Article

Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain

March 2016
JAMA The Journal of the American Medical Association 315(12):1240

DOI:10.1001/jama.2016.2323

Authors:

Karen J Sherman

Kaiser Permanente Washington Health Research Institute

Benjamin Balderson

Kaiser Permanente Washington Health Research Institute

Andrea J Cook

Kaiser Permanente Washington Health Research Institute

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Importance: Mindfulness-based stress reduction (MBSR) has not been rigorously evaluated for young and middle-aged adults with chronic low back pain. Objective: To evaluate the effectiveness for chronic low back pain of MBSR vs cognitive behavioral therapy (CBT) or usual care. Design, setting, and participants: Randomized, interviewer-blind, clinical trial in an integrated health care system in Washington State of 342 adults aged 20 to 70 years with chronic low back pain enrolled between September 2012 and April 2014 and randomly assigned to receive MBSR (n = 116), CBT (n = 113), or usual care (n = 113). Interventions: CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever care participants received. Main outcomes and measures: Coprimary outcomes were the percentages of participants with clinically meaningful (≥30%) improvement from baseline in functional limitations (modified Roland Disability Questionnaire [RDQ]; range, 0-23) and in self-reported back pain bothersomeness (scale, 0-10) at 26 weeks. Outcomes were also assessed at 4, 8, and 52 weeks. Results: There were 342 randomized participants, the mean (SD) [range] age was 49.3 (12.3) [20-70] years, 224 (65.7%) were women, mean duration of back pain was 7.3 years (range, 3 months-50 years), 123 (53.7%) attended 6 or more of the 8 sessions, 294 (86.0%) completed the study at 26 weeks, and 290 (84.8%) completed the study at 52 weeks. In intent-to-treat analyses at 26 weeks, the percentage of participants with clinically meaningful improvement on the RDQ was higher for those who received MBSR (60.5%) and CBT (57.7%) than for usual care (44.1%) (overall P = .04; relative risk [RR] for MBSR vs usual care, 1.37 [95% CI, 1.06-1.77]; RR for MBSR vs CBT, 0.95 [95% CI, 0.77-1.18]; and RR for CBT vs usual care, 1.31 [95% CI, 1.01-1.69]). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 43.6% in the MBSR group and 44.9% in the CBT group, vs 26.6% in the usual care group (overall P = .01; RR for MBSR vs usual care, 1.64 [95% CI, 1.15-2.34]; RR for MBSR vs CBT, 1.03 [95% CI, 0.78-1.36]; and RR for CBT vs usual care, 1.69 [95% CI, 1.18-2.41]). Findings for MBSR persisted with little change at 52 weeks for both primary outcomes. Conclusions and relevance: Among adults with chronic low back pain, treatment with MBSR or CBT, compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain. Trial registration: clinicaltrials.gov Identifier: NCT01467843.

Non-invasive Management of Head and Neck Neuralgia: A Literature Review

Article

Full-text available

Aug 2024

Head and neck neuralgia is a prevalent condition impacting millions worldwide, necessitating both invasive and non-invasive management strategies. This review focuses specifically on non-invasive approaches. Using the International Classification of Headache Disorders (ICHD-3), we categorized neuralgia causing head and neck pain to structure our literature search. Our review identified several non-invasive management techniques, including physiotherapy, pharmacological treatments, Pulsed Radiofrequency, local anesthesia blocks, Botulinum toxin injections, and non-invasive neuromodulation. This review highlights various effective non-invasive strategies for managing head and neck neuralgias, supported by studies published until 2023. These findings emphasize the clinical relevance of tailoring treatment plans to individual patient needs, considering the specific type of neuralgia and optimizing outcomes in clinical practice.

Mindfulness vs. Physiotherapy vs. Medical Therapy: Uncovering the Best Postoperative Recovery Method for Low Back Surgery Patients during the COVID-19 Pandemic—A Single Institution’s Experience

Article

Full-text available

Aug 2024

Introduction: This study aimed to evaluate the efficacy of mindfulness therapy compared to traditional physiotherapy and usual care in alleviating postoperative pain and improving functional outcomes in patients undergoing lumbar spine surgery during the COVID-19 pandemic. Methods: Ninety patients undergoing lumbar decompression and fusion (LDF) who presented persistent low back pain after surgery were prospectively followed for one year. They were randomly divided into three groups: mindfulness therapy, physiotherapy, and medical therapy. The primary outcome was the improvement of the Oswestry Disability Index (ODI) score postoperatively and at six months follow-up. Results: Both mindfulness and physiotherapy groups showed significant improvement in ODI scores compared to the control group, with mean variations of 10.6 and 11.6 points, respectively, versus 4.9 points in the control group. There was no significant difference between mindfulness and physiotherapy (p = 0.52), but both were superior to medical care (p < 0.0001 for physiotherapy and p = 0.0007 for mindfulness). Conclusions: This study demonstrated that mindfulness therapy is more effective than usual care in improving postoperative outcomes for patients undergoing lumbar spine surgery. In our cohort, its efficacy was comparable to that of physiotherapy, making it a viable alternative, especially when access to healthcare services is restricted, as seen during the COVID-19 pandemic. Future research should validate the findings of this study and examine the long-term effects on surgical patient populations.

Enhancing Chronic Non-Cancer Pain Management: A Systematic Review of Mindfulness Therapies and Guided Imagery Interventions

Article

Full-text available

Apr 2024

Background and Objectives: There has been an increasing interest in the use of non-pharmacological approaches for the multidimensional treatment of chronic pain. The aim of this systematic review was to assess the effectiveness of mindfulness-based therapies and Guided Imagery (GI) interventions in managing chronic non-cancer pain and related outcomes. Materials and Methods: Searching three electronic databases (Web of Science, PubMed, and Scopus) and following the PRISMA guidelines, a systematic review was performed on Randomized Controlled Trials (RCTs) and pilot RCTs investigating mindfulness or GI interventions in adult patients with chronic non-cancer pain. The Cochrane Risk of Bias Tool was utilized to assess the quality of the evidence, with outcomes encompassing pain intensity, opioid consumption, and non-sensorial dimensions of pain. Results: Twenty-six trials met the inclusion criteria, with most of them exhibiting a moderate to high risk of bias. A wide diversity of chronic pain types were under analysis. Amongst the mindfulness interventions, and besides the classical programs, Mindfulness-Oriented Recovery Enhancement (MORE) emerges as an approach that improves interoception. Six trials demonstrated that mindfulness techniques resulted in a significant reduction in pain intensity, and three trials also reported significant outcomes with GI. Evidence supports a significant improvement in non-sensory dimensions of pain in ten trials using mindfulness and in two trials involving GI. Significant effects on opioid consumption were reported in four mindfulness-based trials, whereas one study involving GI found a small effect with that variable. Conclusions: This study supports the evidence of benefits of both mindfulness techniques and GI interventions in the management of chronic non-cancer pain. Regarding the various mindfulness interventions, a specific emphasis on the positive results of MORE should be highlighted. Future studies should focus on specific pain types, explore different durations of the mindfulness and GI interventions, and evaluate emotion-related outcomes.

EFFECTIVENESS OF MINDFULNESS-BASED STRESS REDUCTION PROGRAMS ON CHRONIC PAIN, QUALITY OF LIFE, AND PSYCHOLOGICAL WELL-BEING IN PATIENTS WITH CHRONIC PAIN

Article

Jan 2024

Value-based healthcare in management of chronic back pain: A multidisciplinary- and lean-based approach

Article

Full-text available

Sep 2024

Background Chronic back pain stands as the most common musculoskeletal disorder and a primary cause of disability in people under 45 years old. Multidisciplinary consultation offers an efficient approach to chronic back pain management compared to traditional therapeutic-rehabilitative paths. This paper aims to show the benefit of a diagnostic-therapeutic multidisciplinary program pathway for patients with chronic back pain. Methods Twenty-six patients who underwent a second-level multidisciplinary consultation with a neurosurgeon and a pain therapist at our University Hospital were retrospectively identified from April 2023 to September 2023. The second-level multidisciplinary consultation is a second step consultation after a first consultation with a single specialist doctor (neurosurgeon, orthopedic, and pain therapist) who did not get the diagnosis and/or did not solve the painful symptom after medical or surgical treatment. Clinical outcomes, patient experience, and cost-effectiveness analysis were assessed using lean healthcare tools. Results With the introduction of second-level multidisciplinary consultation, patients were assessed by multiple physicians during a single visit, reducing the costs of individual visits, reducing the time to obtain the diagnosis, and facilitating early agreement on a diagnostic-therapeutic plan. The lean value-based healthcare approach showed an average of 45 working days lost per single patient and a total cost per single patient with chronic back pain of € 1069 for the national health system for an average Lead time of 18 months. Questionnaire analysis on service quality and utility, along with overall satisfaction, revealed excellent resolution of back pain in 53.8% of cases and partial resolution of back pain in 11.5% of cases after second-level multidisciplinary consultation. Conclusion Our multidisciplinary approach to chronic back pain has significantly improved healthcare efficiency. This new proposed clinical model reduces waiting times and costs and improves patient experience by improving clinical outcomes in the management of chronic back pain.

Negative Pain Thoughts Questionnaire Short Form (NPTQ-SF) Scores and Outcomes After Arthroscopic Meniscectomy

Article

Aug 2024

Background Pain is multifactorial, and pain intensity has been shown to be influenced by patients’ thoughts. The Negative Pain Thoughts Questionnaire Short Form (NPTQ-SF) can be used to quantify unhelpful negative cognitive biases about pain, but the relationship between negative pain thoughts and orthopaedic surgery outcomes is not known. Purpose To evaluate the prevalence of negative pain thoughts in patients undergoing arthroscopic meniscectomy using the NPTQ-SF survey and assess the relationship these thoughts have to knee function, general health, pain, and satisfaction before and after surgery. Study Design Case series; Level of evidence, 4. Methods In total, 146 patients undergoing arthroscopic meniscectomy were administered the 4-item NPTQ-SF, 12-item Short Form Survey (SF-12), International Knee Documentation Committee (IKDC) questionnaire, and visual analog scale pain survey preoperatively between July 2021 and August 2022. The same surveys were completed at a minimum of 3 months and no later than 1 year postoperatively by 92 patients confirmed to have undergone meniscectomy. Results NPTQ-SF scores were correlated with IKDC, SF-12, and satisfaction score preoperatively and at least 3 months postoperatively (mean, 108.5 ± 43.7 days). Preoperative NPTQ-SF scores were significantly negatively correlated with postoperative IKDC ( R = −0.284), SF-12 ( R = −0.266 and −0.328), and visual analog scale pain ( R = 0.294) scores, while a relationship with postoperative satisfaction did not reach statistical significance ( P = .067). Patients with a preoperative NPTQ-SF score >8 were less likely to achieve a Patient Acceptable Symptom State on the postoperative IKDC questionnaire (39% vs 63%; P = .03). Patients with a history of a psychiatric or chronic pain diagnoses have worse NPTQ-SF, SF-12, and IKDC scores pre- and postoperatively. Conclusion The level of negative pain thoughts in patients undergoing meniscectomy is related to knee function, general health, and pain. Patients with a high level of negative pain thoughts are less likely to achieve a favorable outcome from meniscectomy, with a score ≥8 representing a clinically significant threshold for preoperative screening.

Virtual Reality for Sub-Acute Pain After Orthopedic Traumatic Musculoskeletal Injuries: A Mixed Methods Pilot Study

Article

Jul 2024
CLIN J PAIN

Objectives Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating mindfulness and cognitive behavioral therapy, for pain self-management at home following orthopedic injury. Methods We enrolled 10 adults with recent orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham healthcare system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a-priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and mechanisms (pain self-efficacy, mindfulness, and coping). Results The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients. Discussion The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.

Acceptability of multimodal and multidisciplinary group-based program for chronic low back pain: a qualitative study

Article

Jul 2024
Physiother Theor Pract

Background The Programa d’Atenció Integral pels Pacients amb Dolor Crònic (PAINDOC) is a multimodal and multidisciplinary group-based program that integrates pain neuroscience education, mindfulness meditation, pain psychotherapy, Empowered Relief, and therapeutic exercise. It serves as a therapeutic option for individuals with chronic low back pain, providing them with comprehensive adaptive strategies for pain management. Objective This qualitative study explores participants’ retrospective acceptability of the PAINDOC Program. Methods To ensure demographic variability and information power, a purposive sampling approach was applied. Twelve participants were interviewed through three focus groups, supplemented with four individual semi-structured interviews. Data was analyzed using reflexive thematic analysis and evaluated based on the Therapeutic Framework of Acceptability. Results Participants provide positive feedback regarding active pain coping strategies and improved self-management. While certain aspects of the Program were more emphasized, participants integrated tools from all components. Strategies included pain reconceptualization, positive self-talk, or problem-solving. The Program’s ethicality was closely linked to individual values and may also be influenced by time constraints of certain program elements, the immediate effects of specific approaches, participant perceptions, and individual preferences. Conclusions The findings provide valuable insights into the acceptability of the PAINDOC Program, guiding future improvements and the development of similar interventions.

Prevalence of Sexual Disability and its Relationship with Pain Intensity, Quality of life and Psychological Distress Among Individuals with Chronic Low Back Pain in Nigeria: A Cross-Sectional Study

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Full-text available

May 2024
SEX DISABIL

Nigeria has been reported as having the highest prevalence of low back pain (LBP) in Africa. Despite this, sexual disability among people with LBP in Nigeria is sparsely reported. To examine the prevalence of sexual disability and its relationship with pain intensity, quality of life and psychological distress among individuals with chronic low back pain (CLBP) in Nigeria. A descriptive cross-sectional study of individuals with CLBP was conducted. The Visual Analogue Scale (VAS) was used to assess pain intensity while sexual disability was assessed using the Oswestry Disability Index domain 8 (ODI-8). Quality of life was assessed using the Short-form Health Survey (SF-36) questionnaire and the 42-item Depression, Anxiety, and Stress Scale (DASS-42) was used to measure psychological distress. A total of 375 participants (mean age = 41.4 years, SD = 5.67) with CLBP participated in the study. The majority of the participants have a sexual disability (357, 95.2%), with 33.1% (124) of them reporting that their sex life was severely restricted by pain and 17.9% (67) reporting that pain prevents any sex life at all. Females have a lower quality of life and higher levels of sexual disability, pain, and psychological distress than males (p < 0.05). Sexual disability was strongly correlated with pain intensity, quality of life, and psychological distress (p < 0.05).The findings of this study indicate that there was a high prevalence of sexual disability among individuals with CLBP in Nigeria and this was strongly correlated with pain, quality of life and psychological distress.

