Effects of hypnosis vs mindfulness meditation vs education on chronic pain intensity and secondary outcomes in veterans: a randomized clinical trial.

ABSTRACT: Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) with an active education control (ED). Veterans (N = 328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity [API]) and secondary outcomes were assessed at pretreatment, posttreatment, and 3 and 6 months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pretreatment to posttreatment change in API; however, pretreatment to posttreatment improvements in API and several secondary variables were seen for participants in all 3 conditions. Participation in MM resulted in greater decreases in API and pain interference at 6 months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3 and 6 months posttreatment compared with ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all 3 interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.

Effects of hypnosis, cognitive therapy, hypnotic cognitive therapy, and pain education in adults with chronic pain: a randomized clinical trial.

Chronic pain is a significant health problem worldwide with limited pharmacological treatment options. This study evaluated the relative efficacy of 4 treatment sessions each of 4 nonpharmacological treatments: (1) hypnotic cognitive therapy (using hypnosis to alter the meaning of pain); (2) standard cognitive therapy; (3) hypnosis focused on pain reduction, and (4) pain education. One hundred seventy-three individuals with chronic pain were randomly assigned to receive 4 sessions of 1 of the 4 treatments. Primary (pain intensity) and secondary outcome measures were administered by assessors unaware of treatment allocation at pretreatment, posttreatment, and 3-, 6-, and 12-month follow-up. Treatment effects were evaluated using analysis of variance, a generalized estimating equation approach, or a Fisher exact test, depending on the outcome domain examined. All 4 treatments were associated with medium to large effect size improvements in pain intensity that maintained up to 12 months posttreatment. Pretreatment to posttreatment improvements were observed across the 4 treatment conditions on the secondary outcomes of pain interference and depressive symptoms, with some return towards pretreatment levels at 12-month follow-up. No significant between-group differences emerged in omnibus analyses, and few statistically significant between-group differences emerged in the planned pairwise analyses, although the 2 significant effects that did emerge favored hypnotic cognitive therapy. Future research is needed to determine whether the significant differences that emerged are reliable.

Do Commonly Used Measures of Pain Intensity Only Reflect Pain Intensity in Youths With Bothersome Pain and a Physical Disability?

The objective of this cross-sectional study was to evaluate the extent to which non-pain intensity factors influence the ratings of pain intensity on two commonly used measures: the Wong-Baker Faces pain rating scale (FACES) and the Verbal Rating Scale (VRS) in a sample of youths with physical disabilities and bothersome pain. Study participants came from a convenience sample of 115 youths (age: X ¯ = 14.4 years; SD = 3.3), who participated in a survey on the impact of pain in young people with a physical disability. They were administered measures of pain intensity, pain catastrophizing, depressive symptoms, pain interference, and pain control beliefs. Zero-order correlation analyses were used to examine the associations among the pain intensity scores, while regression analyses were used to test the influence of the non-pain intensity factors on the pain intensity scores. Although pain intensity scores from all scales were significantly associated with one another, the correlations were moderate. Regression analyses showed that the FACES and VRS also reflect pain interference, in addition to pain intensity. The fact that the FACES and VRS ratings reflect more than pain intensity should be considered when selecting a pain measure. The results of this study also provide information to help interpret results after treatment.

The role of perceived family social support and parental solicitous responses in adjustment to bothersome pain in young people with physical disabilities.

PURPOSE: Family social support and parental solicitous responses have been hypothesised to play an important role in paediatric pain. However, research testing the hypothesised associations between these social domains and measures of adjustment to pain in youths with disabilities and chronic pain is non-existent. METHODS: About 111 youths with physical disabilities and bothersome pain were interviewed and asked to complete measures of average pain intensity, pain interference, family social support, parent solicitous responding, and catastrophising. RESULTS: Children's perceptions of pain-related solicitous responses from their parent/guardian were associated both with more pain interference and greater pain-related catastrophising; perceived social support was negatively associated with pain interference. CONCLUSIONS: The findings provide new information regarding the role that psychosocial factors have in predicting function and adjustment, and have important implications as to how youth with physical disabilities with pain might be most effectively treated. Implications for rehabilitation Little is known about the role of perceived family social support or parental solicitous responses in the adjustment to chronic pain in young people with physical disabilities. This study provides new and important findings that have significant theoretical and practical implications that could help to understand and manage function in these patients. Results show that it matters how parents respond to their children with disabilities who have pain, and raise the possibility that interventions which target these responses may result in significant benefits for the children.

