Feasibility randomized-controlled trial of online acceptance and commitment therapy for painful peripheral neuropathy in people living with HIV: The OPEN study.

BACKGROUND: Neuropathic pain negatively affects quality of life among people living with HIV (PLWH). This study examined the feasibility of conducting a full-scale randomized-controlled trial of online acceptance and commitment therapy ("ACT OPEN") for neuropathic pain in PLWH. METHODS: Using a parallel-groups design, thirty-eight participants were randomized to ACT OPEN or a waitlist control (2:1). Participants completed standard self-report outcome measures at baseline, and two- and five-months post-randomization. Participants were aware of their allocation, but assessment was blinded. RESULTS: Twenty-five participants were randomized to ACT OPEN and 13 to the control (of 133 referrals). ACT OPEN completion was 69% and two-month trial retention was 82%. Treatment credibility and satisfaction scores for ACT OPEN were comparable to scores reported in previous trials of cognitive-behavioural treatments for pain. Four adverse events were reported during the study, including one serious adverse event; all of these were unrelated to the research procedures. Small to moderate effects and 95% confidence intervals suggest that the true effect may favour ACT OPEN for improvements in pain intensity/interference and depression. CONCLUSIONS: A full-scale RCT of online ACT for pain management in PLWH may be feasible with refinements to trial design to facilitate recruitment. SIGNIFICANCE: Research on pain management in people living with HIV has primarily focused on pharmacological treatments with limited success. This is the first study to show the potential feasibility of a psychological treatment based on acceptance and commitment therapy delivered online and tailored for pain management in people with HIV ("ACT OPEN"). ACT OPEN may be a promising treatment in this population and further evaluation in a full-scale randomized-controlled trial appears warranted. TRIAL REGISTRATION: The trial was registered (clinicaltrials.gov; NCT03584412).

Assessment and patient selection process for a pain management programme: a case study in specialty care.

INTRODUCTION: The present study audited the process of assessing and selecting patients for a pain management programme with the aim of reviewing best practice in the light of the latest British Pain Society guidelines for pain management programmes for adults. The guidelines include defined inclusion/exclusion criteria and it was explored how they are used by clinicians providing a pain management service. METHOD: The records of 200 consecutive patients who attended a multidisciplinary assessment for a central London specialist Pain Management Service from September 2014 to December 2014 were audited. The proportions of patients who were offered a programme, were discharged or referred for a different service were calculated. Clinic letters were reviewed to collect information on assessment outcomes, recommendations and inclusion/exclusion criteria used. RESULTS: About half the patients (53%) seen for assessment were offered treatment within the service, most frequently the intensive residential programme (30.5%, with an additional 11.6% offered case management first), followed by the five session outpatient programme (8.1%) and a minority was offered individual treatment (2.5%); 44.7% of the patients were discharged following the assessment. The three most frequently used reasons for exclusion were: not ready to engage with the pain management approach (35%), complex psychological or other needs needing to be prioritised (29.5%) and the patient declining a programme (19.3%). CONCLUSION: Reviewing the use of inclusion/exclusion criteria revealed some challenges regarding patient selection. For example, a sizable proportion of patients were still seeking pain reduction and were not open to a self-management approach when this was the recommended treatment for them. Complex patients might need other treatment approaches before they can be considered for a programme. Having a range of pain management options of varying intensities available seems helpful in meeting individual patient need.

Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change.

Long-term use of opioid medication is associated with a host of negative effects on health and quality of life. Guidelines state that people with chronic pain taking high doses of opioids without benefit should be supported to discontinue them. Little research has investigated psychological processes associated with analgesic use and tapering. This study investigated (1) analgesic use pre- and post-participation in an interdisciplinary pain management programme and its relationship to functioning and (2) psychological processes associated with analgesic use. Opioid use was associated with poorer functioning at baseline. Participating in an interdisciplinary pain management programme was associated with reductions in opioid dose and number of classes of analgesics used. Reductions in analgesic use were associated with improvements in functioning. Psychological inflexibility was associated with using higher doses of opioid medication and with using a greater number of classes of analgesics. Psychological flexibility appears relevant in explaining analgesic use. Future research could focus on targeting this process to improve tapering outcomes.

Assessing physical functioning on pain management programmes: the unique contribution of directly assessed physical performance measures and their relationship to self-reports.

Physical functioning is a recommended outcome domain for pain management programmes. It can be assessed by self-report and by direct assessment of performance. Although physical performance measures may provide unique and useful information about patient functioning over and above self-report measures, it is not entirely clear which of the many possible performances to assess. This study investigated a battery of three directly assessed physical performance measures and their relationship to three currently used self-report measures of general health and functioning. The three performance measures were sensitive to treatment; patients performed significantly better on all three measures following completion of the pain management programme. The three performance measures were shown to represent a single underlying dimension, and there was a significant degree of overlap between them. The performance measures were shown to be relevant in explaining variation in the self-report measures, as well as to offer a clinically relevant different dimension of assessment to self-report. Future research could focus on developing performance-based measures that capture quality of movement and that are sensitive to relevant processes of therapeutic change.

Brief psychologically informed physiotherapy training is associated with changes in physiotherapists' attitudes and beliefs towards working with people with chronic pain.

This study aimed to investigate the impact of a brief psychologically informed physiotherapy training (PIPT) course on physiotherapists' attitudes and beliefs towards working with people with chronic pain. Specifically, the training aimed to help the participants better recognise the role of psychosocial factors in chronic pain and to better target the key processes of the psychological flexibility (PF) model in their treatment interactions. A total of 26 physiotherapists working in an outpatient musculoskeletal (MSK) department participated in the 7-hour training session. A total of 25 participants completed self-report questionnaires on attitudes and beliefs, burnout and PF-relevant processes pre- and post-training. The pre- and post-measures were completed on the day of training. PIPT was associated with significant changes in the expected direction in physiotherapists' attitudes towards treatment of people with chronic pain, including a moderate effect size on the Health Care Provider-Pain and Impairment Relationship Scale (HC-PAIRS) (decreased biomedical scores) and a large effect size on the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) (increased biopsychosocial scores and decreased biomedical scores). In conclusion, brief PIPT could help physiotherapists working in non-specialist centres with complex patients, many of whom present with significant emotional distress and pain-related disability. Further research is required to determine whether the changes in attitudes detected in this study translate into clinical practice and whether changes are maintained over a follow-up period.