Examining efficacy and potential mechanisms of mindfulness-based cognitive therapy for anxiety and stress reduction among college students in a cluster-randomized controlled trial

Article

Full-text available

Oct 2024
INT J CLIN HLTH PSYC

The pervasiveness of anxiety and stress among college students necessitates the investigation of potential alternative and accessible interventions which can be implemented into existing curricular and student-support programming to improve students' mental health. Mindfulness based cognitive therapy (MBCT) smartphone applications have shown promising outcomes in alleviating anxiety and stress. However, it is essential to gain insight into the feasibility and efficacy of such an interventional approach in a collegiate population, as well as explore potential underlying mechanisms, which could be better targeted to enhance the efficacy of future interventions for promoting mental health and well-being. The aims for this study were (1) to assess the efficacy of a 4-week MBCT intervention using the Sanvello smartphone application in reducing trait-level anxiety and chronic stress in college-aged young adults (n = 150) compared to a positive control group (n = 139), and (2) to examine potential mediators of this effect. Participants completed assessments of trait anxiety, chronic stress, cognitive reappraisal, cognitive refocusing, distractive refocusing, and negative automatic thoughts at pretest and following 4 weeks of the interventions. Analysis of primary outcomes revealed greater reductions in trait anxiety and chronic stress for the MBCT group, relative to the positive control group with small to moderate effect sizes. The anxiolytic and stress-reducing effects of the MBCT intervention were observed to be mediated by changes in negative automatic thoughts but not by changes in cognitive reappraisal, constructive refocusing, or distractive refocusing. Given the efficacy of the Sanvello smartphone application and the overwhelmingly strong assessments of the appropriateness and feasibility of it use; student support initiatives may be well served by adopting such a platform within the context of first-line treatment and prevention of high anxiety and chronic stress within first year college students. Registered at ClinicalTrials.gov [number NCT06019299].

Results of a Randomized Waitlist-Controlled Trial of Online Cognitive Behavioral Sex Therapy and Online Mindfulness-Based Sex Therapy for Hypoactive Sexual Desire Dysfunction in Women

Article

Full-text available

Oct 2024

Objective: This study aimed to investigate the efficacy of two internet-delivered psychological treatments for hypoactive sexual desire dysfunction (HSDD) in women: internet-based cognitive behavioral sex therapy (iCBST) and internet-based mindfulness-based sex therapy (iMBST). Method: Women with HSDD were randomly assigned to one of three groups: iCBST, iMBST, or a waitlist control group. The interventions consisted of eight modules delivered via an e-health platform with e-coach support to enhance adherence. Sexual desire and sexual distress were assessed at baseline and at 3-, 6-, and 12-month follow-ups (active conditions only). Per protocol, of the 266 consenting women, 106 were randomized to iCBST (Mage = 36.1, SD = 10.3), 106 to iMBST (Mage = 36.4, SD = 0.2), and 54 to the control condition (Mage = 36.7, SD = 11.0). Primary analyses utilized an intention-to-treat approach with linear mixed models. Clinical significance, assessed with clinical cutoffs and the reliable change index, was examined for active conditions. Results: Compared to the control condition, both iCBST and iMBST demonstrated significant improvements in sexual desire and sexual distress at 3-month (d = 0.89–1.14) and 6-month follow-up (d = 0.74–1.18). Results were sustained at 12-month follow-up, with 35 and 41% demonstrating reliable improvements and additional 20 and 24% achieving clinically significant improvements in sexual desire after iCBST and iMBST. Regarding sexual distress, 49 and 42% exhibited reliable change, with an additional 37%–42% achieving clinically significant improvements. Conclusions: Results provide support for the overall long-term efficacy of psychological therapies in treating HSDD in women. However, fewer than one in four women showed improvements in sexual desire that met the threshold for clinically significant change.

Evaluating associations between social risks and health care utilization in patients with chronic low back pain

Article

Full-text available

Oct 2024

Introduction Care and outcomes for patients with chronic low back pain (cLBP) are influenced by the social risk factors that they experience. Social risk factors such as food insecurity and housing instability have detrimental effects on patient health and wellness, healthcare outcomes, and health disparities. Objectives This retrospective cross-sectional study examined how social risk factors identified in unstructured and structured electronic health record (EHR) data for 1,295 patients with cLBP were associated with health care utilization. We also studied the impact of social risk factors, controlling for back pain–related disability on health care utilization. Methods Included patients who received outpatient spine and/or physical therapy services at an urban academic medical center between 2018 and 2020. Five identified social risks were financial insecurity, housing instability, food insecurity, transportation barriers, and social isolation. Outcomes included 4 categories of health care utilization: emergency department (ED) visits/hospitalizations, imaging, outpatient specialty visits related to spine care, and physical therapy (PT) visits. Poisson regression models tested associations between the presence of identified social risks and each outcome measure. Results Identified social risks in 12.8% of the study population (N = 166/1,295). In multivariate models, social isolation was positively associated with imaging, specialty visits, and PT visits; housing instability was positively associated with ED visits/hospitalizations and imaging; food insecurity was positively associated with ED visits/hospitalizations and specialty visits but negatively associated with PT visits; and financial strain was positively associated with PT visits but negatively associated with ED visits/hospitalization. Conclusion These associations were seen above and beyond other factors used as markers of socioeconomic marginalization, including neighborhood-level social determinants of health, race/ethnicity, and insurance type. Identifying and intervening on social risk factors that patients with cLBP experience may improve outcomes and be cost-saving.

Twelve-month results for a randomized sham-controlled effectiveness trial of an in-home skills-based virtual reality program for chronic low back pain

Article

Full-text available

Sep 2024

Introduction Low-risk, accessible, and long-term effective nonpharmacologic behavioral interventions for chronic low back pain (cLBP) are needed. Pain education and cognitive behavioral therapy (CBT) are recommended first-line treatments, but access is poor, treatment effectiveness is variable, and long-term effectiveness is inconsistent. In-home virtual reality (VR)-delivered therapies might address these shortcomings because therapeutic content can be delivered in a consistent and quality-controlled manner. Objective To determine whether a 56-session, self-administered in-home, Skills-Based VR program for cLBP (RelieVRx) yields long-term reductions in pain intensity and pain interference 12 months posttreatment in a large demographically diverse and clinically severe real-world sample. Methods Participants were 1,093 demographically diverse individuals with self-reported nonmalignant cLBP > 3 months duration and average pain intensity and interference scores > 4/10. Participants were randomized to Skills-Based VR or active Sham, and data were collected from January 31, 2022 to October 31, 2023. Pretreatment to 12-month posttreatment analyses were conducted. Results From baseline to 12 months posttreatment, Skills-Based VR reductions for average pain intensity (1.7 ± 2.1) and pain interference (1.9 ± 2.3) were robust and significantly greater than those found for Sham. More than half of Skills-Based VR participants reported at least a 2-point reduction in pain intensity, pain interference, or both at 12 months posttreatment. Conclusions A standardized, in-home Skills-Based VR therapy is effective for reducing pain intensity and pain interference, and these effects are maintained to 12 months posttreatment.

Treatment mechanism and outcome decoupling effects in cognitive therapy, mindfulness-based stress reduction, and behavior therapy for chronic pain

Article

Aug 2024
PAIN

Findings suggest that cognitive therapy (CT), mindfulness-based stress reduction (MBSR), and behavior therapy (BT) for chronic pain produce improvements through changes in putative mechanisms. Evidence supporting this notion is largely based on findings showing significant associations between treatment mechanism variables and outcomes. An alternative view is that treatments may work by reducing or decoupling the impact of changes in mechanism variables on changes in outcomes. We examined the degree to which relationships between previous changes in potential treatment mechanisms and subsequent changes in outcomes changed as treatment progressed and vice versa. Cognitive therapy, MBSR, BT, and treatment as usual (TAU) were compared in people with chronic low back pain (N = 521). Eight individual sessions were administered with weekly assessments of putative treatment mechanisms and outcomes. Lagged analyses revealed mechanism × session number interactions and outcome × session number interactions, such that associations between mechanism and outcome variables were strong and significant in the first third of treatment, but weakened over time and became nonsignificant by the last third of treatment. These effects were similar across treatment conditions but did not emerge among people undergoing TAU. Results suggest that during the course of CT, MBSR, and BT, the links between changes in treatment mechanism variables became decoupled from subsequent changes in outcomes and vice versa. Thus, starting by midtreatment and continuing into late treatment, participants may have learned through participation in the treatments that episodes of maladaptive pain-related thoughts and/or spikes in pain need not have detrimental consequences on their subsequent experience.

Mindfulness Meditation and Placebo Modulate Distinct Multivariate Neural Signatures to Reduce Pain

Article

Full-text available

Aug 2024
BIOL PSYCHIAT

Protocol for a randomised trial of a self-directed digital pain management intervention (Empowered Relief) tailored to adults with chronic pain and prescription opioid misuse/disorder: the MOBILE Relief study

Article

Full-text available

Aug 2024

Introduction Chronic pain increases the risk of prescription opioid misuse or opioid use disorder (OUD). Non-pharmacological treatments are needed to dually address pain and opioid risks. The purpose of the Mobile and Online-Based Interventions to Lessen Pain (MOBILE Relief) study is to compare a one-session, video-based, on-demand digital pain relief skills intervention for chronic pain (‘Empowered Relief’ (ER); tailored to people at risk for opioid misuse or with opioid misuse/OUD) to a one-session digital health education intervention (‘Living Better’; no pain management skills). Methods and analysis MOBILE Relief is an international online randomised controlled clinical trial. Study participants are adults with chronic, non-cancer pain (≥6 months) with daily pain intensity ≥3/10, taking ≥10 morphine equivalent daily dose and score ≥6 on the Current Opioid Misuse Measure. Participants are recruited through clinician referrals and clinic advertisements. Study procedures include electronic eligibility screening, informed consent, automated 1:1 randomisation to the treatment group, baseline measures, receipt of assigned digital treatment and six post-treatment surveys spanning 3 months. Study staff will call participants at baseline and 1-month and 3 months post-treatment to verify the opioid prescription. The main statistical analyses will include analysis of covariance and mixed effects model for repeated measurements regression. Main outcomes Primary outcomes are self-reported pain catastrophising, pain intensity, pain interference, opioid craving and opioid misuse at 1-month and 3 months post-treatment. We will determine the feasibility of ER (≥50% participant engagement, ≥70% treatment appraisal ratings). We hypothesise the ER group will be superior to the Living Better group in the reduction of multiprimary pain outcomes at 1-month post-treatment and opioid outcomes at 1-month and 3 months post-treatment. Ethics and dissemination The study protocol was approved by the Stanford University School of Medicine Institutional Review Board (IRB 61643). We will publish results in peer-reviewed journals; National Institute of Drug Abuse (funder) and MOBILE Relief participants will receive result summaries. Trial registration number NCT05152134 .

Psychophysiologic symptom relief therapy for chronic back pain: hypothesis and trial rationale

Article

Full-text available

Jul 2024

Chronic pain syndromes affect over one-third of the US adult population and often lead to significant disability and a reduced quality of life. Despite their high prevalence, causal links between chronic pain syndromes and anatomic abnormalities are often not apparent. Most current chronic pain treatments provide modest, if any, relief. Thus, there is a pressing need to understand the causal mechanisms implicated in chronic pain as a means to develop more targeted interventions for improvement in clinical outcomes and reduction in morbidity and financial burden. In the present manuscript, we summarize the current literature on treatment for chronic pain, and hypothesize that non-specific chronic back pain (without a clear organic etiology, such as tumors, infections or fractures) is of psychophysiologic origin. Based on this hypothesis, we developed Psychophysiologic Symptom Relief Therapy (PSRT), a novel pain reduction intervention for understanding and treating chronic pain. In this manuscript, we provide the rationale for PSRT, which we have tested in a pilot trial with a subsequent larger randomized trial underway. In the proposed trial, we will evaluate whether non-specific chronic back pain can be treated by addressing the underlying stressors and psychological underpinnings without specific physical interventions.

Meditation for perioperative pain and anxiety: A systematic review

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Full-text available

Jul 2024

Introduction Effective pain and anxiety management during the perioperative phase remains a challenge for patients undergoing surgeries and other invasive procedures. The current standard of care involves prescribing analgesics to treat these conditions; however, there has been recent interest in applying multimodal strategies that limit the use of these medications. One such modality is meditation, which has been shown to be effective in alleviating various physical and psychological symptoms in other settings. This systematic review aims to assess how current meditative practices affect perioperative pain and anxiety. Methods We conducted a systematic review of randomized controlled trials following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. A comprehensive literature search was conducted using PubMed MEDLINE, Embase, PsycINFO, APA PsycINFO, EBM Reviews, Scopus, and Web of Science for all available dates. Our primary outcomes of interest were patient‐reported pain and anxiety scores using the Visual Analog Scale, the Brief Pain Inventory, the Depression Anxiety Stress Scale, the State‐Trait Anxiety Inventory (STAI), and the Hospital Anxiety and Depression Scale (HADS). For the HADS and STAI scales, only the anxiety and anxiety‐state subgroups were reported, respectively. Results The literature search yielded 1746 articles. A total of 286 full‐text articles were screened, and 16 studies were included in this systematic review. A total of eight studies assessed pain scores after invasive procedures; five reported improvements in pain scores, and three reported no change after meditative practices. Ten studies assessed anxiety outcomes after invasive procedures: nine reported a decrease in overall anxiety levels as a result of meditation practices while one study reported no change in anxiety scores. Conclusion Data from this limited literature suggests that different meditation practices could be effective in alleviating pain and anxiety within the perioperative phase for patients undergoing various types of invasive procedures. Future prospective studies are needed to determine whether routine meditation in the perioperative setting is effective in mitigating perioperative pain and anxiety.

