The role of stigma in health and functioning in chronic pain: Not just catastrophizing.

BACKGROUND: People with chronic pain are frequently exposed to stigma, which is typically distressing and may lead to internal stigmatizing thoughts. The thought content associated with stigma has similarities to pain catastrophizing, although these concepts differ in that stigma is arguably more social in origin. Stigma can be measured by the Stigma Scale for Chronic Illness - 8-item version (SSCI-8). In this study, we first demonstrate the validity of this measure in Swedish. We then examine the role of stigma in the health and functioning of people with chronic pain, particularly beyond the role played by pain catastrophizing. METHODS: Adult participants (N = 404) with chronic pain recruited online completed measures of pain, stigma, catastrophizing, pain interference, work and social adjustment and depression on two occasions. RESULTS: A one-factor solution had an overall good model fit as long as residuals were allowed to covary, indicating some redundancy in the items. The SSCI-8 demonstrated good internal consistency and moderate temporal stability, and SSCI-8 scores demonstrated medium-to-large correlations with the measures of health and functioning. Furthermore, stigma was found to significantly contribute to explained variance in pain interference, work and social adjustment and depression, uniquely adding to the explained variance in these outcomes even after accounting for pain catastrophizing. CONCLUSIONS: The SSCI-8 provides an adequate measure to capture stigma experiences. Stigma is uniquely associated with pain-related outcomes and should be further considered in pain research and clinical practice in the future. SIGNIFICANCE: This study points to the importance of a social perspective on pain-related outcomes. We may need to more fully appreciate the way that people with chronic pain are treated by both health care providers and others can have an impact on their well-being. Potential negative impacts of stigmatizing responses to people with chronic pain are highlighted by the current results.

Does free nicotine replacement improve smoking cessation rates in cancer patients?

Background: Cigarette smoking is carcinogenic and has been linked to inferior treatment outcomes and complication rates in cancer patients. Here, we report the results of an 18-month pilot smoking cessation program that provided free nicotine replacement therapy (nrt). Methods: In January 2017, the smoking cessation program at our institution began offering free nrt for actively cigarette-smoking patients with cancer. The cost of 4 weeks of nrt was covered by the program, and follow-up was provided by smoking cessation champions. Results: From January 2017 to June 2018, 8095 patients with cancer were screened for cigarette use, of whom 1135 self-identified as current or recent smokers. Of those 1135 patients, 117 enrolled in the program and accepted a prescription for nrt. The rates of patient referral and patients attending a referral appointment were significantly higher in 2018-2018 than they had been in 2015-2016 (100% vs. 80.3%, p < 0.001, and 27.6% vs. 11.3%, p < 0.001, respectively). Median follow-up was 9.0 months (25%-75% interquartile range: 5.7-11.6 months). Of the patients who accepted nrt and who also had complete data (n = 71), 25 (35.2%) reported complete smoking cessation, and 32 (45.1%) reported only decreased cigarette smoking. On univariable analysis, no factors were significantly predictive of smoking cessation, although initial cigarette use (>10 vs. ≤10 initial cigarettes) was significantly predictive of smoking reduction (odds ratio: 5.04; 95% confidence interval: 1.46 to 17.45; p = 0.011). Conclusions: This pilot study of free nrt demonstrated rates of referral and acceptance of nrt that were improved compared with historical rates, and most referred patients either decreased their use of cigarettes or quit entirely.

The role of psychological flexibility in relation to suicidal thinking in chronic pain.

BACKGROUND: Suicidal thinking (ST) is common in people with chronic pain. It is relevant as it can be associated with suicidal attempts, and typically reflects significant suffering. While little is known about the psychological processes that contribute to ST, current psychological models, such as the Psychological Flexibility (PF) model, could help guide further investigation. This study investigates relations between ST and components of PF in chronic pain. METHODS: Participants were 424 adults attending treatment for chronic pain in the UK. Included in measures administered before treatment were standardized measures of depression, pain, pain-related interference, and measures of PF, including acceptance, cognitive defusion, committed action, and self-as-context. An item from the measure of depression was used to reflect ST. RESULTS: A large proportion of the sample reported ST, 45.7%. ST was uncorrelated with participant background characteristic, medications taken, or pain intensity. However, it was correlated with the presence of widespread pain, pain-related interference, and depression. Each component of PF was found to be significantly negatively associated with ST, as predicted. General acceptance correlated with ST at a level equal to that achieved by the depression score. In adjusted multivariate logistic regression general acceptance and committed action remained significantly uniquely associated with it. CONCLUSION: This preliminary study suggests for the first time that components of PF are associated with part of a pattern of suicidal behaviour in people with chronic pain. They may be relevant for reducing avoidance in general and providing more positive behavioural options. SIGNIFICANCE: This study provides evidence that components of psychological flexibility are associated with a reduced frequency of suicidal thinking in people with chronic pain. Treatments targeting psychological flexibility may help mitigate the impact of chronic pain on suicidal thinking.

Feasibility randomized-controlled trial of online Acceptance and Commitment Therapy for patients with complex chronic pain in the United Kingdom.