The Association Between Mindfulness and Hypnotizability: Clinical and Theoretical Implications.

Mindfulness-based interventions and hypnosis are efficacious treatments for addressing a large number of psychological and physical conditions, including chronic pain. However, there continues to be debate surrounding the relative uniqueness of the theorized mechanisms of these treatments-reflected by measures of mindfulness facets and hypnotizability-with some concern that there may be so much overlap as to make the mechanism constructs (and, therefore, the respective interventions) redundant. Given these considerations, the primary aim of the current study was to examine the degree of unique versus shared variance between two common measures of mindfulness facets and hypnotizability: the Five Facet Mindfulness Questionnaire and the Stanford Hypnotic Clinical Scale. A cross-sectional survey was conducted with a sample of (N = 154) veterans with heterogeneous chronic pain conditions. Bivariate Pearson correlations were used to examine the associations between the target scales. Results showed that the correlations between the Five Facet Mindfulness Questionnaire scales and Stanford Hypnotic Clinical Scale total score were uniformly weak, although significant negative correlations were found between mindfulness facets of observe and nonreact with hypnotizability (ps < 0.05). Thus, not only are the mindfulness and hypnotizability constructs unique, but when significantly associated, hypnotic suggestibility corresponds with a tendency to be less mindful. These findings have important implications for future research aimed toward matching patients to the treatment most likely to be of benefit, and suggest that matching patients on the basis of these theoretically derived "unique" moderators may hold potential.

Improving the quality of depression and pain care in multiple sclerosis using collaborative care: The MS-care trial protocol.

BACKGROUND AND OBJECTIVES: Evidence-based pharmacological and behavioral interventions are often underutilized or inaccessible to persons with multiple sclerosis (MS) who have chronic pain and/or depression. Collaborative care is an evidence-based patient-centered, integrated, system-level approach to improving the quality and outcomes of depression care. We describe the development of and randomized controlled trial testing a novel intervention, MS Care, which uses a collaborative care model to improve the care of depression and chronic pain in a MS specialty care setting. METHODS: We describe a 16-week randomized controlled trial comparing the MS Care collaborative care intervention to usual care in an outpatient MS specialty center. Eligible participants with chronic pain of at least moderate intensity (≥3/10) and/or major depressive disorder are randomly assigned to MS Care or usual care. MS Care utilizes a care manager to implement and coordinate guideline-based medical and behavioral treatments with the patient, clinic providers, and pain/depression treatment experts. We will compare outcomes at post-treatment and 6-month follow up. PROJECTED PATIENT OUTCOMES: We hypothesize that participants randomly assigned to MS Care will demonstrate significantly greater control of both pain and depression at post-treatment (primary endpoint) relative to those assigned to usual care. Secondary analyses will examine quality of care, patient satisfaction, adherence to MS care, and quality of life. Study findings will aid patients, clinicians, healthcare system leaders, and policy makers in making decisions about effective care for pain and depression in MS healthcare systems. (PCORI- IH-1304-6379; clinicaltrials.gov: NCT02137044). This trial is registered at ClinicalTrials.gov, protocol NCT02137044.

Development and Preliminary Testing of a Screening Measure of Acceptance and Willingness in Relation to Pain, Fatigue, and Sadness in Chronic Pain.