Chronic pain management and a comprehensive approach for integration of Ayurveda with modern medicine

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Full-text available

Jul 2023

Rajeev Gupta

This paper aims to provide a comparative analysis of pain relief techniques for chronic pain management in Ayurveda and modern medicine. The analysis is based on available literature and evidence of efficacy. The paper also explores the commonalities between these disciplines and suggests methods for integrating both disciplines for effective pain management.

The Efficacy of Integrative Medicine in Managing Chronic Pain

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Full-text available

Aug 2023

Rajia Rajia

Purpose: This study investigates the efficacy of integrative medicine in managing chronic pain, exploring various complementary therapies such as acupuncture and mindfulness-based stress reduction. Research Design and Methodology: Using a mixed-methods approach, this study conducted a systematic review of existing literature and analyzed quantitative data to assess the impact of integrative interventions on chronic pain outcomes. Findings and Discussion: The research findings suggest integrative medicine modalities, including acupuncture and mindfulness-based interventions, demonstrate promising results in reducing pain intensity, improving physical function, and enhancing overall well-being among chronic pain sufferers. However, limitations such as small sample sizes and short-term follow-up periods underscore the need for further research to validate these findings and explore long-term efficacy. Implications: These findings significantly impact scientific knowledge and clinical practice in chronic pain management. Integrative medicine offers a holistic and patient-centered approach that complements conventional treatments, highlighting the potential to address the multifaceted nature of chronic pain and improve patient's quality of life. Future research should focus on overcoming methodological limitations and integrating integrative approaches into mainstream healthcare to optimize patient care.

Experimental Setup for Evaluating Depth Sensors in Augmented Reality Technologies Used in Medical Devices

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Full-text available

Jun 2024
SENSORS-BASEL

This paper presents a fully automated experimental setup tailored for evaluating the effectiveness of augmented and virtual reality technologies in healthcare settings for regulatory purposes, with a focus on the characterization of depth sensors. The setup is constructed as a modular benchtop platform that enables quantitative analysis of depth cameras essential for extended reality technologies in a controlled environment. We detail a design concept and considerations for an experimental configuration aimed at simulating realistic scenarios for head-mounted displays. The system includes an observation platform equipped with a three-degree-of-freedom motorized system and a test object stage. To accurately replicate real-world scenarios, we utilized an array of sensors, including commonly available range-sensing cameras and commercial augmented reality headsets, notably the Intel RealSense L515 LiDAR camera, integrated into the motion control system. The paper elaborates on the system architecture and the automated data collection process. We discuss several evaluation studies performed with this setup, examining factors such as spatial resolution, Z-accuracy, and pixel-to-pixel correlation. These studies provide valuable insights into the precision and reliability of these technologies in simulated healthcare environments.

Mind-Body Medicine: A Funder´s Perspective

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Jun 2024

Rainer Lüdtke

Periodontal Health and Its Relationship with Psychological Stress: A Cross-Sectional Study

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Full-text available

May 2024

Background: Studies suggest that chronic psychological stress can lead to oral health deterioration, alter the immune response, and possibly contribute to increased inflammation, which can impact the physiological healing of periodontal tissues. This cross-sectional study seeks to assess and improve clinical understanding regarding the relationship between perceived stress, mindfulness, and periodontal health. Methods: A total of 203 people were analyzed from December 2022 to June 2023. The Periodontal Screening and Recording (PSR) score and Gingival Bleeding Index (GBI), and Plaque Control Record (PCR) of every patient were registered. Subsequently, participants completed the Sheldon Cohen Perceived Stress Scale (PSS) and the Mindfulness Awareness Attention Scale (MAAS) questionnaires. The collected data underwent statistical analysis, encompassing the evaluation of correlations and dependencies. Applying Welch’s t-test to assess the relationship between MAAS and the variable indicating the presence or absence of periodontitis, a noteworthy p-value of 0.004265 was obtained. Results: This underscores a significant distinction in MAAS scores between patients affected by periodontitis and those unaffected by the condition. Additionally, Pearson correlations were computed for GBI and perceived stress, PCR and perceived stress, PCR and MAAS. The resulting p-values of 2.2–16, 3.925–8, and 2.468–8, respectively, indicate a statistically significant correlation in each instance. Conclusions: These findings contribute valuable insights into the interconnectedness of these variables, emphasizing the significance of their associations in the study context. Despite the limitations, the findings of this study suggest a significant relationship between psychological stress, mindfulness, and periodontal tissue health. Clinical trials are necessary to incorporate the assessment of a patient’s psychological status as a new valuable tool in the management of periodontal health.

Impact Of Meditation On Mental Health And Well-Being

Article

Full-text available

May 2023

Ambrien Ahmed

With a growing interest in meditation as a means of enhancing overall well-being, it is essential to understand the effects of meditation on mental health outcomes. The review reveals consistent findings indicating that meditation practices have a positive impact on mental health and well-being. Cross-sectional studies demonstrate that individuals who engage in regular meditation exhibit lower levels of anxiety, depression, and perceived stress. Controlled studies, including randomized controlled trials, provide stronger evidence, showing that meditation interventions effectively reduce symptoms of mental health disorders and improve psychological well-being. Intervention studies further highlight the benefits of meditation practices in improving attention, cognitive functioning, emotional regulation, and overall subjective well-being. The findings suggest that meditation practices can be valuable tools for promoting mental health and well-being. It highlights the potential of meditation as an effective approach for reducing symptoms of mental health disorders, enhancing psychological well-being, and improving overall quality of life. However, there are areas in need of further research, such as understanding the underlying mechanisms of action, determining optimal dosage and duration of meditation practice, and exploring the long-term effects of meditation.

Feasibility of Web-Based Single-Session Empowered Relief in Patients With Chronic Pain Taking Methadone or Buprenorphine: Protocol for a Single-Arm Trial

Article

Full-text available

Jun 2024

Background: Chronic pain affects tens of millions of US adults and continues to rise in prevalence. Nonpharmacologic behavioral pain treatments are greatly needed and yet are often inaccessible, particularly in settings where medication prescribing is prioritized. Objective: This study aims to test the feasibility of a live-instructor, web-based 1-session pain relief skills class in an underserved and potentially at-risk population: people with chronic pain prescribed methadone or buprenorphine either solely for pain or for comorbid opioid use disorder (OUD). Methods: This is a national, prospective, single-arm, uncontrolled feasibility trial. The trial is untethered from medical care; to enhance participants’ willingness to join the study, no medical records or drug-monitoring records are accessed. At least 45 participants will be recruited from outpatient pain clinics and from an existing research database of individuals who have chronic pain and are taking methadone or buprenorphine. Patient-reported measures will be collected at 6 time points (baseline, immediately post treatment, 2 weeks, and months 1-3) via a web-based platform, paper, or phone formats to include individuals with limited internet or computer access and low literacy skills. At baseline, participants complete demographic questions and 13 study measures (Treatment Expectations, Body Pain Map, Medication Use, Pain Catastrophizing Scale [PCS], Patient-Reported Outcomes Measurement Information System [PROMIS] Measures, and Opioid Craving Scale). Immediately post treatment, a treatment satisfaction and acceptability measure is administered on a 0 (very dissatisfied) to 10 (completely satisfied) scale, with 3 of these items being the primary outcome (perceived usefulness, participant satisfaction, and likelihood of using the skills). At each remaining time point, the participants complete all study measures minus treatment expectations and satisfaction. Participants who do not have current OUD will be assessed for historical OUD, with presence of OUD (yes or no), and history of OUD (yes or no) reported separately. Feasibility threshold is set as an overall group treatment satisfaction rating of 8 of 10. In-depth qualitative interviews will be conducted with about 10 participants to obtain additional data on patient perceptions, satisfactions, needs, and wants. To assess preliminary efficacy, we will examine changes in pain catastrophizing, pain intensity, pain bothersomeness, sleep disturbance, pain interference, depression, anxiety, physical function, global impression of change, and opioid craving at 1 month post treatment. Results: This project opened to enrollment in September 2021 and completed the recruitment in October 2023. The data collection was completed in February 2024. Results are expected to be published in late 2024. Conclusions: Results from this trial will inform the feasibility and preliminary efficacy of Empowered Relief in this population and will inform the design of a future randomized controlled trial testing web-based Empowered Relief in chronic pain and comorbid OUD.

اثر برنامج ارشادي لتخفيف الافلاس العاطفي لدى المعنفات من طالبات الجامعة المتزوجات

Article

Oct 2024

Prof. Huda Abdel Razzaq Muhammad Al-Jandil (Ph.D.)

Degenerative Rotator-Cuff Disorders

Article

Nov 2024
NEW ENGL J MED

Problem-solving in people with chronic pain

Article

Full-text available

Jun 2024

O presente estudo objetiva verificar as estratégias e características de resolução de problemas (RP) utilizadas por pessoas com dor crônica. Participaram deste estudo 10 pessoas com dor crônica. As informações foram coletadas por meio de entrevista semiestruturada individual on-line, e submetidas à análise de conteúdo de Bardin. Com base nos fragmentos de discurso, foram elencadas as seguintes categorias de análise: (1) Problemas no cotidiano de pessoas com dor crônica; (2) Definição dos problemas; (3) Estratégias de RP. Os problemas enfrentados pelos participantes estão relacionados com limitações físicas, relações interpessoais, atividades de lazer e o trabalho. Por outro lado, as relações significativas podem ser fontes de conforto e apoio. Os problemas bem definidos no cotidiano dos participantes estão relacionados a limitações físicas, ao trabalho e às dificuldades psicológicas. As estratégias de RP utilizadas pelos participantes são baseadas na aceitação e na focalização no problema. Conhecer as estratégias de RP mais utilizadas pelos participantes pode direcionar a prática profissional em saúde para um manejo mais efetivo.

Resolução de Problemas de Pessoas com Dor Crônica

Article

Full-text available

Jun 2024

How Bud Craig’s Insights Reshape the Research on Pain and Mind–Body Therapies

Chapter

Oct 2024

Wolf Mehling

With his elegant studies, Bud Craig determined the structural neural basis for interoception and critically expanded our conceptual understanding of it. Importantly, he placed pain in the framework of interoception and redefined pain as a homeostatic emotion. Craig understood emotions and pain as experiences based on inferential brain processes within the theoretical model of prediction processing. This chapter aims to give a brief overview of relevant research. Mind–body therapies, such as meditation, mindfulness, yoga, Tai Chi, and others, are included as first-line non-pharmacological approaches in clinical guidelines for the management of chronic pain. Craig’s groundbreaking work provided the background for our contemporary understanding of mind–body therapies and for the key role that interoceptive processes play in these therapies as they apply to a wide range of clinical conditions, including pain. This chapter reviews the tremendous influence that Craig’s work had on the current state of research on mind–body therapies for managing chronic pain and how it led to new directions for cutting-edge clinical and neuroscientific research.

Decoding Depth of Meditation: EEG Insights from Expert Vipassana Practitioners

Article

Oct 2024

Efficacy of a blended low-intensity internet-delivered psychological programme in patients with multimorbidity in primary care: a randomized controlled trial

Article

Oct 2024
J MED INTERNET RES

Background: Multimorbidity is a highly prevalent phenomenon whose presence causes profound physical, psychological and economic impact. It hinders help-seeking, diagnosis, quality of care and adherence to treatment, and it poses a significant dilemma for present-day health care systems. The aim of this study was to assess the effectiveness of improved treatment as usual (iTAU) combined with a blended, low-intensity psychological intervention delivered using information and communication technologies for the treatment of multimorbidity (depression, and type 2 diabetes or low back pain) in primary care (PC) settings. Methods: A two-armed, parallel group, superiority randomized controlled trial was designed for this study. Participants diagnosed with depression and either type 2 diabetes or low back pain (n=183) were randomized to ‘Intervention + iTAU’ (combining a face-to-face intervention with a supporting online programme), or ‘iTAU’ alone. The main outcome consisted of a standardized composite score that considered (I) severity of depressive symptoms and (IIa) diabetes control or (IIb) pain intensity and physical disability at three months after the end of treatment as the primary endpoint. Differences between the groups were estimated using mixed effects linear regression models, and mediation evaluations were conducted using path analyses to evaluate the potential mechanistic role of positive and negative affectivity, and openness to the future. Results: At three-month follow-up, the Intervention + iTAU group (vs iTAU) exhibited greater reductions in composite multimorbidity score (B = -0.34; 95% CI = -0.64, -0.04; g = 0.39), as well as in depression and negative affect, and improvements in perceived health, positive affect and openness to the future. Similar positive effects were observed post-intervention, also with improvements in physical disability. No significant differences were found in glycosylated haemoglobin, pain intensity or disability at three-month follow-up. Path analyses indicated a significant impact from the intervention on the primary outcome and mediated by positive and negative affect (positive affect: ab = -0.15, bootstrapped 95% CI = -0.28, -0.03); negative affect: ab = -0.14, bootstrapped 95% CI = -0.28, -0.02). Conclusions: The present study supports the efficacy of a low-intensity psychological intervention applied in a blended format on multimorbidity in PC. It justifies exploration of the conceptualization of depression in type 2 diabetes, as well as analysis of the implementation of such interventions in routine clinical practice. Trial registration: ClinicalTrials.gov NCT03426709,

Mindfulness-Based Intervention for Non-Farmacological Pain Control after Total Hip and Total Knee Arthroplasty: a Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Article

Oct 2024

اثر برنامج ارشادي لتخفيف الافلاس العاطفي لدى المعنفات من طالبات الجامعة المتزوجات The effect of a counseling program on the mitigation of emotional Bankruptcy among Abused married university Students

