Reasons for Treatment Non-Response: A Controlled Study of Patients' Views in Pain Rehabilitation.

BACKGROUND: Understanding successful and unsuccessful behavioural treatment for pain is essential. AIMS: We carried out a retrospective survey of 130 people who had undergone pain rehabilitation based on acceptance and commitment therapy, aiming to identify factors associated with non-response. METHOD: The sample was selected using the reliable change index to define 'responders' and 'non-responders' to key outcome measures. We surveyed a range of treatment-related, systemic, practical and personal factors that may have affected their treatment, and then compared 'non-responders' with 'responders', controlling for factors that might not be causal or specific to non-response. RESULTS: Logistic regression analysis showed two themes that distinguished the groups, 'people outside programme' and 'emotional state'. CONCLUSIONS: These data have clinical implications, as such factors can be addressed directly or incorporated into an assessment of treatment 'readiness'. This study introduced a novel methodology for the investigation of pain treatment response, which allowed a broad study of clinically relevant variables, but with greater rigour than conventional self-reports of 'helpful factors' in treatment.

Psychologically informed physiotherapy for chronic pain: patient experiences of treatment and therapeutic process.

OBJECTIVES: Psychologically informed physiotherapy is used widely with patients with chronic pain. This study aimed to investigate patients' beliefs about, and experiences of, this type of treatment, and helpful and unhelpful experiences. DESIGN: A qualitative study using Interpretative Phenomenological Analysis of semi-structured interviews. PARTICIPANTS: Participants (n=8) were recruited within a national specialist pain centre following a residential pain management programme including 2.25hours of physiotherapy each day. Participants were eligible for inclusion if they had achieved clinically reliable improvements in physical functioning during treatment. Interviews were conducted 3 months post-treatment. RESULTS: Participants reported differing experiences of physiotherapy interventions and differences in the therapeutic relationship, valuing a more individualised approach. The themes of 'working with the whole of me', 'more than just a professional', 'awareness' and 'working through challenges in the therapeutic relationship' emerged as central to behavioural change, together with promotion of perceptions of improved capability and physical capacity. CONCLUSION: Psychologically informed physiotherapy is an effective treatment for some patients with chronic pain. Participants experienced this approach as uniquely different from non-psychologically informed physiotherapy approaches due to its focus on working with the patient's whole experience. Therapeutic alliance and management of relationship ruptures may have more importance than previously appreciated in physiotherapy.

Mechanisms underlying attentional set-shifting in Parkinson's disease.

Patients with Parkinson's disease (PD) show impairments on tasks that require them to switch attention between two perceptual dimensions (extradimensional (ED) shifting). It has been suggested that ED shifting deficits can be caused by two separate mechanisms, 'learned irrelevance' and 'perseveration'. This study set out to test the hypothesis that enhanced learned irrelevance is present in medicated patients with PD. An enhancement of learned irrelevance in PD patients should result in increased errors on a 'deficit' shift relative to controls and decreased errors on an 'improvement' shift. A similar pair of deficit and improvement shifts were used to detect possible enhanced perseveration in patients. Instead of showing the predicted patterns of deficit and improvement, patients displayed a consistent deficit on those shifts that required that they switch their attention to a different dimension (ED shifts). In contrast, patients were not impaired on shifts that required no such shift of attention (intradimensional shifts). Although there was an increase in errors at the learned irrelevance deficit shift, a similar increase at the learned irrelevance improvement shift shows that enhanced learned irrelevance is not responsible for either of these results. Patients were no more distractible than controls, but displayed increased 'loss of set' as measured by errors generated after a rule was learned. These results point to the existence of exaggerated, rigid selective attention in patients with PD rather than a breakdown in the ability to selectively attend. There was no evidence for the existence of enhanced learned irrelevance in the patients.

Reaction time deficits and Parkinson's disease.

Controversy surrounds the existence and nature of reaction time deficits in Parkinson's disease. Three areas of research are reviewed: the use of precues to speed movement (motor preprogramming), the effects of medication on reaction time, and simple reaction times. No evidence is found for a motor preprogramming deficit, and the presence of a parkinsonian reaction time deficit after medication withdrawal is found to be dependent upon experimental design and the withdrawal method used. Parkinson's disease is found to cause a consistent deficit in simple reaction time. A quantitative analysis of past studies reveals that a parkinsonian reaction time deficit is more likely to be present in tasks that controls can perform with a fast reaction time. This relationship between deficit and control group reaction time applies to choice, but not simple, reaction time tasks. Many studies compare patient and control choice reaction times across experimental conditions that cause control reaction time to vary. The authors of these studies should consider whether their results can be explained in terms of the simple relationship between patient reaction time deficit and control reaction time before drawing more complex conclusions from their data.