BACKGROUND: The manner in which one responds to the experience of chronic pain is a primary determinant of pain-related distress and disruptions in functioning. In particular, responses to pain that reflect substantial unwillingness, or a lack of acceptance, in relation to pain are reliably associated with greater difficulties in comparison with responses that reflect willingness and acceptance. To date, several multi-item self-report assessments have been developed to evaluate pain-related willingness and acceptance. The purpose of the present research was to develop and evaluate a single item measure, the Acceptance and Willingness screener (AWS). METHODS: Participants included 172 individuals with chronic pain. The AWS consisted of 4 statements, reflecting various degrees of acceptance and willingness to experience pain, and participants were asked to endorse the statement that was most reflective of their views. RESULTS: Overall, responses were fairly evenly distributed across the statements (range, 20% to 29%). Correlation and regression results indicated significant associations between AWS responses and measures of pain intensity, depression, pain interference, and engagement in activity. Furthermore, when individuals were grouped according to the statement endorsed, significant between-group differences were indicated across these same measures. Differences were particularly pronounced for groups endorsing the lowest levels of acceptance and willingness and those endorsing the highest. CONCLUSIONS: These results correspond with previous work and provide initial support for the validity of a single item screening measure of acceptance and willingness in chronic pain.

The Associations Between Pain-related Beliefs, Pain Intensity, and Patient Functioning: Hypnotizability as a Moderator.

OBJECTIVES: On the basis of the idea that thoughts held about pain may represent "self-suggestions" and evidence indicating that people with higher levels of trait hypnotizability are more responsive to suggestions, the current study evaluated hypothesized moderating effects of hypnotizability on the associations between pain-related thoughts and both pain intensity and pain interference. METHODS: Eighty-five individuals with chronic pain were given measures of hypnotizability, pain intensity, pain interference, and pain-related thoughts (control beliefs, catastrophizing). RESULTS: Analyses supported a moderating role of hypnotizability on the association between control beliefs and pain interference. Specifically, the negative association between pain control beliefs and pain interference were stronger among those with higher trait hypnotizability than between those with lower trait hypnotizability. DISCUSSION: The study findings, if replicated in additional samples of individuals with chronic pain, have important clinical and theoretical implications. For example, if trait hypnotizability is found to predict an individual's response to a particular technique of cognitive therapy-such as focusing on and repeating pain control belief self-statements-measures of hypnotizability could be used to identify individuals who might be most responsive to this technique. The current findings indicate that research to further examine this possibility is warranted.

Effects of a Tailored Positive Psychology Intervention on Well-Being and Pain in Individuals With Chronic Pain and a Physical Disability: A Feasibility Trial.

OBJECTIVES: To determine the feasibility, acceptability, and efficacy of a computer-based positive psychology intervention in individuals with a physical disability and chronic pain. METHODS: Individuals with spinal cord injury, multiple sclerosis, neuromuscular disease, or postpolio syndrome and chronic pain were randomly assigned to a positive psychology or a control condition. Participants in the intervention group were instructed to practice 4 personalized positive psychology exercises. Participants in the control group were instructed to write about life details for 8 weeks. Participants completed online well-being and pain-related questionnaires at baseline, posttreatment, and at the 2.5-month follow-up, and rated treatment satisfaction at posttreatment. RESULTS: Ninety-six participants were randomized and 68 (70%) completed follow-up assessments. Participants in the positive psychology intervention group reported significant pretreatment to posttreatment improvements in pain intensity, pain control, pain catastrophizing, pain interference, life satisfaction, positive affect, and depression. Improvements in life satisfaction, depression, pain intensity, pain interference, and pain control were maintained to the 2.5-month follow-up. Participants in the control group reported significant pretreatment to posttreatment improvements in life satisfaction, and pretreatment to follow-up improvements in pain intensity and pain control. Significant between-group differences, favoring the treatment group, emerged for pretreatment to posttreatment improvements in pain intensity and pain control. Participants were similarly satisfied with both treatments. DISCUSSION/CONCLUSIONS: The results support the feasibility, acceptability, and potential efficacy of a computer-based positive psychology intervention for improving well-being and pain-related outcomes in individuals with physical disabilities and chronic pain, and indicate that a full trial of the intervention is warranted.