Article

Full-text available

Oct 2024

هدفت الدراسة الى تحديد تأثير برنامج ارشادي لتخفيف الافلاس العاطفي لدى المعنفات من طالبات الجامعة المتزوجات، وقد استخدمت الباحثة منهج البحث التجريبي ،ولاختبار فرضية البحث استخدمت الباحثة التصميم التجريبي للمجموعتين التجريبية و الضابطة ذات الاختبار البعدي ، وتكونت عينة البحث من (60) طالبة تم توزيعهن الى مجموعتين متكافئتين ، بواقع (30) طالبة في كل مجموعة و بعد إجراءات التكافؤ بين المجموعتين في المتغيرات (العمر و الافلاس العاطفي) قامت الباحثة بتطبيق البرنامج الارشادي باسلوب اليقظة الذهنية لتخفيف الافلاس العاطفي مع المجموعة التجريبية ، في حين لم يطبق أي برنامج مع افراد المجموعة الضابطة ، وقامت الباحثة ببناء مقياس الافلاس العاطفي الذي تكون من (24) فقرة وبناء برنامج ارشادي باسلوب اليقظة الذهنية يتكون من(10) جلسات ارشادية واستعملت الباحثة الوسائل الإحصائية لمعالجة بيانات هذا البحث وهي : الاختبار التائي لعينتين مستقلتين والاختبار التائي لعينة واحدة ، والفا كرونباخ ومعامل ارتباط بيرسون. وكانت نتيجة البحث هي : وجود فرق ذو دلالة إحصائية لصالح المجموعة التجريبية على مقياس الافلاس العاطفي بعد تطبيق البرنامج الارشادي باسلوب اليقظة الذهنية في تخفيف الافلاس العاطفي. The study sought to investigate the impact of a counseling intervention aimed at alleviating emotional distress among married university students who have experienced abuse. An experimental research approach was employed by the researcher. In order to assess the research hypothesis, an experimental design was utilized for both the experimental and control groups, followed by a post-test. A total of sixty female students were selected as the research sample and evenly distributed into two groups, with thirty students in each group. Following the establishment of equivalence between the groups in terms of variables such as age and emotional distress, the counseling program was administered to reduce emotional distress in the experimental group, while no intervention was provided to the control group members. The researcher developed a comprehensive emotional distress scale comprising twenty-four items and a structured format. The counseling program, designed in a mindfulness style, consisted of ten counseling sessions. Various statistical methods, including the t-test for two independent samples, Cronbach's alpha, and Pearson's correlation coefficient, were utilized to analyze the research data. The findings of the study revealed a significant statistical difference in favor of the experimental group on the emotional distress scale subsequent to the implementation of the counseling program utilizing a mindfulness approach to alleviate emotional distress.

Mindfulness-Based Interventions for Psychiatry

Chapter

Sep 2024

Psychotherapeutische Interventionen bei Personen mit Multipler Sklerose (MS): Review und Handlungsempfehlungen

Article

Full-text available

Aug 2024

Zusammenfassung: Der psychotherapeutischen Versorgung von Personen mit Multipler Sklerose (MS) kommt eine hohe Relevanz zu. Denn neben den offensichtlichen motorischen und sensorischen Dysfunktionen ist die Lebensqualität der Betroffenen auch durch die sogenannten „unsichtbaren Symptome“ der MS eingeschränkt. Zu diesen unsichtbaren Symptomen zählen depressive Symptome, Fatigue, Angst, Schmerz und kognitive Defizite. Ziel dieses Reviews ist es, einen Überblick über die psychotherapeutischen Behandlungsmöglichkeiten hinsichtlich der einzelnen Symptome, sowie eine Handlungsempfehlung für behandelnde (Neuro-)Psychologinnen und Psychologen und Therapeutinnen und Therapeuten zu geben. Zu diesem Zweck wurde eine (nicht-systematische) Literaturrecherche über PubMed durchgeführt. Der Review ergibt, dass die Verhaltenstherapie (KVT) und Achtsamkeitsbasierte Interventionen (AIs) potenziell wirksame Methoden zur Reduktion der genannten Symptome darstellen, jedoch noch qualitativ hochwertige Studien mit ausreichender Stichprobengröße in diesem Forschungsfeld fehlen.

Integrating Chiropractic Care and Tai Chi Training for the Treatment of Chronic Nonspecific Neck Pain in Nurses: A Single-Arm Mixed-Methods Pilot Trial

Article

Aug 2024

Objectives: Chronic nonspecific neck pain (CNNP) is prevalent among health care workers, with particularly high rates among nurses. Nurses experiencing CNNP often report decreased job satisfaction, increased absenteeism, and reduced productivity. In recent years, nonpharmacologic approaches have gained attention as effective treatments for the management of CNNP, with exercise and manual therapies representing two of the most common. Early evidence shows that multimodal treatments may be more effective than unimodal strategies. The purpose of this current study was to assess the feasibility and observe the clinical outcomes of combined multimodal chiropractic care (MCC) and Tai Chi (TC) for CNNP in nurses. Methods: A single-arm mixed-methods pilot trial was conducted including 16 weeks of MCC and TC in nurses with self-reported CNNP. Feasibility outcomes were recruitment, retention, and adherence to the interventions. Clinical outcomes of interest included neck pain and related disabilities. Secondary outcomes of interest were functional, affective, and work-related performance. Qualitative interviews were also conducted. Results: Of the 59 screened, 36 met the eligibility criteria, and 21 were enrolled. The retention rate was 71.4%, and adherence rates were 85.3% for MCC and 62.5% for TC classes. Multiple pain and disability-related outcomes exhibited modest improvement from baseline to 16-week follow-up. Qualitative analysis identified six emergent themes: (1) neck pain being an inherent part of nursing, (2) nurses push through their pain, (3) MCC relieves pain and is instructive for preventing pain, (4) TC provides overall relaxation, (5) both interventions increased body awareness and improved posture, and (6) scheduling difficulties were a key obstacle for participating. Conclusions: Observed reductions in neck pain and disability suggest the potential utility of combined MCC and TC interventions for managing CNNP. Along with qualitative feedback regarding facilitators and barriers to participation, the findings support and inform a future randomized trial evaluating the combined benefits of MCC and TC for CNNP in nurses. Clinical Trial Registration #NCT06523036.

Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial

Article

Aug 2024

Importance Although mindfulness-based interventions (MBIs) are evidence-based treatments for chronic pain and comorbid conditions, implementing them at scale poses many challenges, such as the need for dedicated space and trained instructors. Objective To examine group and self-paced, scalable, telehealth MBIs, for veterans with chronic pain, compared to usual care. Design, Setting, and Participants This was a randomized clinical trial of veterans with moderate to severe chronic pain, recruited from 3 Veterans Affairs facilities from November 2020 to May 2022. Follow-up was completed in August 2023. Interventions Two 8-week telehealth MBIs (group and self-paced) were compared to usual care (control). The group MBI was done via videoconference with prerecorded mindfulness education and skill training videos by an experienced instructor, accompanied by facilitated discussions. The self-paced MBI was similar but completed asynchronously and supplemented by 3 individual facilitator calls. Main Outcomes and Measures The primary outcome was pain-related function using the Brief Pain Inventory interference scale at 3 time points: 10 weeks, 6 months, and 1 year. Secondary outcomes included biopsychosocial outcomes: pain intensity, physical function, anxiety, fatigue, sleep disturbance, participation in social roles and activities, depression, patient ratings of improvement of pain, and posttraumatic stress disorder. Results Among 811 veterans randomized (mean [SD] age, 54.6 [12.9] years; 387 [47.7%] women), 694 participants (85.6%) completed the trial. Averaged across all 3 time points, pain interference scores were significantly lower for both MBIs compared to usual care (group MBI vs control difference: −0.4 [95% CI, −0.7 to −0.2]; self-paced vs control difference: −0.7 [95% CI, −1.0 to −0.4]). Additionally, both MBI arms had significantly better scores on the following secondary outcomes: pain intensity, patient global impression of change, physical function, fatigue, sleep disturbance, social roles and activities, depression, and posttraumatic stress disorder. Both group and self-paced MBIs did not significantly differ from one another. The probability of 30% improvement from baseline compared to control was greater for group MBI at 10 weeks and 6 months, and for self-paced MBI, at all 3 time points. Conclusions and Relevance In this randomized clinical trial, scalable telehealth MBIs improved pain-related function and biopsychosocial outcomes compared to usual care among veterans with chronic pain. Relatively low-resource telehealth-based MBIs could help accelerate and improve the implementation of nonpharmacological pain treatment in health care systems. Trial Registration ClinicalTrials.gov Identifier: NCT04526158

Multidisciplinary options for the correction of chronic nonspecific low back pain syndrome (literature review)

Article

Aug 2024

Chronic back pain is the complaint with which patients most often seek medical help from general practitioners, neurologists, surgeons, traumatologists and other subspecialists. Pain in the lower back can be either nonspecific, i. e., have no specific nosologic cause, or be specific, i. e., have a certain pathophysiologic mechanism of occurrence due to both spinal and extra-spinal causes. This fact determines the importance of complex and multidisciplinary assessment of the characteristics of chronic low back pain syndrome. The aim of the present study was to investigate the possibility of realizing a multidisciplinary approach in the treatment of nonspecific low back pain syndrome. Results. Low back pain is pain that is localized between the twelfth pair of ribs and the gluteal folds. It is not always possible to determine the source of pain when it is nonspecific; moreover, there is no convincing evidence that clarification of localization will favorably affect the course and outcome of the disease. There are three main causes of nonspecific low back pain: myofascial syndrome; pathology of joints and ligamentous apparatus of the spine; and lumbar osteochondrosis, which is a natural process of degeneration of spinal structures and is observed to varying degrees in all people, increasing significantly with age. It is believed that the pain syndrome of the back region has a multifaceted pathophysiology, which is influenced by somatic pathology, psychological and social factors. This explains the need for an integrated multidisciplinary approach to a particular patient and the compilation of an individual program of treatment, rehabilitation and prevention of subsequent exacerbations. Multidisciplinary approach means complex coordinated parallel work of specialists aimed at solving the problem of chronic pain. Conclusion. Multidisciplinary approach to the treatment of patients with chronic nonspecific low back pain syndrome is more effective than monotherapy, because it takes into account individual features of clinical symptoms, allows to carry out treatment and rehabilitation according to an individual plan, including a set of interrelated measures aimed at improving the quality of life of the patient and his functional capabilities.

Combined Physiotherapy and Cognitive Behavioral Therapy for Functional Movement Disorders: A Randomized Clinical Trial

Article

Aug 2024

Importance Functional movement disorders (FMDs) are frequent and disabling neurological disorders with a substantial socioeconomic impact. Few randomized studies have analyzed the effectiveness of combined physiotherapy and psychotherapy in patients’ quality of life. Objective To assess the efficacy of multidisciplinary treatment (physiotherapy plus cognitive behavioral therapy) in FMDs. Design, Setting, and Participants This was a parallel, rater-blinded, single-center, randomized clinical trial. Recruitment took place from June 2022 to April 2023, and follow-up visits were performed at months 3 and 5, concluding in October 2023. Participants were recruited from a national referral center for movement disorders: the Movement Disorders Unit from the Hospital Universitario Virgen Rocio in Seville, Spain. Patients had to be 18 years or older with a confirmed FMD diagnosis and capable of giving consent to participate. Patients who did not meet eligibility criteria or refused to participate were excluded. Any uncontrolled psychiatric disorder was considered an exclusion criterion. Interventions Patients were randomly assigned, in a ratio of 1:1 to multidisciplinary treatment (physiotherapy plus cognitive behavioral therapy), or a control intervention (psychological support intervention). Main Outcomes and Measures Primary outcomes: between-group differences in changes from baseline to month 3 and month 5 in patients’ quality of life (EQ-5D-5L score: EQ Index and EQ visual analog scale [EQ VAS]; and 36-Item Short-Form Survey Physical Component Summary [SF-36 PCS] and SF-36 Mental Component Summary [MCS]). Linear mixed models were applied, controlling by baseline severity and applying Bonferroni correction. Results Of 70 patients screened with an FMD, 40 were enrolled (mean [SD] age, 43.5 [12.8] years; age range, 18-66 years; 32 female [80%]; mean [SD] age at FMD onset, 38.4 [12.1] years), and 38 completed all the follow-up visits and were included in the analysis for primary outcomes. Multidisciplinary treatment improved SF-36 PCS with a mean between-group difference at 3 months of 4.23 points (95% CI, −0.9 to 9.4 points; P = .11) and a significant mean between-group difference at 5 months of 5.62 points (95% CI, 2.3-8.9 points; P < .001), after multiple-comparisons adjustment. There were no significant differences in other quality-of-life outcomes such as SF-36 MCS (mean between-group difference at 3 and 5 months: 0.72 points; 95% CI, −5.5 to 7.0 points; P = .82 and 0.69 points; 95% CI, 2.3-8.9 points; P = .83, respectively), EQ VAS (9.34 points; 95% CI, −0.6 to 19.3 points; P = .07 and 13.7 points; 95% CI, −1.7 to 29.0 points; P = .09, respectively) and EQ Index (0.001 point; 95% CI, −0.1 to 0.1 point; P = .98 and 0.08 points; 95% CI, 0-0.2 points; P = .13, respectively). At months 3 and 5, 42% and 47% of patients, respectively, in the multidisciplinary group reported improved health using the EQ-5D system, compared with 26% and 16% of patients, respectively, in the control group. Conclusions and Relevance Results show that multidisciplinary treatment (physiotherapy plus cognitive behavioral therapy) effectively improves FMD symptoms and physical aspects of patients’ quality of life. Further studies must be performed to evaluate the potential cost-effectiveness of this approach in FMD. Trial Registration ClinicalTrials.gov Identifier: NCT05634486

Emerging Use of Yogic Techniques and Behavioural Approaches in Pain Management

Chapter

Jul 2024

Yoga is a physical and mental exercise regimen that has its roots in India and has been practised for thousands of years. It offers a chance to work on the body and mind simultaneously. Pain is defined as unpleasant bodily sensations that heighten our sensitivity. Pain results from nervous system activity. Chronic pain is a considerably more complicated issue that can have an impact on a person’s biological, psychological, social, functional, and financial elements of life. It is evident that chronic pain has been associated with ambit negative impact on physical health and also higher probability of developing mental health problems. Yoga, as an adjunct treatment for chronic pain, has emerged as a potential intervention. The bio-psychosocial medical approach, which views pain as a complex relation between physiological, psychological, and social aspects, is one that Yoga incorporates. In pain management non-pharmacological intervention has proven to be effective along with pharmacological treatment, that is Yoga, behavioural and bio-psychosocial models, mindfulness, therapeutic neurosciences intervention, progressive muscle relaxation, and other alternative treatments. Therefore, in order to address the psychological component of pain, a well-designed multidisciplinary pain management programme is required.

