite being able to drive, a significant proportion of drivers with chronic pain are facing challenges not only with driving the vehicle but also with entering and positioning themselves within the vehicle. Our results suggest that chronic pain does have an impact on driving. However, it appears to be generally unrecognized as a factor for driving other than when the implications of opioid use are considered.