Development of the Pain-Related Beliefs and Attitudes about Sleep (PBAS) Scale for the Assessment and Treatment of Insomnia Comorbid with Chronic Pain.

STUDY OBJECTIVES: Dysfunctional beliefs and attitudes about sleep is a cognitive-behavioral factor central to the development and perpetuation of insomnia. Previous works to unravel the complex interrelationship between pain and insomnia have not explored the role of inflexible beliefs about the sleep-pain interaction, possibly due to a lack of a valid instrument for doing so. The current study evaluated the psychometric and functional properties of a 10-item Pain-Related Beliefs and Attitudes about Sleep (PBAS) scale. METHODS: The PBAS scale was administered to four clinical samples of chronic pain patients with comorbid insomnia: to examine the scale's psychometric properties (n = 137), test-retest reliability (n = 26), sensitivity to treatment (n = 20), and generalizability (n = 62). All participants completed the PBAS together with validated measures of pain interference, insomnia severity, and cognitive-behavioral processes hypothesized to underpin insomnia. RESULTS: The PBAS scale was found to be reliable, with adequate internal consistency and temporal stability. Factor analysis suggested a 2-factor solution representing beliefs about "pain as the primary cause of insomnia" and the "inevitable consequences of insomnia on pain and coping." The PBAS total score was positively correlated with scores from the Insomnia Severity Index (ISI) scale, Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scale, and the Anxiety and Preoccupation about Sleep Questionnaire (APSQ). It was a significant predictor of insomnia severity and pain interference. A significant reduction in PBAS was also observed in patients after receiving a hybrid cognitive-behavioral intervention for both pain and insomnia. CONCLUSIONS: Pain-related sleep beliefs appear to be an integral part of chronic pain patients' insomnia experience. The PBAS is a valid and reliable instrument for evaluating the role of these beliefs in chronic pain patients.

Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review.

BACKGROUND CONTEXT: Exercise has been shown to reduce pain and increase function in patients with chronic low back pain. However up to 70% of patients do not engage in prescribed home exercise. Physiotherapists need to understand more about the complex factors influencing patients' adherence to prescribed home exercise to tailor their exercise interventions more effectively and support patients to self-manage. PURPOSE: This review identifies factors associated with adherence to health care practitioner-prescribed home exercise in adults with chronic low back pain. STUDY DESIGN: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used for the reporting of this review. PATIENT SAMPLE: We explored literature in which the authors studied adherence to home exercise in adults with CLBP. OUTCOME MEASURES: Adherence to home exercise was the primary outcome. Additional outcome measures were recorded in the data extraction table. METHODS: The following databases were searched: Embase, PsychINFO, MEDLINE, PEDro, and the Cochrane Central Register of Controlled Trials. Data were independently extracted and assessed for methodologic quality by two reviewers. RESULTS: Eleven randomized controlled trials, including 1,088 participants, met the inclusion criteria. Moderate evidence was found for one individual patient subfactor and three intervention-related subfactors associated with increased adherence to home exercise. These subfactors were greater health locus of control, supervision, participation in an exercise program, and participation in a general behavior change program incorporating motivational strategies. CONCLUSIONS: This is the first systematic review investigating adherence to prescribed home exercise in a chronic low back pain population. It is difficult to draw firm conclusions because the research lacks detailed descriptions of intervention content. The use of a taxonomy of behavior change techniques has been suggested to overcome this key problem. This review has highlighted the lack of standardized measures of adherence to prescribed home exercise. The development of a validated measure of adherence should be a priority because this will provide a better understanding of the multitude of factors that may influence adherence to home exercise.

Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: a pilot randomised controlled trial.

OBJECTIVE: Insomnia is a debilitating comorbidity of chronic pain. This pilot trial tested the utility of a hybrid treatment that simultaneously targets insomnia and pain-related interference. METHODS: Chronic pain patients with clinical insomnia were randomly allocated to receive 4 weekly 2-h sessions of hybrid treatment (Hybrid Group; n = 10) or to keep a pain and sleep diary for 4 weeks, before receiving the hybrid treatment (Monitoring Group; n = 10). Participants were assessed at the beginning and end of this 4-week period. Primary outcomes were insomnia severity and pain interference. Secondary outcomes were fatigue, anxiety, depression and pain intensity. Ancillary information about the hybrid treatment's effect on psychological processes and sleep (as measured with sleep diary and actigraphy) are also presented, alongside data demonstrating the treatment's clinical significance, acceptability and durability after one and six months. Data from all participants (n = 20) were combined for this purpose. RESULTS: Compared to symptom monitoring, the hybrid intervention was associated with greater improvement in sleep (as measured with the Insomnia Severity Index and sleep diary) at post-treatment. Although pain intensity did not change, the Hybrid Group reported greater reductions in pain interference, fatigue and depression than the Monitoring Group. Overall, changes associated with the hybrid intervention were clinically significant and durable at 1- and 6-month follow-ups. Participants also rated highly on treatment acceptability. CONCLUSION: The hybrid intervention appeared to be an effective treatment for chronic pain patients with insomnia. It may be a treatment approach more suited to tackle challenges presented in clinical practice, where problems seldom occur in isolation.