Meditation and Compassion Therapy in Psychiatric Disorders: A Pilot Study

Article

Full-text available

Jul 2024

Introduction Our study aimed to compare meditation and compassion-based group therapy with the standard of care in patients with eating disorders, drug addiction, alcohol addiction, and depression, concerning acceptance, mindfulness awareness, self-compassion, and psychological distress. Methods A controlled designed study was performed, comparing meditation and compassion-focused group therapy added to the standard of care with the standard of care alone, on patients with eating disorders, drug addiction, alcohol addiction, and mood disorders. Four validated questionnaires were administered: the Acceptance and Action Questionnaire-II (AAQ-II), which assesses the ability to be fully in touch with the present moment; the Mindful Attention Awareness Scale (MAAS), which assesses the ability to experience consciously what is happening in the present moment; the Self-Compassion Scale (SCS), which assesses self-compassion characteristics, including loving-kindness; and the Symptom Checklist-90 (SCL-90), which measures psychological distress (anxiety, depression, psychotic behavior, etc.). Results There was a total of 75 subjects, out of which 48 represented the experimental group, and 27 represented the control group. The overall mean age of the subjects was 44.8 ± 13.2 years. There were statistically significant increases in the experimental group (baseline vs. end of study) for the AAQ-II, MAAS, and SCS scores, and a statistically significant decrease in the SCL-90 score. In the control group, there was a statistically significant decrease in the SCL-90 score, but no significant differences for other measurements. The comparisons between the two groups at the end of the study were as follows: AAQ-II: 0.7 (-5.74 to 7.15), p = 0.827; MAAS: 4.78 (-3.19 to 12.75), p = 0.233; SCS: 5.89 (-3.18 to 14.96), p = 0.199; SCL-90: -0.26 (-0.62 to 0.1), p = 0.157. Conclusion Within the experimental group, all scales improved statistically significantly. There were no statistically significant differences at the end of the study concerning the four scales between the groups. The comparison between groups was limited by data availability.

“What helps your back pain?” A qualitative analysis of pain management strategies in opioid-treated adults with chronic low back pain

Article

May 2024

Objective: The purpose of this qualitative analysis was to better understand what pain management strategies adults with opioid-treated chronic low back pain (CLBP) found most helpful. Design: A subgroup of participants from a larger randomized control trial of two psychological interventions were asked: "What helps your back pain?" at baseline and 12 months (exit) in brief, video-recorded interviews. Videos were analyzed using qualitative thematic content analysis utilizing Transana™. Setting: Participants were recruited from the community and outpatient clinics in three United States sites. Participants: Seventy-nine adults with long-term (≥3 months) opioid-treated (≥15 mg/day morphine equivalent) CLBP. Main outcome measure(s): Participants' baseline and exit qualitative responses to the question "What helps your back pain?" Results: At baseline, participants identified medication (n = 63), body position (n = 59), thermal application (n = 50), physical activity (n = 49), and stretching (n = 24) as the CLBP management strategies they found helpful. At exit, the reports of medication (n = 55), physical activity (n = 41), and stretching (n = 21) were often considered helpful for CLBP and remained relatively stable, while position (n = 36) and thermal application (n = 35) strategies were mentioned less frequently and psychological strategies (n = 29) were mentioned more frequently (up from n = 5) compared to baseline. Conclusions: Over time, the reports of medication and active pain management strategies, eg, physical activity, remained stable, while the reports of some passive pain management strategies, eg, position and thermal, declined over time. Increased use of psychological strategies implies that study interventions were incorporated as useful pain self-management strategies.

THE COMPARISON OF THE EFFECTIVENESS OF BIBLIOTHERAPY, BEHAVIORAL ACTIVATION THERAPY AND MINDFULNESS-BASED COGNITIVE THERAPY ON PSYCHOLOGICAL DISTRESS IN FEMALES WITH TYPE 2 DIABETES: A SEMI EXPERIMENTAL STUDY

Article

Full-text available

May 2024

The hidden cost of chronic pain: A narrative review of the environmental impact of outpatient spine and musculoskeletal care

Article

Jul 2024

Health care is a major driver of greenhouse gas emissions and is closely intertwined with industrial processes responsible for air, water, and soil pollution. Chronic pain – particularly as it relates to spine and musculoskeletal diagnoses – comprises a significant portion of health care utilization and affects millions of people worldwide. Despite the prevalence of chronic spine and musculoskeletal pain, there has been limited discussion of the environmental impacts of outpatient clinics and interventional processes as they relate to these conditions. This narrative review explores the environmental impact related to diagnostics, pharmacologics, and common nonoperative interventional procedures utilized in the management of patients with chronic musculoskeletal and spine pain. Topics explored include energy utilization, production and disposal of pharmaceuticals, and waste production from interventional procedures. This study aims to educate providers involved in spine and musculoskeletal disease management regarding the possible environmental consequences of their practices. The article also focuses on modifying approaches to patient care to those that are more sustainable as well as highlighting areas in need of further investigation.

An Integrative Approach to the Development of the "Mental Retreat" Wellness Program to Prevent Early Aging

Article

Full-text available

Mar 2024

In today's society, where everyday challenges and pressures can significantly impact one's psych-emotional state, it is crucial to develop effective stress reduction strategies and maintain mental well-being. Prolonged stress, as recognized in global practice, can trigger the development of various ailments, such as cardiovascular pathologies, endocrine disorders, and psychosomatic deviations, and can also predispose individuals to autoimmune and oncological conditions. Furthermore, the influence of stressful situations over one's lifetime is a well-acknowledged risk factor that heightens the likelihood of early-onset age-associated illnesses and premature death. The primary objective of this study is to analyze and assess the effectiveness of health-promoting procedures in reducing stress levels and to develop a comprehensive wellness Program called "Mental Retreat." The application of this Program aims to mitigate the risk of various chronic diseases and preempt changes at the gene expression level to decelerate intracellular aging, enhance the body's antioxidant system, and stimulate the immune system. This work lays the groundwork for understanding the effects of procedures with substantial empirical support, highlighting synergistic influences in their combination, such as meditative practices, respiratory exercises, aromatherapy, outdoor physical activities, thermal and contrast procedures with elements of aroma and halotherapy, as well as lymphatic drainage massage effects, among others. The developed wellness Program is intended to be evaluated through dynamic observation and monitoring of integrative organism indicators: based on results from bioimpedance analysis (body composition), assessment of stress levels, and biological age accounting for the imbalance between the parasympathetic and sympathetic nervous systems and heart rate variability. Based on a global analysis of existing research, it has been found that the use of a variety of wellness methods has proven to improve concentration and overall psycho-emotional well-being, have a positive effect on the respiratory and cardiovascular systems, promote relaxation and improve sleep, strengthen the immune system and metabolism, increase stress tolerance, and can also have a positive effect on skin health. It's worth underscoring that the successful implementation of such a wellness Program could have immense implications for public healthcare by preventing the onset of numerous chronic diseases and contributing to an overall enhancement of quality of life.

Telehealth Mindful Exercise for People with Knee Osteoarthritis: A Decentralized Feasibility Randomized Controlled Trial

Article

Jun 2024

Objective Negative psychological beliefs like fear avoidance and catastrophizing can interfere with exercise engagement in people with knee osteoarthritis (OA). Mindfulness, when integrated with exercise, could potentially address both psychological and physical impairments. Our objectives were to optimize and assess the feasibility of a novel telehealth, group-based mindful exercise intervention for people with knee OA. Methods We conducted a decentralized randomized controlled trial where participants (n = 40) with symptomatic knee OA were randomized into mindful exercise (n = 21) or exercise-only (n = 19) groups. Both groups received supervised group-based interventions weekly for 8-weeks via Zoom. Primary outcomes were safety, fidelity, and feasibility of the mindful exercise intervention. Participants completed patient-reported outcomes (PRO) for pain, function, and psychological measures at baseline, week-8, and week-14. Results Participants were from 21 US states; >90% identified as having White race, 16% were from rural areas, and approximately 40% had an annual income < $50,000. At 8-weeks, mindful exercise and exercise groups had retention rates of 86% (18/21) and 100% (19/19), and attendance was 54% (11.4/21) and 68% (13/19) respectively. There were no adverse events in the mindful exercise group and four in the exercise group related to exacerbation of knee pain. Preliminary findings showed numerically larger improvements in several PROs for the mindful exercise group. Conclusion An 8-week telehealth, group-based, mindful exercise intervention was safe for people with knee OA. Our decentralized approach was feasible in terms of recruitment and retention. Further refinement is needed to improve intervention attendance and participant diversity.

Efficacy of mindfulness-based Stress reduction on reducing catastrophizing and pain intensity in patients suffering chronic musculoskeletal pain

Article

May 2024

Maryam Amini Fasakhoudi

Aim and Background: Chronic pain is a degenerative and disabling situation which is accompanied by several psychological variables. Therefore, this study aimed at investigating results the effectiveness of mindfulness-based stress reduction (MBSR) in reduction of catastrophizing, and pain intensity in patients suffering musculoskeletal chronic pain. Materials and methods: The present study was an sub - experimental study with pre-test and post-test design and a control group. The study statistical population included all the patients with musculoskeletal chronic pain referred to the professional clinic of pain of Tabriz in 2014 who overall, 40 patients were selected through purposive non-random sampling method based on pain specialist diagnosis, and clinical interview. Then participants were randomly allocated into two experimental and control groups. The instrumentals of this study were catastrophizing scale (PCS) and visual analog scale (VAS) who participants completed in pre-test and post-test. Descriptive statistical methods and covariance analysis were used for analysis of the data. Findings: The results showed that training mindfulness based stress was effective in reducing catastrophizing, and pain intensity in patients. Conclusion: Performing psychological treatments beside medicine treatment is effective in treating patients suffering chronic musculoskeletal pain. Keywords: Mindfulness based stress reduction, catastrophizing, pain intensity. and chronic musculoskeletal pain. Shafiei

Postoperative Negative Pain Thoughts and Their Correlation With Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair: An Observational Cohort Study

Article

May 2024

Background Pain and pain perception are influenced by patients’ thoughts. The short form Negative Pain Thoughts Questionnaire (NPTQ-SF) can be used to quantify unhelpful negative cognitive biases about pain, but the relationship between NPTQ-SF scores and orthopaedic surgery outcomes is not known. Purpose/Hypothesis The purpose was to assess the relationship between negative pain thoughts, as measured by the NPTQ-SF, and patient-reported outcomes in patients undergoing arthroscopic rotator cuff repair, as well as to compare NPTQ-SF scores and outcomes between patients with and without a history of chronic pain and psychiatric history. It was hypothesized that patients with worse negative pain thoughts would have worse patient-reported outcomes. Study Design Cohort study; Level of evidence, 2. Methods In total, 109 patients undergoing arthroscopic rotator cuff repair were administered the 4-item NPTQ-SF, 12-item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons (ASES) Shoulder Evaluation Form, and visual analog scale pain survey preoperatively between July 2021 and August 2022. The same surveys were completed ≥6 months postoperatively by 74 patients confirmed to have undergone arthroscopic rotator cuff repair. Results Preoperative NPTQ-SF scores did not show any correlation with the postoperative patient-reported outcomes measured in this study. Postoperative NPTQ-SF scores were statistically significantly negatively correlated with postoperative SF-12 Physical Health Score, SF-12 Mental Health Score, ASES, and satisfaction scores ( P < .05). Postoperative NPTQ-SF scores were statistically significantly positively correlated with postoperative visual analog scale scores ( P < .001). Moreover, postoperative NPTQ-SF scores were statistically significantly negatively correlated with achieving a Patient Acceptable Symptom State and the minimal clinically important difference on the postoperative ASES form ( P < .001 and P = .009, respectively). Conclusion Postoperative patient thought patterns and their perception of pain are correlated with postoperative outcomes after rotator cuff repair. This correlation suggests a role for counseling and expectation management in the postoperative setting. Conversely, preoperative thought patterns regarding pain, as measured by the NPTQ-SF, do not correlate with postoperative patient-reported outcome measures. Therefore, the NPTQ-SF should not be used as a preoperative tool to aid the prediction of outcomes after rotator cuff repair.

Pain Catastrophizing: How Far Have We Come

Article

Full-text available

Apr 2024

The perception of pain is strongly influenced by various social, emotional, and cognitive factors. A psychological variable which has consistently been shown to exert its influence on pain is a cognitive process referred to as pain catastrophizing. Numerous studies have found it to be a strong predictor of pain intensity and disability across different clinical populations. It signifies a maladaptive response to pain marked by an exaggerated negative assessment, magnification of symptoms related to pain, and, in general, a tendency to experience marked pain-related worry, as well as experiencing feelings of helplessness when it comes to dealing with pain. Pain catastrophizing has been correlated to many adverse pain-related outcomes, including poor treatment response, unsatisfactory quality of life, and high disability related to both acute and chronic pain. Furthermore, there has been consistent evidence in support of a correlation between pain catastrophizing and mental health disorders, such as anxiety and depression. In this review, we aim to provide a comprehensive overview of the current state of knowledge regarding pain catastrophizing, with special emphasis on its clinical significance, and emerging treatment modalities which target it.