Living Well with Pain: Development and Preliminary Evaluation of the Valued Living Scale.

OBJECTIVES: Encouraging individuals with chronic pain to focus on nonpain-related goals that are consistent with personal values is a goal of most psychosocial pain interventions. A valid and reliable measure of goal-related variables would be useful to evaluate the importance of these to patient quality of life and as factors that may explain treatment outcome. DESIGN: We developed items for a measure (the Valued Living Scale, VLS) to assess goal importance, success, and confidence with respect to eight value domains and 26 specific values-related goals, and administered these items to individuals with three chronic pain conditions (low back pain, N = 58; fibromyalgia, N = 55; headache, N = 61). RESULTS: Analyses supported: 1) a two-factor model of the VLS items assessing goal-related variables associated with a) health and productivity and b) social relations; 2) VLS scale score reliability, with Cronbach's alphas greater than 0.70; and 3) VLS scale score validity, as indicated by significant associations with pain intensity, depression, and pain interference in the expected directions. CONCLUSIONS: The VLS items can be administered and scored to assess: 1) the importance of as well as 2) confidence in and 3) success in achieving values-consistent goals. The measure can be used by clinicians to monitor and track changes in patient's perceptions about their goals with treatment. Researchers can use the VLS to test theoretical models of the roles that patient perceptions about goal importance, confidence, and success play in chronic pain treatment outcome.

Contributions of four pain domains to the prediction of patient functioning and pain interference

Pain is a multidimensional experience that can vary in intensity, quality and spatial and temporal characteristics. Although there is a great deal of research supporting the importance of pain intensity as a correlate of patient functioning, there is a lack of research examining the importance of the other components of pain, especially the temporal domain. The purpose of this study was to advance the understanding of the role of four pain domains in predicting both pain interference and psychological functioning in a sample of patients with multiple sclerosis. The findings confirmed the significant association between pain intensity and measures of pain interference and psychological functioning, providing additional support for the importance of assessing pain intensity as a key component of chronic pain assessment. None of the other domains showed statistically significant associations with either of the criterion variables. However, we did find non-significant trends for pain temporal patterns to be associated with depressive symptoms. Specifically, there was a trend for patients reporting constant pain to report more depression than those reporting intermittent and variable pain. This suggests the possibility that the temporal pattern of pain may play a role in the impact of pain on depression; however, more research is needed to confirm this finding.(AU)

Contributions of four pain domains to the prediction of patient functioning and pain interference

Pain is a multidimensional experience that can vary in intensity, quality and spatial and temporal characteristics. Although there is a great deal of research supporting the importance of pain intensity as a correlate of patient functioning, there is a lack of research examining the importance of the other components of pain, especially the temporal domain. The purpose of this study was to advance the understanding of the role of four pain domains in predicting both pain interference and psychological functioning in a sample of patients with multiple sclerosis. The findings confirmed the significant association between pain intensity and measures of pain interference and psychological functioning, providing additional support for the importance of assessing pain intensity as a key component of chronic pain assessment. None of the other domains showed statistically significant associations with either of the criterion variables. However, we did find non-significant trends for pain temporal patterns to be associated with depressive symptoms. Specifically, there was a trend for patients reporting constant pain to report more depression than those reporting intermittent and variable pain. This suggests the possibility that the temporal pattern of pain may play a role in the impact of pain on depression; however, more research is needed to confirm this finding.

Pain location and functioning in persons with spinal cord injury.