Deciphering the temporal link between pain and sleep in a heterogeneous chronic pain patient sample: a multilevel daily process study.

OBJECTIVES: Because insomnia is a common comorbidity of chronic pain, scientific and clinical interest in the relationship of pain and sleep has surged in recent years. Although experimental studies suggest a sleep-interfering property of pain and a pain-enhancing effect of sleep deprivation/fragmentation, the temporal association between pain and sleep as experienced by patients is less understood. The current study was conducted to examine the influence of presleep pain on subsequent sleep and sleep on pain reports the next day, taking into consideration other related psychophysiologic variables such as mood and arousal. DESIGN: A daily process study, involving participants to monitor their pain, sleep, mood, and presleep arousal for 1 wk. Multilevel modeling was used to analyze the data. SETTING: In the patients' natural living and sleeping environment. PATIENTS: One hundred nineteen patients (73.9% female, mean age = 46 years) with chronic pain and concomitant insomnia. MEASUREMENT: An electronic diary was used to record patients' self-reported sleep quality/efficiency and ratings of pain, mood, and arousal at different times of the day; actigraphy was also used to provide estimates of sleep efficiency. RESULTS: Results indicated that presleep pain was not a reliable predictor of subsequent sleep. Instead, sleep was better predicted by presleep cognitive arousal. Although sleep quality was a consistent predictor of pain the next day, the pain-relieving effect of sleep was only evident during the first half of the day. CONCLUSIONS: These findings challenge the often-assumed reciprocal relationship between pain and sleep and call for a diversification in thinking of the daily interaction of these 2 processes.

Pain-related insomnia versus primary insomnia: a comparison study of sleep pattern, psychological characteristics, and cognitive-behavioral processes.

BACKGROUND: Recent applications of cognitive-behavior therapy for primary insomnia in the management of pain-related insomnia are based on the implicit assumption that the 2 types of insomnia share the same presentation and maintaining mechanisms. The objectives of this study were to compare the characteristics of patients who have pain-related insomnia with those reporting primary insomnia and to identify psychological factors that predict pain-related insomnia. METHODS: Chronic pain patients with concomitant insomnia (n=137; Pain-related Insomnia Group) completed a selection of questionnaires that measure sleep patterns, psychological attributes, and cognitive-behavioral processes associated with the persistence of insomnia. Their responses were compared with those of primary insomnia patients (n=33; Primary Insomnia Group), using 3 sets of multivariate analyses of covariance that took account of demographic differences. Hierarchical regression analyses were performed to identify predictors of insomnia severity among the chronic pain patients. RESULTS: The Pain-related Insomnia Group did not differ from the Primary Insomnia Group in their pattern and severity of sleep disturbance. The 2 groups were largely comparable in terms of their psychological characteristics, except that the Primary Insomnia Group was distinguishable from the Pain-related Insomnia Group by their greater tendency to worry. Patients in the Pain-related Insomnia Group reported levels of sleep-related anxiety and presleep somatic arousal that matched with those reported by patients in the Primary Insomnia Group. However, relative to patients in the Pain-related Insomnia Group, those in the Primary Insomnia Group reported more dysfunctional sleep beliefs and presleep cognitive arousal. In addition to pain intensity, depression, and presleep cognitive arousal were significant predictors of insomnia severity within the Pain-related Insomnia Group. CONCLUSIONS: There are more similarities than differences between the 2 types of insomnia. Besides pain, mood, and presleep, thought processes also seem to have a role in the manifestation of pain-related insomnia. It is suggested that hybrid treatments that seek to simultaneously address factors across these domains may represent more effective treatments than 1-dimensional interventions.

Mental defeat is linked to interference, distress and disability in chronic pain.

Mental defeat is a psychological construct that has recently been applied to characterize the experience of chronic pain. Elevated levels of mental defeat have been identified in patients with chronic pain, and while its presence distinguishes treatment seeking from non-treatment seeking individuals, the link between mental defeat and disability in chronic pain is yet to be established. The current study investigated the extent to which mental defeat is associated with pain-related interference, distress and disability. A total of 133 participants completed the Pain Self Perception Scale that assessed mental defeat in relation to pain. Moreover, the participants were asked to complete a set of questionnaires that measured pain interference, distress, disability and other demographic (age, body mass index), clinical (pain intensity) and psychological (catastrophizing, worry, rumination and health anxiety) predictors of disability. Mental defeat was found to be strongly correlated with pain interference, sleep disturbance, anxiety, depression, functional disability and psychosocial disability. These correlations remained significant even when pain intensity and demographic variables were partialled out. Relative to chronic pain patients with lower levels of mental defeat, those with higher levels of mental defeat reported greater degree of pain interference, distress and disability. In a series of regression analyses, mental defeat emerged as the strongest predictor of pain interference, depression and psychosocial disability, whereas catastrophizing was the best predictor of sleep interference, anxiety and functional disability. These findings suggest that mental defeat may be an important mediator of distress and disability in chronic pain. Theoretical and clinical implications are discussed.