A Mind-Body Program for Older Adults With Chronic Low Back Pain: A Randomized Clinical Trial

Article

Full-text available

Dec 2017

Importance Treatment of chronic low back pain (LBP) in older adults is limited by the adverse effects of analgesics. Effective nonpharmacologic treatment options are needed. Objective To determine the effectiveness of a mind-body program at increasing function and reducing pain in older adults with chronic LBP. Design, setting, and participants This single-blind, randomized clinical trial compared a mind-body program (n = 140) with a health education program (n = 142). Community-dwelling older adults residing within the Pittsburgh metropolitan area were recruited from February 14, 2011, to June 30, 2014, with 6-month follow-up completed by April 9, 2015. Eligible participants were 65 years or older with functional limitations owing to their chronic LBP (≥ 11 points on the Roland and Morris Disability Questionnaire) and chronic pain (duration ≥ 3 months) of moderate intensity. Data were analyzed from March 1 to July 1, 2015. Interventions The intervention and control groups received an 8-week group program followed by 6 monthly sessions. The intervention was modeled on the Mindfulness-Based Stress Reduction program; the control program, on the ”10 Keys” to Healthy Aging. Main outcomes and measures Follow-up occurred at program completion and 6 months later. The score on the Roland and Morris Disability Questionnaire was the primary outcome and measured functional limitations owing to LBP. Pain (current, mean, and most severe in the past week) was measured with the Numeric Pain Rating Scale. Secondary outcomes included quality of life, pain self-efficacy, and mindfulness. Intent-to-treat analyses were conducted. Results Of 1160 persons who underwent screening, 282 participants enrolled in the trial (95 men [33.7%] and 187 women [66.3%]; mean [SD] age, 74.5 [6.6] years). The baseline mean (SD) Roland and Morris Disability Questionnaire scores for the intervention and control groups were 15.6 (3.0) and 15.4 (3.0), respectively. Compared with the control group, intervention participants improved an additional –1.1 (mean, 12.1 vs 13.1) points at 8 weeks and –0.04 (mean, 12.2 vs 12.6) points at 6 months (effect sizes, –0.23 and –0.08, respectively) on the Roland and Morris Disability Questionnaire. By 6 months, the intervention participants improved on the Numeric Pain Rating Scale current and most severe pain measures an additional –1.8 points (95% CI, –3.1 to –0.05 points; effect size, –0.33) and –1.0 points (95% CI, –2.1 to 0.2 points; effect size, –0.19), respectively. The changes in Numeric Pain Rating Scale mean pain measure after the intervention were not significant (–0.1 [95% CI, –1.1 to 1.0] at 8 weeks and –1.1 [95% CI, –2.2 to –0.01] at 6 months; effect size, –0.01 and –0.22, respectively). Conclusions and relevance A mind-body program for chronic LBP improved short-term function and long-term current and most severe pain. The functional improvement was not sustained, suggesting that future development of the intervention could focus on durability.

The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis

Article

Full-text available

Aug 2015
PLOS ONE

To assess whether cognitive behavioural (CB) approaches improve disability, pain, quality of life and/or work disability for patients with low back pain (LBP) of any duration and of any age. Nine databases were searched for randomised controlled trials (RCTs) from inception to November 2014. Two independent reviewers rated trial quality and extracted trial data. Standardised mean differences (SMD) and 95% confidence intervals were calculated for individual trials. Pooled effect sizes were calculated using a random-effects model for two contrasts: CB versus no treatment (including wait-list and usual care (WL/UC)), and CB versus other guideline-based active treatment (GAT). The review included 23 studies with a total of 3359 participants. Of these, the majority studied patients with persistent LBP (>6 weeks; n=20). At long term follow-up, the pooled SMD for the WL/UC comparison was -0.19 (-0.38, 0.01) for disability, and -0.23 (-0.43, -0.04) for pain, in favour of CB. For the GAT comparison, at long term the pooled SMD was -0.83 (-1.46, -0.19) for disability and -0.48 (-0.93, -0.04) for pain, in favour of CB. While trials varied considerably in methodological quality, and in intervention factors such as provider, mode of delivery, dose, duration, and pragmatism, there were several examples of lower intensity, low cost interventions that were effective. CB interventions yield long-term improvements in pain, disability and quality of life in comparison to no treatment and other guideline-based active treatments for patients with LBP of any duration and of any age. PROSPERO protocol registration number: CRD42014010536.

Comparison of complementary and alternative medicine with conventional mind-body therapies for chronic back pain: Protocol for the Mind-body Approaches to Pain (MAP) randomized controlled trial

Article

Full-text available

Jun 2014
TRIALS

Background The self-reported health and functional status of persons with back pain in the United States have declined in recent years, despite greatly increased medical expenditures due to this problem. Although patient psychosocial factors such as pain-related beliefs, thoughts and coping behaviors have been demonstrated to affect how well patients respond to treatments for back pain, few patients receive treatments that address these factors. Cognitive-behavioral therapy (CBT), which addresses psychosocial factors, has been found to be effective for back pain, but access to qualified therapists is limited. Another treatment option with potential for addressing psychosocial issues, mindfulness-based stress reduction (MBSR), is increasingly available. MBSR has been found to be helpful for various mental and physical conditions, but it has not been well-studied for application with chronic back pain patients. In this trial, we will seek to determine whether MBSR is an effective and cost-effective treatment option for persons with chronic back pain, compare its effectiveness and cost-effectiveness compared with CBT and explore the psychosocial variables that may mediate the effects of MBSR and CBT on patient outcomes. Methods/Design In this trial, we will randomize 397 adults with nonspecific chronic back pain to CBT, MBSR or usual care arms (99 per group). Both interventions will consist of eight weekly 2-hour group sessions supplemented by home practice. The MBSR protocol also includes an optional 6-hour retreat. Interviewers masked to treatment assignments will assess outcomes 5, 10, 26 and 52 weeks postrandomization. The primary outcomes will be pain-related functional limitations (based on the Roland Disability Questionnaire) and symptom bothersomeness (rated on a 0 to 10 numerical rating scale) at 26 weeks. Discussion If MBSR is found to be an effective and cost-effective treatment option for patients with chronic back pain, it will become a valuable addition to the limited treatment options available to patients with significant psychosocial contributors to their pain. Trial registration Clinicaltrials.gov Identifier: NCT01467843.

Cognitive-Behavioral Therapy for Individuals With Chronic Pain Efficacy, Innovations, and Directions for Research

Article

Full-text available

Feb 2014

Over the past three decades, cognitive-behavioral therapy (CBT) has become a first-line psychosocial treatment for individuals with chronic pain. Evidence for efficacy in improving pain and pain-related problems across a wide spectrum of chronic pain syndromes has come from multiple randomized controlled trials. CBT has been tailored to, and found beneficial for, special populations with chronic pain, including children and older adults. Innovations in CBT delivery formats (e.g., Web-based, telephone-delivered) and treatments based on CBT principles that are delivered by health professionals other than psychologists show promise for chronic pain problems. This article reviews (a) the evidence base for CBT as applied to chronic pain, (b) recent innovations in target populations and delivery methods that expand the application of CBT to underserved populations, (c) current limitations and knowledge gaps, and (d) promising directions for improving CBT efficacy and access for people living with chronic pain. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Worsening Trends in the Management and Treatment of Back Pain

Article

Full-text available

Jul 2013

Importance Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines. Few studies have evaluated recent national trends in guideline adherence of spine-related care.Objective To characterize the treatment of back pain from January 1, 1999, through December 26, 2010. Design, Setting, and Patients Using nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we studied outpatient visits with a chief symptom and/or primary diagnosis of back or neck pain, as well as those with secondary symptoms and diagnoses of back or neck pain. We excluded visits with concomitant “red flags,” including fever, neurologic symptoms, or cancer. Results were analyzed using logistic regression adjusted for patient and health care professional characteristics and weighted to reflect national estimates. We also present adjusted results stratified by symptom duration and whether the health care professional was the primary care physician (PCP).Main Outcomes and Measures We assessed imaging, narcotics, and referrals to physicians (guideline discordant indicators). In addition, we evaluated use of nonsteroidal anti-inflammatory drugs or acetaminophen and referrals to physical therapy (guideline concordant indicators).Results We identified 23 918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P < .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P < .001). In contrast, narcotic use increased from 19.3% to 29.1% (P < .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P < .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P < .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location.Conclusions and Relevance Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.

A Controlled, Powerful Multiple-Comparison Strategy for Several Situations

Article

Full-text available

Jan 1994

The multiple-comparison procedure originally proposed by R. A. Fisher (1935) for the 1-way ANOVA context has several desirable properties when K (the number of groups) is equal to 3. In this article, the logic of the procedure is described in conjunction with those properties. A discussion follows of how the Fisher procedure can be similarly applied in a number of other K = 3 (and, more generally, 2-degree-of-freedom) hypothesis-testing situations. Finally, the Fisher logic is combined with recent sequential applications of the Bonferroni inequality to illustrate the utility and versatility of that combination for the applied researcher. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Mindfulness-based stress reduction for low back pain. A systematic review

Article

Full-text available

Sep 2012
BMC Compl Alternative Med

Background Mindfulness-based stress reduction (MBSR) is frequently used for pain conditions. While systematic reviews on MBSR for chronic pain have been conducted, there are no reviews for specific pain conditions. Therefore a systematic review of the effectiveness of MBSR in low back pain was performed. Methods MEDLINE, the Cochrane Library, EMBASE, CAMBASE, and PsycInfo were screened through November 2011. The search strategy combined keywords for MBSR with keywords for low back pain. Randomized controlled trials (RCTs) comparing MBSR to control conditions in patients with low back pain were included. Two authors independently assessed risk of bias using the Cochrane risk of bias tool. Clinical importance of group differences was assessed for the main outcome measures pain intensity and back-specific disability. Results Three RCTs with a total of 117 chronic low back pain patients were included. One RCT on failed back surgery syndrome reported significant and clinically important short-term improvements in pain intensity and disability for MBSR compared to no treatment. Two RCTs on older adults (age ≥ 65 years) with chronic specific or non-specific low back pain reported no short-term or long-term improvements in pain or disability for MBSR compared to no treatment or health education. Two RCTs reported larger short-term improvements of pain acceptance for MBSR compared to no treatment. Conclusion This review found inconclusive evidence of effectiveness of MBSR in improving pain intensity or disability in chronic low back pain patients. However, there is limited evidence that MBSR can improve pain acceptance. Further RCTs with larger sample sizes, adequate control interventions, and longer follow-ups are needed before firm conclusions can be drawn.

Group cognitive behavioural interventions for low back pain in primary care: Extended follow-up of the Back Skills Training Trial (ISRCTN54717854)

Article

Full-text available

Feb 2012
PAIN

Group cognitive behavioural intervention (CBI) is effective in reducing low back pain and disability over a 12-month period, in comparison to best practice advice in primary care. The aim was to study the effects of this CBI beyond 12 months. We undertook an extended follow-up of our original randomised, controlled trial of a group CBI and best practice advice in primary care, in comparison to best practice advice alone. Participants were mailed a questionnaire including measures of disability, pain, health services resource use, and health-related quality of life. The time of extended follow-up ranged between 20 and 50 months (mean 34 months). Fifty-six percent (395 of 701) of the original cohort provided extended follow-up. Those who responded were older and had less disability and pain at baseline than did the original trial cohort. After 12 months, the improvements in pain and disability observed with CBI were sustained. For disability measures, the treatment difference in favour of CBI persisted (mean difference 1.3 Roland and Morris Disability Questionnaire points, 95% confidence interval 0.27 to 2.26; 5.5 Modified von Korff Scale disability points, 95% confidence interval 0.27 to 10.64). There was no between-group difference in Modified von Korff Scale pain outcomes. The results suggest that the effects of a group CBI are maintained up to an average of 34 months. Although pain improves in response to best practice advice, longer-term recovery of disability remains substantially less.

A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain

Article

Full-text available

Dec 2011

Chronic low back pain is a common problem lacking highly effective treatment options. Small trials suggest that yoga may have benefits for this condition. This trial was designed to determine whether yoga is more effective than conventional stretching exercises or a self-care book for primary care patients with chronic low back pain. A total of 228 adults with chronic low back pain were randomized to 12 weekly classes of yoga (92 patients) or conventional stretching exercises (91 patients) or a self-care book (45 patients). Back-related functional status (modified Roland Disability Questionnaire, a 23-point scale) and bothersomeness of pain (an 11-point numerical scale) at 12 weeks were the primary outcomes. Outcomes were assessed at baseline, 6, 12, and 26 weeks by interviewers unaware of treatment group. After adjustment for baseline values, 12-week outcomes for the yoga group were superior to those for the self-care group (mean difference for function, -2.5 [95% CI, -3.7 to -1.3]; P < .001; mean difference for symptoms, -1.1 [95% CI, -1.7 to -0.4]; P < .001). At 26 weeks, function for the yoga group remained superior (mean difference, -1.8 [95% CI, -3.1 to -0.5]; P < .001). Yoga was not superior to conventional stretching exercises at any time point. Yoga classes were more effective than a self-care book, but not more effective than stretching classes, in improving function and reducing symptoms due to chronic low back pain, with benefits lasting at least several months. clinicaltrials.gov Identifier: NCT00447668.

A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain

Article

Full-text available

Jul 2011
ANN INTERN MED

Few studies have evaluated the effectiveness of massage for chronic low back pain. To compare the effectiveness of 2 types of massage and usual care for chronic back pain. Parallel-group randomized, controlled trial. Randomization was computer-generated, with centralized allocation concealment. Participants were blinded to massage type but not to assignment to massage versus usual care. Massage therapists were unblinded. The study personnel who assessed outcomes were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00371384) An integrated health care delivery system in the Seattle area. 401 persons 20 to 65 years of age with nonspecific chronic low back pain. Structural massage (n = 132), relaxation massage (n = 136), or usual care (n = 133). Roland Disability Questionnaire (RDQ) and symptom bothersomeness scores at 10 weeks (primary outcome) and at 26 and 52 weeks (secondary outcomes). Mean group differences of at least 2 points on the RDQ and at least 1.5 points on the symptom bothersomeness scale were considered clinically meaningful. The massage groups had similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI, 1.8 to 4.0 points) lower in the relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the structural massage group than in the usual care group, and adjusted mean symptom bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and 1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. The beneficial effects of relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were small. Participants were not blinded to treatment. Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms. National Center for Complementary and Alternative Medicine.

