Video-telecare collaborative pain management during COVID-19: a single-arm feasibility study.

BACKGROUND: Chronic pain is among the most common conditions presenting to primary care and guideline-based care faces several challenges. A novel pain management program, Video-Telecare Collaborative Pain Management (VCPM), was established to support primary care providers and meet new challenges to care presented by the COVID-19 pandemic. METHODS: The present single-arm feasibility study aimed to evaluate the feasibility and acceptability of VCPM and its components among U.S. veterans on long-term opioid therapy for chronic pain at ≥ 50 mg morphine equivalent daily dose (MEDD). VCPM consists of evidence-based interventions, including opioid reassessment and tapering, rotation to buprenorphine and monitoring, and encouraging behavioral pain and opioid-use disorder self-management. RESULTS: Of the 133 patients outreached for VPCM, 44 completed an initial intake (33%) and 19 attended multiple VCPM appointments (14%). Patients were generally satisfied with VCPM, virtual modalities, and provider interactions. Nearly all patients who attended multiple appointments maintained a buprenorphine switch or tapered opioids (16/19; 84%), and buprenorphine switches were generally reported as acceptable by patients. Patients completing an initial intake with VCPM had reduced morphine equivalent daily dose after three months (means = 109 mg MEDD vs 78 mg), with greater reductions among those who attended multiple appointments compared to intake only (ΔMEDD = -58.1 vs. -8.40). Finally, 29 referrals were placed for evidence-based non-pharmacologic interventions. CONCLUSION: Pre-defined feasibility and acceptability targets for VCPM and its components were broadly met, and preliminary data are encouraging. Novel strategies to improve enrollment and engagement and future directions are discussed.

Behavioral Health, Telemedicine, and Opportunities for Improving Access.

PURPOSE OF REVIEW: The purpose of this review is to summarize advances in behavioral treatments for pain and headache disorders, as well as recent innovations in telemedicine for behavioral treatments. RECENT FINDINGS: Research for behavioral treatments continues to support their use as part of a multidisciplinary approach to comprehensive management for pain and headache conditions. Behavioral treatments incorporate both behavioral change and cognitive interventions and have been shown to improve outcomes beyond that of medical management alone. The onset of the COVID-19 public health emergency necessitated the rapid uptake of nontraditional modalities for behavioral treatments, particularly telemedicine. Telemedicine has long been considered the answer to several barriers to accessing behavioral treatments, and as a result of COVID-19 significant progress has been made evaluating a variety of telemedicine modalities including synchronous, asynchronous, and mobile health applications. Researchers are encouraged to continue investigating how best to leverage these modalities to improve access to behavioral treatments and to continue evaluating the efficacy of telemedicine compared to traditional in-person care. Comprehensive pain and headache management should include behavioral treatments to address a variety of behavior change and cognitive targets. Policy changes and advances in telemedicine for behavioral treatments provide the opportunity to address historical barriers limiting access.

Objectively Measured Physical Activity in Migraine as a Function of Headache Activity.

OBJECTIVE: This study sought to compare ambulatory physical activity (PA) between young adults with migraine, tension-type headache (TTH), and non-headache controls and determine if differences in PA were attributable to headache activity or other relevant covariates. BACKGROUND: PA has been implicated in the development, manifestation, and treatment of various headache disorders. However, objective quantification of PA across headache types is lacking, and no study has quantified both prospective PA and the influence of headache occurrence on PA. METHODS: A prospective cohort study followed university participants with migraine, with TTH, or without headache for 7 days using an Omron HJ-112 pedometer and daily headache diaries. Daily free-living PA was compared between groups, and differences in PA as a function of headache day vs non-headache day were compared among those with migraine and TTH. RESULTS: The final sample consisted of 516 observations from 100 young adults (81/100 female, mean age = 19.0 ± 1.7) comprised of 28 individuals with migraine, 37 individuals with TTH, and 35 non-headache controls. On average, individuals with migraine engaged in less total PA than non-headache controls (6847 vs 8573 steps/day; mean difference = -1726 [95% CI: -3135 to -318], P = .017) across the 7-day monitoring period. After adjusting for relevant covariates (psychological symptoms, body mass index, weekend vs weekday), this difference was evident on both non-headache days (adjusted mean = 5987 vs 8610, P = .002) and headache days (adjusted mean = 6986 vs 9958, P = .017). In contrast, PA of individuals with TTH (mean = 7691 steps/day) did not significantly differ from those with migraine. PA within groups as a function of headache day (vs non-headache day) did not significantly differ for individuals with migraine (mean = 7357 vs 6191, P = .061) or individuals with TTH (mean = 7814 vs 7641, P = .736). CONCLUSIONS: Consistent with other studies, individuals with migraine reported lower levels of PA compared to non-headache controls. Notably, relative reductions in PA occurred even on days in which headache was not experienced and were not attributable to the examined covariates, instead supporting a more global pattern of reduced PA. Further research is needed to isolate the mechanisms underlying interictal reductions in PA among those with migraine.

Fear, Avoidance, and Disability in Headache Disorders.

PURPOSE OF REVIEW: The purpose of this review is to summarize the role of avoidance behavior in headache-related disability and overview relevant clinical implications. RECENT FINDINGS: Avoidance occupies a central role in contemporary psychological perspectives on headache disorders and other chronic pain conditions. Several cognitive constructs of relevance to headache are influenced and maintained by avoidance behavior. A growing body of literature attests to the notion that avoidance of headache triggers, of stimuli that exacerbate headache, and of broader life domains can negatively affect headache progression, disability/quality of life, and comorbid psychiatric symptoms. Interventions targeting avoidance behavior, such as therapeutic exposure to headache triggers, mindfulness, and acceptance and commitment therapy (ACT), hold promise for headache disorders but need to be tested in larger trials. Researchers and clinicians are encouraged to attend to functional impairment as a critically important treatment outcome. Comprehensive understanding of headache disorders necessitates attention not merely to diagnostic symptoms and their reduction, but to patterns of avoidance behavior that inadvertently exacerbate headache and contribute to functional impairment.