BACKGROUND: The influence of pain location and extent on functioning in persons with spinal cord injury (SCI) and chronic pain is not well understood. OBJECTIVE: To investigate the correlations between pain location and extent to determine which pain domains may be important to assess and potentially target in treating chronic pain in SCI populations. DESIGN: Prospective, observational study. SETTING: University medical center. PARTICIPANTS: A total of 259 persons with an SCI and chronic pain. METHODS: Postal mail survey questionnaire. MAIN OUTCOME MEASUREMENTS: Pain sites, pain extent (number of sites), pain intensity in specific body locations, pain interference, and physical and psychological functioning. RESULTS: A positive association between pain extent and intensity with pain interference (r = 0.33, P < .01) and a negative association with psychological functioning were noted in the study sample (r = -0.21, P < .01). Pain intensity in the lower back and legs (r = 0.55, P < .01) and a number of other sites showed strong associations with patient functioning. Correlation with psychological functioning was significant but weaker (r = -0.22, P < .01 for the lower back and legs). Ambulatory status had only a small moderating effect on the associations between pain intensity in specific sites and pain interference and no effect on psychological functioning. CONCLUSIONS: The findings support the importance of assessing pain intensity at specific locations as a part of a thorough evaluation of chronic pain, as well as the importance of addressing pain at multiple sites, when managing pain in persons with an SCI.

Pain location and intensity impacts function in persons with myotonic dystrophy type 1 and facioscapulohumeral dystrophy with chronic pain.

INTRODUCTION: We examined the effects of pain site and intensity on function in patients with myotonic dystrophy type 1 (DM1) and facioscapulohumeral muscular dystrophy (FSHD) and chronic pain. METHODS: Questionnaires assessing pain sites, pain extent (number of sites), pain intensity, and pain interference were completed by 182 individuals with DM1 (43%) or FSHD (57%) and chronic pain. RESULTS: There was a positive association between pain extent and intensity with pain interference, and a negative association with psychological functioning in both DM1 and FSHD. Pain intensity at specific sites had differential impact beyond the effects of pain intensity alone. Head pain intensity independently affected psychological functioning, whereas leg, foot, hip, and knee pain contributed independently to the prediction of pain interference. CONCLUSIONS: Pain site and intensity differentially modulates the effect of chronic pain on function in DM1 and FSHD patients. Researchers and clinicians should consider these factors when assessing and treating pain.

The words patients use to describe chronic pain: implications for measuring pain quality.

Patients with low back pain (LBP; N = 102), fibromyalgia (FM; N = 100), and headache (HA; N = 100) were asked to describe their pain in their own words, and the words and phrases they used were then classified into 7 global domains (eg, Pain Quality, Pain Magnitude) and as many specific subdomains as needed to capture all of the ideas expressed (eg, under Pain Quality, subdomains such as sharp, achy, and throbbing). Fifteen pain quality subdomains were identified as most common. Nine of these demonstrated significant between-group differences in frequency. For example, patients with FM described their pain as achy more often than patients with LBP or HA; patients with HA described their pain as more throbbing than patients with LBP or FM; and patients with LBP described their pain as more shooting than patients with FM or HA. With the 15 pain quality subdomains representing the universe of most important pain qualities to assess, only 2 of 8 descriptive measures of pain quality were determined to have content validity. The findings are generally consistent with a study that used similar procedures in other patient samples to identify the most common words patients use to describe pain, supporting their generalizability. The findings also support the use of pain quality measures for discriminating between chronic pain conditions. Finally, the findings have important implications for evaluating and modifying pain quality measures as needed.

Steps toward developing an EEG biofeedback treatment for chronic pain.

Chronic pain, usually refractory to analgesics, is a significant problem for many individuals with spinal cord injury (SCI). Preliminary studies suggest that electroencephalography (EEG) biofeedback (also known as neurofeedback, NF) has the potential to help patients with otherwise refractory chronic pain. However, there remain many unanswered questions about the effects and mechanisms of this treatment. We studied 13 individuals with SCI and chronic pain with NF. Ten of the 13 individuals completed 4 sessions each of three different neurofeedback protocols assigned in random order for a total of 12 NF sessions. All three protocols had similar immediate effects on pain intensity. In addition, the participants reported modest pre- to post-treatment decreases in worst pain and pain unpleasantness following completion of the 12 NF sessions. These improvements were maintained at 3-month follow-up. The majority of the participants felt they benefited from and were satisfied with the treatment. No significant effects on measures of other outcome domains (sleep quality, pain interference and fatigue) were observed, although there was a non-significant trend for an increase in fatigue. Finally, pre- to post-treatment changes in EEG bandwidth activity, consistent with the training protocols, were observed in θ and α but not ß frequencies. The findings provide preliminary support for the potential efficacy of NF for the treatment of SCI-related pain, and suggest that further clinical studies are warranted.