Group cognitive behavioral treatment for low-back pain in primary care: A randomized controlled trial and cost-effectiveness analysis

Article

Full-text available

Feb 2010
LANCET

Low-back pain is a common and costly problem. We estimated the effectiveness of a group cognitive behavioural intervention in addition to best practice advice in people with low-back pain in primary care. In this pragmatic, multicentre, randomised controlled trial with parallel cost-effectiveness analysis undertaken in England, 701 adults with troublesome subacute or chronic low-back pain were recruited from 56 general practices and received an active management advisory consultation. Participants were randomly assigned by computer-generated block randomisation to receive an additional assessment and up to six sessions of a group cognitive behavioural intervention (n=468) or no further intervention (control; n=233). Primary outcomes were the change from baseline in Roland Morris disability questionnaire and modified Von Korff scores at 12 months. Assessment of outcomes was blinded and followed the intention-to-treat principle, including all randomised participants who provided follow-up data. This study is registered, number ISRCTN54717854. 399 (85%) participants in the cognitive behavioural intervention group and 199 (85%) participants in the control group were included in the primary analysis at 12 months. The most frequent reason for participant withdrawal was unwillingness to complete questionnaires. At 12 months, mean change from baseline in the Roland Morris questionnaire score was 1.1 points (95% CI 0.39-1.72) in the control group and 2.4 points (1.89-2.84) in the cognitive behavioural intervention group (difference between groups 1.3 points, 0.56-2.06; p=0.0008). The modified Von Korff disability score changed by 5.4% (1.99-8.90) and 13.8% (11.39-16.28), respectively (difference between groups 8.4%, 4.47-12.32; p<0.0001). The modified Von Korff pain score changed by 6.4% (3.14-9.66) and 13.4% (10.77-15.96), respectively (difference between groups 7.0%, 3.12-10.81; p<0.0001). The additional quality-adjusted life-year (QALY) gained from cognitive behavioural intervention was 0.099; the incremental cost per QALY was 1786 pound sterling, and the probability of cost-effectiveness was greater than 90% at a threshold of 3000 pound sterling per QALY. There were no serious adverse events attributable to either treatment. Over 1 year, the cognitive behavioural intervention had a sustained effect on troublesome subacute and chronic low-back pain at a low cost to the health-care provider. National Institute for Health Research Health Technology Assessment Programme.

A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain

Article

Full-text available

May 2009

Acupuncture is a popular complementary and alternative treatment for chronic back pain. Recent European trials suggest similar short-term benefits from real and sham acupuncture needling. This trial addresses the importance of needle placement and skin penetration in eliciting acupuncture effects for patients with chronic low back pain. A total of 638 adults with chronic mechanical low back pain were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care. Ten treatments were provided over 7 weeks by experienced acupuncturists. The primary outcomes were back-related dysfunction (Roland-Morris Disability Questionnaire score; range, 0-23) and symptom bothersomeness (0-10 scale). Outcomes were assessed at baseline and after 8, 26, and 52 weeks. At 8 weeks, mean dysfunction scores for the individualized, standardized, and simulated acupuncture groups improved by 4.4, 4.5, and 4.4 points, respectively, compared with 2.1 points for those receiving usual care (P < .001). Participants receiving real or simulated acupuncture were more likely than those receiving usual care to experience clinically meaningful improvements on the dysfunction scale (60% vs 39%; P < .001). Symptoms improved by 1.6 to 1.9 points in the treatment groups compared with 0.7 points in the usual care group (P < .001). After 1 year, participants in the treatment groups were more likely than those receiving usual care to experience clinically meaningful improvements in dysfunction (59% to 65% vs 50%, respectively; P = .02) but not in symptoms (P > .05). Although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appear to be unimportant in eliciting therapeutic benefits. These findings raise questions about acupuncture's purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.

A 12-Item Short-Form Health Survey: Construction of Scales and Preliminary Tests of Reliability and Validity

Article

Full-text available

Apr 1996
MED CARE

Regression methods were used to select and score 12 items from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to reproduce the Physical Component Summary and Mental Component Summary scales in the general US population (n=2,333). The resulting 12-item short-form (SF-12) achieved multiple R squares of 0.911 and 0.918 in predictions of the SF-36 Physical Component Summary and SF-36 Mental Component Summary scores, respectively. Scoring algorithms from the general population used to score 12-item versions of the two components (Physical Components Summary and Mental Component Summary) achieved R squares of 0.905 with the SF-36 Physical Component Summary and 0.938 with SF-36 Mental Component Summary when cross-validated in the Medical Outcomes Study. Test-retest (2-week)correlations of 0.89 and 0.76 were observed for the 12-item Physical Component Summary and the 12-item Mental Component Summary, respectively, in the general US population (n=232). Twenty cross-sectional and longitudinal tests of empirical validity previously published for the 36-item short-form scales and summary measures were replicated for the 12-item Physical Component Summary and the 12-item Mental Component Summary, including comparisons between patient groups known to differ or to change in terms of the presence and seriousness of physical and mental conditions, acute symptoms, age and aging, self-reported 1-year changes in health, and recovery for depression. In 14 validity tests involving physical criteria, relative validity estimates for the 12-item Physical Component Summary ranged from 0.43 to 0.93 (median=0.67) in comparison with the best 36-item short-form scale. Relative validity estimates for the 12-item Mental Component Summary in 6 tests involving mental criteria ranged from 0.60 to 107 (median=0.97) in relation to the best 36-item short-form scale. Average scores for the 2 summary measures, and those for most scales in the 8-scale profile based on the 12-item short-form, closely mirrored those for the 36-item short-form, although standard errors were nearly always larger for the 12-item short-form.

The 2-item Generalized Anxiety Disorder scale had high sensitivity and specificity for detecting GAD in primary care

Article

Full-text available

Nov 2007
Evid Base Med

Petros Skapinakis

Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society

Article

Full-text available

Nov 2007
ANN INTERN MED

RECOMMENDATION 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). RECOMMENDATION 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). RECOMMENDATION 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). RECOMMENDATION 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. RECOMMENDATION 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

Interpreting Change Scores for Pain and Functional Status in Low Back Pain: Towards International Consensus Regarding Minimal Important Change

Article

Full-text available

Feb 2008
SPINE

Literature review, expert panel, and a workshop during the "VIII International Forum on Primary Care Research on Low Back Pain" (Amsterdam, June 2006). To develop practical guidance regarding the minimal important change (MIC) on frequently used measures of pain and functional status for low back pain. Empirical studies have tried to determine meaningful changes for back pain, using different methodologies. This has led to confusion about what change is clinically important for commonly used back pain outcome measures. This study covered the Visual Analogue Scale (0-100) and the Numerical Rating Scale (0-10) for pain and for function, the Roland Disability Questionnaire (0-24), the Oswestry Disability Index (0-100), and the Quebec Back Pain Disability Questionnaire (0-100). The literature was reviewed for empirical evidence. Additionally, experts and participants of the VIII International Forum on Primary Care Research on Low Back Pain were consulted to develop international consensus on clinical interpretation. There was wide variation in study design and the methods used to estimate MICs, and in values found for MIC, where MIC is the improvement in clinical status of an individual patient. However, after discussion among experts and workshop participants a reasonable consensus was achieved. Proposed MIC values are: 15 for the Visual Analogue Scale, 2 for the Numerical Rating Scale, 5 for the Roland Disability Questionnaire, 10 for the Oswestry Disability Index, and 20 for the QBDQ. When the baseline score is taken into account, a 30% improvement was considered a useful threshold for identifying clinically meaningful improvement on each of these measures. For a range of commonly used back pain outcome measures, a 30% change from baseline may be considered clinically meaningful improvement when comparing before and after measures for individual patients. It is hoped that these proposals facilitate the use of these measures in clinical practice and the comparability of future studies. The proposed MIC values are not the final answer but offer a common starting point for future research.

Expenditures and Health Status Among Adults With Back and Neck Problems

Article

Full-text available

Feb 2008
J Am Med Assoc

Back and neck problems are among the symptoms most commonly encountered in clinical practice. However, few studies have examined national trends in expenditures for back and neck problems or related these trends to health status measures. To estimate inpatient, outpatient, emergency department, and pharmacy expenditures related to back and neck problems in the United States from 1997 through 2005 and to examine associated trends in health status. Age- and sex-adjusted analysis of the nationally representative Medical Expenditure Panel Survey (MEPS) from 1997 to 2005 using complex survey regression methods. The MEPS is a household survey of medical expenditures weighted to represent national estimates. Respondents were US adults (> 17 years) who self-reported back and neck problems (referred to as "spine problems" based on MEPS descriptions and International Classification of Diseases, Ninth Revision, Clinical Modification definitions). Spine-related expenditures for health services (inflation-adjusted); annual surveys of self-reported health status. National estimates were based on annual samples of survey respondents with and without self-reported spine problems from 1997 through 2005. A total of 23 045 respondents were sampled in 1997, including 3139 who reported spine problems. In 2005, the sample included 22 258 respondents, including 3187 who reported spine problems. In 1997, the mean age- and sex-adjusted medical costs for respondents with spine problems was

4695 (95% confidence interval [CI],

4181-

5209), compared with

2731 (95% CI,

2557-

2904) among those without spine problems (inflation-adjusted to 2005 dollars). In 2005, the mean age- and sex- adjusted medical expenditure among respondents with spine problems was

6096 (95% CI,

5670-

6522), compared with

3516 (95% CI,

3266-

3765) among those without spine problems. Total estimated expenditures among respondents with spine problems increased 65% (adjusted for inflation) from 1997 to 2005, more rapidly than overall health expenditures. The estimated proportion of persons with back or neck problems who self-reported physical functioning limitations increased from 20.7% (95% CI, 19.9%-21.4%) to 24.7% (95% CI, 23.7%-25.6%) from 1997 to 2005. Age- and sex-adjusted self-reported measures of mental health, physical functioning, work or school limitations, and social limitations among adults with spine problems were worse in 2005 than in 1997. In this survey population, self-reported back and neck problems accounted for a large proportion of health care expenditures. These spine-related expenditures have increased substantially from 1997 to 2005, without evidence of corresponding improvement in self-assessed health status.

Managing Chronic Pain: Therapist Guide: A Cognitive-Behavioral Therapy Approach

Book

Sep 2007

John D Otis

This online Therapist Guide to helping patients manage chronic pain uses Cognitive-Behavioural Therapy (CBT), which has been proven effective at managing various chronic pain conditions, including rheumatoid arthritis, osteoarthritis, chronic back pain and tension/migraine headache. CBT engages patients in an active coping process aimed at changing maladaptive thoughts and behaviours that can serve to maintain and exacerbate the experience of chronic pain. Sessions present the basic methods of a technique, such as stress management, sleep hygiene, relaxation therapy, and cognitive restructuring. Designed to be used in conjunction with the corresponding online workbook, this online guide offers a complete treatment program. It provides session outlines, sample dialogues, and homework assignments for each technique, as well as addresses assessment and relapse.

Longitudinal data analysis using generalized linear models

Article

Jan 1986
BIOMETRIKA

Psychological therapies for the management of chronic pain (excluding headache) in adults

Article

Jan 2008

A Mind-Body Program for Older Adults With Chronic Low Back Pain: A Randomized Clinical Trial

Article

Feb 2016

Importance: Treatment of chronic low back pain (LBP) in older adults is limited by the adverse effects of analgesics. Effective nonpharmacologic treatment options are needed. Objective: To determine the effectiveness of a mind-body program at increasing function and reducing pain in older adults with chronic LBP. Design, setting, and participants: This single-blind, randomized clinical trial compared a mind-body program (n = 140) with a health education program (n = 142). Community-dwelling older adults residing within the Pittsburgh metropolitan area were recruited from February 14, 2011, to June 30, 2014, with 6-month follow-up completed by April 9, 2015. Eligible participants were 65 years or older with functional limitations owing to their chronic LBP (≥11 points on the Roland and Morris Disability Questionnaire) and chronic pain (duration ≥3 months) of moderate intensity. Data were analyzed from March 1 to July 1, 2015. Interventions: The intervention and control groups received an 8-week group program followed by 6 monthly sessions. The intervention was modeled on the Mindfulness-Based Stress Reduction program; the control program, on the "10 Keys" to Healthy Aging. Main outcomes and measures: Follow-up occurred at program completion and 6 months later. The score on the Roland and Morris Disability Questionnaire was the primary outcome and measured functional limitations owing to LBP. Pain (current, mean, and most severe in the past week) was measured with the Numeric Pain Rating Scale. Secondary outcomes included quality of life, pain self-efficacy, and mindfulness. Intent-to-treat analyses were conducted. Results: Of 1160 persons who underwent screening, 282 participants enrolled in the trial (95 men [33.7%] and 187 women [66.3%]; mean [SD] age,74.5 [6.6] years). The baseline mean (SD) Roland and Morris Disability Questionnaire scores for the intervention and control groups were 15.6 (3.0) and 15.4 (3.0), respectively. Compared with the control group, intervention participants improved an additional -1.1 (mean, 12.1 vs 13.1) points at 8 weeks and -0.04 (mean, 12.2 vs 12.6) points at 6 months (effect sizes, -0.23 and -0.08, respectively) on the Roland and Morris Disability Questionnaire. By 6 months, the intervention participants improved on the Numeric Pain Rating Scale current and most severe pain measures an additional -1.8 points (95% CI, -3.1 to -0.05 points; effect size, -0.33) and -1.0 points (95% CI, -2.1 to 0.2 points; effect size, -0.19), respectively. The changes in Numeric Pain Rating Scale mean pain measure after the intervention were not significant (-0.1 [95% CI, -1.1 to 1.0] at 8 weeks and -1.1 [95% CI, -2.2 to -0.01] at 6 months; effect size, -0.01 and -0.22, respectively). Conclusions and relevance: A mind-body program for chronic LBP improved short-term function and long-term current and most severe pain. The functional improvement was not sustained, suggesting that future development of the intervention could focus on durability. Trial registration: clinicaltrials.gov Identifier: NCT01405716.

Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness By Jon Kabat-Zinn

Book

Jan 1990

Jon Kabat-Zinn

Assessment of chronic pain in epidemiological and health services research: Empirical bases and new directions

Article

Jan 2011

M. Von Korff

Team RDC.R: A Language And Environment For Statistical Computing. R Foundation for Statistical Computing: Vienna, Austria

Technical Report

Jan 2012

Core R Team

The Pain Survival Guide: How to Reclaim Your Life

Article

Jan 2005

Effectiveness of Group Versus Individual Cognitive-Behavioral Therapy in Patients With Abridged Somatization Disorder: A Randomized Controlled Trial

Article

Jun 2013
PSYCHOSOM MED

Objective To evaluate the effectiveness and feasibility of a cognitive-behavioral program for patients in primary care units who were diagnosed as having abridged somatization disorder.MethodA multicenter, randomized controlled trial was designed. One hundred sixty-eight patients were recruited from 29 primary care units and randomly assigned to one of three arms: treatment as usual (TAU), individual cognitive-behavioral therapy (CBT), and group CBT. Somatic symptoms were measured using the Screening for Somatoform Disorders and the Severity of Somatic Symptoms scale. The Hamilton Anxiety Rating Scale and the Hamilton Depression Rating Scale were used to assess the severity of anxiety and depression.ResultsIndividual CBT achieves greater changes in the Screening for Somatoform Disorders posttreatment compared with group CBT (mean [95% confidence interval], 14.17 [11.9-16.3] versus 11.63 [9.4-13.7], p < .001). These improvements were observed at 6 and 12 months (p < .001 and p < .001, respectively). For individual CBT versus TAU, the number-needed-to-treat was 8, whereas for group CBT versus TAU, the number-needed-to-treat was 9. Individual CBT treatment resulted in lower anxiety scores compared with group CBT and TAU (7.33 [5.4-9.2] versus 11.47 [9.4-13.9] versus 13.07 [10.9-15.2], p < .001) posttreatment. Individual CBT and group CBT were associated with sustained benefits at 12-month follow-up compared with TAU (8.6 [6.6-10.6] versus 9.28 [7.2-11.2] versus 16.2 [13.9-18.5], p < .001). Depressive symptoms were lower for individual CBT posttreatment than for TAU (6.96 [5.3-8.6] versus 10.87-12.7], p < .01).ConclusionsCBT in individual and group settings results in significant improvements in somatic symptoms among patients with somatoform abridged disorder compared with TAU. Individual CBT results in greater posttreatment improvements at 6-month and 12-month follow-ups.Trial Registrationcurrent controlled trials identifier ISRCTN69944771.

A Systematic Review and Meta-analysis of Yoga for Low Back Pain

Article

Dec 2012
CLIN J PAIN

Objectives: To systematically review and meta-analyze the effectiveness of yoga for low back pain. Methods: MEDLINE, the Cochrane Library, EMBASE, CAMBASE, and PsycINFO, were screened through January 2012. Randomized controlled trials comparing yoga to control conditions in patients with low back pain were included. Two authors independently assessed risk of bias using the risk of bias tool recommended by the Cochrane Back Review Group. Main outcome measures were pain, back-specific disability, generic disability, health-related quality of life, and global improvement. For each outcome, standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated. Results: Ten randomized controlled trials with a total of 967 chronic low back pain patients were included. Eight studies had low risk of bias. There was strong evidence for short-term effects on pain (SMD=-0.48; 95% CI, -0.65 to -0.31; P<0.01), back-specific disability (SMD=-0.59; 95% CI, -0.87 to -0.30; P<0.01), and global improvement (risk ratio=3.27; 95% CI, 1.89-5.66; P<0.01). There was strong evidence for a long-term effect on pain (SMD=-0.33; 95% CI, -0.59 to -0.07; P=0.01) and moderate evidence for a long-term effect on back-specific disability (SMD=-0.35; 95% CI, -0.55 to -0.15; P<0.01). There was no evidence for either short-term or long-term effects on health-related quality of life. Yoga was not associated with serious adverse events. Discussion: This systematic review found strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness of yoga for chronic low back pain in the most important patient-centered outcomes. Yoga can be recommended as an additional therapy to chronic low back pain patients.

Do Mindfulness-Based Interventions Reduce Pain Intensity? A Critical Review of the Literature

Article

Dec 2012
PAIN MED

Mindfulness-based interventions (MBIs) emphasizing a nonjudgmental attitude toward present moment experience are widely used for chronic pain patients. Although changing or controlling pain is not an explicit aim of MBIs, recent experimental studies suggest that mindfulness practice may lead to changes in pain tolerance and pain intensity ratings. The objective of this review is to investigate the specific effect of MBIs on pain intensity. A literature search was conducted using the databases PUBMED and PsycINFO for relevant articles published from 1960 to December 2010. We additionally conducted a manual search of references from the retrieved articles. Only studies providing detailed results on change in pain intensity ratings were included. Sixteen studies were included in this review (eight uncontrolled and eight controlled trials). In most studies (10 of 16), there was significantly decreased pain intensity in the MBI group. Findings were more consistently positive for samples limited to clinical pain (9 of 11). In addition, most controlled trials (6 of 8) reveal higher reductions in pain intensity for MBIs compared with control groups. Results from follow-up assessments reveal that reductions in pain intensity were generally well maintained. Findings suggest that MBIs decrease the intensity of pain for chronic pain patients. We discuss implications for understanding mechanisms of change in MBIs.

Mindfulness‐Based Stress Reduction and Mindfulness‐Based Cognitive Therapy—A systematic review of randomized controlled trials

Article

Apr 2011
ACTA PSYCHIAT SCAND

Unlabelled: Fjorback LO, Arendt M, Ørnbøl E, Fink P, Walach H. Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy - a systematic review of randomized controlled trials. Objective: To systematically review the evidence for MBSR and MBCT. Method: Systematic searches of Medline, PsycInfo and Embase were performed in October 2010. MBSR, MBCT and Mindfulness Meditation were key words. Only randomized controlled trials (RCT) using the standard MBSR/MBCT programme with a minimum of 33 participants were included. Results: The search produced 72 articles, of which 21 were included. MBSR improved mental health in 11 studies compared to wait list control or treatment as usual (TAU) and was as efficacious as active control group in three studies. MBCT reduced the risk of depressive relapse in two studies compared to TAU and was equally efficacious to TAU or an active control group in two studies. Overall, studies showed medium effect sizes. Among other limitations are lack of active control group and long-term follow-up in several studies. Conclusion: Evidence supports that MBSR improves mental health and MBCT prevents depressive relapse. Future RCTs should apply optimal design including active treatment for comparison, properly trained instructors and at least one-year follow-up. Future research should primarily tackle the question of whether mindfulness itself is a decisive ingredient by controlling against other active control conditions or true treatments.

Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis

Article

Mar 2011
PAIN

Acceptance-based interventions such as mindfulness-based stress reduction program and acceptance and commitment therapy are alternative therapies for cognitive behavioral therapy for treating chronic pain patients. To assess the effects of acceptance-based interventions on patients with chronic pain, we conducted a systematic review and meta-analysis of controlled and noncontrolled studies reporting effects on mental and physical health of pain patients. All studies were rated for quality. Primary outcome measures were pain intensity and depression. Secondary outcomes were anxiety, physical wellbeing, and quality of life. Twenty-two studies (9 randomized controlled studies, 5 clinical controlled studies [without randomization] and 8 noncontrolled studies) were included, totaling 1235 patients with chronic pain. An effect size on pain of 0.37 was found for the controlled studies. The effect on depression was 0.32. The quality of the studies was not found to moderate the effects of acceptance-based interventions. The results suggest that at present mindfulness-based stress reduction program and acceptance and commitment therapy are not superior to cognitive behavioral therapy but can be good alternatives. More high-quality studies are needed. It is recommended to focus on therapies that integrate mindfulness and behavioral therapy. Acceptance-based therapies have small to medium effects on physical and mental health in chronic pain patients. These effects are comparable to those of cognitive behavioral therapy.

Behavioural treatment for chronic low-back pain

Article

Jul 2010

Background: Behavioural treatment is commonly used in the management of chronic low-back pain (CLBP) to reduce disability through modification of maladaptive pain behaviours and cognitive processes. Three behavioural approaches are generally distinguished: operant, cognitive, and respondent; but are often combined as a treatment package. Objectives: To determine the effects of behavioural therapy for CLBP and the most effective behavioural approach. Search strategy: The Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, and PsycINFO were searched up to February 2009. Reference lists and citations of identified trials and relevant systematic reviews were screened. Selection criteria: Randomised trials on behavioural treatments for non-specific CLBP were included. Data collection and analysis: Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach. Main results: We included 30 randomised trials (3438 participants) in this review, up 11 from the previous version. Fourteen trials (47%) had low risk of bias. For most comparisons, there was only low or very low quality evidence to support the results. There was moderate quality evidence that:i) operant therapy was more effective than waiting list (SMD -0.43; 95%CI -0.75 to -0.11) for short-term pain relief;ii) little or no difference exists between operant, cognitive, or combined behavioural therapy for short- to intermediate-term pain relief;iii) behavioural treatment was more effective than usual care for short-term pain relief (MD -5.18; 95%CI -9.79 to -0.57), but there were no differences in the intermediate- to long-term, or on functional status;iv) there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate- to long-term;v) adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone. Authors' conclusions: For patients with CLBP, there is moderate quality evidence that in the short-term, operant therapy is more effective than waiting list and behavioural therapy is more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.

The PHQ-8 as a Measure of Current Depression in the General Population

Article

Sep 2008

The eight-item Patient Health Questionnaire depression scale (PHQ-8) is established as a valid diagnostic and severity measure for depressive disorders in large clinical studies. Our objectives were to assess the PHQ-8 as a depression measure in a large, epidemiological population-based study, and to determine the comparability of depression as defined by the PHQ-8 diagnostic algorithm vs. a PHQ-8 cutpoint > or = 10. Random-digit-dialed telephone survey of 198,678 participants in the 2006 Behavioral Risk Factor Surveillance Survey (BRFSS), a population-based survey in the United States. Current depression as defined by either the DSM-IV based diagnostic algorithm (i.e., major depressive or other depressive disorder) of the PHQ-8 or a PHQ-8 score > or = 10; respondent sociodemographic characteristics; number of days of impairment in the past 30 days in multiple domains of health-related quality of life (HRQoL). The prevalence of current depression was similar whether defined by the diagnostic algorithm or a PHQ-8 score > or = 10 (9.1% vs. 8.6%). Depressed patients had substantially more days of impairment across multiple domains of HRQoL, and the impairment was nearly identical in depressed groups defined by either method. Of the 17,040 respondents with a PHQ-8 score > or = 10, major depressive disorder was present in 49.7%, other depressive disorder in 23.9%, depressed mood or anhedonia in another 22.8%, and no evidence of depressive disorder or depressive symptoms in only 3.5%. The PHQ-8 diagnostic algorithm rather than an independent structured psychiatric interview was used as the criterion standard. The PHQ-8 is a useful depression measure for population-based studies, and either its diagnostic algorithm or a cutpoint > or = 10 can be used for defining current depression.

Assessing Health-Related Quality of Life in Patients With Sciatica

Article

Oct 1995

This study analyzed health-related quality-of-life measures and other clinical and questionnaire data obtained from the Maine Lumbar Spine Study, a prospective cohort study of persons with low back problems. For persons with sciatica, back pain-specific and general measures of health-related quality-of-life were compared with regard to internal consistency, construct validity, reproducibility, and responsiveness in detecting small changes over a 3-month period. Data were collected from 427 participants with sciatica. Baseline in-person interviews were conducted with surgical and medical patients before treatment and by mail at 3 months. Health-related quality-of-life measures included symptoms (frequency and bothersomeness of pain and sciatica) functional status and well-being (modified back pain-specific Roland scale and Medical Outcomes Study 36-item Short Form Health Survey (SF-36), and disability (bed rest, work loss, and restricted activity days). Internal consistency of measures was high. Reproducibility was moderate, as expected after a 3-month interval. The SF-36 bodily pain item and the modified Roland measure demonstrated the greatest amount of change and were the most highly associated with self-rated improvement. The specific and generic measures changed in the expected direction, except for general health perceptions, which declined slightly. A high correlation between clinical findings or symptoms and the modified Roland measure, SF-36, and disability days indicated a high degree of construct validity. These measures performed well in measuring the health-related quality-of-life of patients with sciatica. The modified Roland and the physical dimension of the SF-36 were the measures most responsive to change over time, suggesting their use in prospective evaluation. Disability day measures, although valuable for assessing the societal impact of dysfunction, were less responsive to changes over this short-term follow-up of 3 months.

The Roland???Morris Disability Questionnaire and the Oswestry Disability Questionnaire

Article

Jan 2001

The RDQ is a short and simple method of a self-rated assessment of physical function in patients with back pain. Its ease of use makes it suitable for following up on the progress of individual patients in clinical settings and for combining with other measures of function (e.g., psychological or work disability) in research settings. The ODI is likewise an effective method of measuring disability in patients with back pain with a wide degree of severity and causes. Both instruments have stood the test of time and have been used in a wide variety of clinical situations, in the United Kingdom, the United States, and many other countries. Both instruments perform as well as most other currently available instruments and better than some. The RDQ may be better suited to settings

Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain

Abstract

No full-text available