Chronic pain in neuromuscular disease: pain site and intensity differentially impacts function.

The importance of pain extent (ie, number of body areas with pain) and pain site as factors contributing to dysfunction in persons with chronic, slowly progressive neuromuscular disease (NMD), remains poorly understood. This article discusses the importance of assessing pain site in addition to global pain intensity in patients with chronic, slowly progressive NMD. The importance of addressing pain at multiple sites will have a major impact on future studies assessing interventions to treat pain in this patient population.

Physical activity and depression in middle and older-aged adults with multiple sclerosis.

BACKGROUND: Depression is common among people with multiple sclerosis (MS), and research shows that individuals, including individuals with MS, who are more physically active report lower rates of depression. However, little is known about the relative importance of level of physical activity (e.g., moderate versus vigorous) in relationship to depression, or the role that age might play in this relationship among people with MS. The current study sought to (1) clarify the associations between moderate and vigorous physical activity and depression in a sample of individuals with MS, (2) determine the associations between age and physical activity, and (3) test for the potential moderating influence of age on the associations between physical activity and depression. OBJECTIVE/HYPOTHESIS: Cross-sectional survey. METHODS: 112 individuals with MS completed a survey assessing demographic variables, amount of moderate and vigorous physical activity, and depression. RESULTS: There was a gradual decrease in the amount of moderate and vigorous physical activity as age increased, but this decrease was not statistically significant. Moderate physical activity was significantly (negatively) associated with depression across all age cohorts. Time spent in vigorous physical activity was significantly (negatively) associated with depression among the middle-aged but not younger or older participants who are physically active. CONCLUSIONS: The findings support a link between moderate physical activity and depression and, for middle-aged individuals, vigorous physical activity and depression in persons with MS. The findings indicate that research examining the impact of activity enhancing treatments on depression in individuals with MS is warranted.

Hypnosis for symptom management in women with breast cancer: a pilot study.

Eight women who were in treatment for breast cancer (n = 4) or breast cancer survivors (n = 4), presenting with 1 or more of 4 symptoms (chronic pain, fatigue, hot flashes, and sleep difficulties), were given 4 to 5 sessions of self-hypnosis training for symptom management. Analyses revealed (a) significant pre- to posttreatment decreases in pain intensity, fatigue, and sleep problems and (b) that pain intensity continued to decrease from posttreatment to 6-month follow-up. Although there was a slight increase in fatigue severity and sleep problems from posttreatment to 6-month follow-up, the follow-up scores did not return to pretreatment levels. The findings provide initial support for using hypnosis to manage symptoms in women who are breast cancer survivors. Clinical trials evaluating hypnosis efficacy over and above other treatments are warranted.

Effects of self-hypnosis training and cognitive restructuring on daily pain intensity and catastrophizing in individuals with multiple sclerosis and chronic pain.

Fifteen adults with multiple sclerosis were given 16 sessions of treatment for chronic pain that included 4 sessions each of 4 different treatment modules: (a) an education control intervention; (b) self-hypnosis training (HYP); (c) cognitive restructuring (CR); and (d) a combined hypnosis-cognitive restructuring intervention (CR-HYP). The findings supported the greater beneficial effects of HYP, relative to CR, on average pain intensity. The CR-HYP treatment appeared to have beneficial effects greater than the effects of CR and HYP alone. Future research examining the efficacy of an intervention that combines CR and HYP is warranted.