BACKGROUND: Acceptance and Commitment Therapy (ACT) has growing support for chronic pain. However, more accessible treatment delivery is needed. This study evaluated the feasibility of online ACT for patients with complex chronic pain in the United Kingdom to determine whether a larger trial is justified. METHODS: Participants with chronic pain and clinically meaningful disability and distress were randomly assigned to ACT online plus specialty medical pain management, or specialty medical management alone. Participants completed questionnaires at baseline, and 3- and 9-month post-randomization. Primary feasibility outcomes included recruitment, retention and treatment completion rates. Secondary outcomes were between-groups effects on treatment outcomes and psychological flexibility. RESULTS: Of 139 potential participants, 63 were eligible and randomized (45% recruitment rate). Retention rates were 76-78% for follow-up assessments. Sixty-one per cent of ACT online participants completed treatment. ACT online was less often completed by employed (44%) compared to unemployed (80%) participants. Fifty-six per cent of ACT online participants rated themselves as 'much improved' or better on a global impression of change rating, compared to only 20 per cent of control participants. Three-month effects favouring ACT online were small for functioning, medication and healthcare use, committed action and decentring, medium for mood, and large for acceptance. Small-to-medium effects were maintained for functioning, healthcare use and committed action at 9 months. CONCLUSIONS: Online ACT for patients with chronic pain in the United Kingdom appears feasible to study in a larger efficacy trial. Some adjustments to treatment and trial procedures are warranted, particularly to enhance engagement among employed participants. SIGNIFICANCE: This study supports the feasibility of online Acceptance and Commitment Therapy for chronic pain in the United Kingdom and a larger efficacy trial. Refinements to treatment delivery, particularly to better engage employed patients, may improve treatment completion and outcomes.

Distant delivery of a mindfulness-based intervention for people with Parkinson's disease: the study protocol of a randomised pilot trial.

BACKGROUND: Psychological difficulties, especially depression and anxiety, are the most prevalent non-motor symptoms in Parkinson's disease. Pharmacological treatments for these conditions appear relatively ineffective in Parkinson's disease. Mindfulness courses are increasingly popular and recognised as effective for managing emotional states, and there is growing evidence for the effectiveness of mindfulness courses for people with long-term medical conditions. With this exploratory pilot trial, we want to assess the feasibility of the procedures and processes, including recruitment, most appropriate outcome measure(s), acceptability of type and number of measures, potential nocebo effects, and potential effectiveness and cost-effectiveness of a specially adapted distance-delivered mindfulness-based intervention in people affected by Parkinson's disease. METHODS/DESIGN: This is a pilot two-arm randomised parallel group controlled trial. Sixty participants who meet eligibility criteria will be randomly assigned either to an 8-week mindfulness-based intervention group or a wait-list control group. The mindfulness intervention will include 1-h weekly sessions delivered by a health psychologist trained to facilitate mindfulness courses. Participants in both groups will complete standardised questionnaires assessing anxiety, depression, pain, insomnia, fatigue, and daily activities at four time points (baseline, 4, 8, and 20 weeks). The analysis will also consider potential mechanisms of change, such as acceptance, self-compassion, and tolerance of uncertainty, as well as health economic outcomes. Participants' experiences of the mindfulness interventions will be explored via in-depth interviews. DISCUSSION: A mindfulness-based intervention for people with Parkinson's delivered remotely, through Skype group videoconferences, may represent a viable, more accessible, intervention for people with mobility limitations and people who live in rural areas. The trial will provide important information about the feasibility, potential efficacy and cost-effectiveness, and acceptability of the intervention as well as mechanisms of psychosocial adjustment. The results of this pilot trial will help us design a phase III trial to assess efficacy of an online mindfulness-based intervention in Parkinson's disease and evaluate significance. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02683330.

Beyond a physical symptom: the importance of psychosocial factors in multiple sclerosis pain.

BACKGROUND AND PURPOSE: Pain affects around two-thirds of people with Multiple Sclerosis (pwMS). Biomedical treatments show limited efficacy. A recently developed cognitive-behavioural model of Multiple Sclerosis (MS) pain suggests several psychosocial factors may worsen pain and related disability. The current study investigated whether psychosocial factors drawn from this model explain significant amounts of the variance in pain severity and interference over and above measures of disease severity and pain subtype. METHODS: Six hundred and twelve pwMS experiencing pain completed a U.K. wide cross-sectional survey including valid and reliable psychometric questionnaires. Hierarchical regressions determined the relative contribution of disease severity and psychosocial factors to predicting pain severity and interference. RESULTS: All psychosocial factors including distress, negative beliefs about pain and its consequences, and avoidance of activity, were related to pain outcomes, explaining a further 24% and 30% of the variance in pain severity and interference after controlling for demographic and disease variables. Findings were similar for neuropathic and non-neuropathic pain subgroups. CONCLUSIONS: All pwMS reported significant pain and associated disability even though over 90% were taking pain medication. Psychosocial factors identified as important in predicting pain severity and, to a greater extent, pain interference are potentially modifiable and may be important treatment targets for both pain subtypes.

Further development in the assessment of psychological flexibility: a shortened Committed Action Questionnaire (CAQ-8).

BACKGROUND: Committed action is a relatively understudied facet of the psychological flexibility model but a potentially important process of overt behaviour in relation to chronic pain. In this study, we take a previously developed measure of committed action, the Committed Action Questionnaire (CAQ), and validate a shorter version. METHODS: A total of 664 adults seeking treatment for chronic pain participated in this study. They provided responses to the CAQ and also completed measures of acceptance and health-related daily functioning. Exploratory and confirmatory factor analyses as well as Mokken scaling analysis were used to explore the structure of the CAQ and produce an 8-item version (CAQ-8). RESULTS: A two-factor scale emerged from the analyses that both meets criteria for reliability and validity and performs comparably to the longer original version. In validity correlation analyses, committed action as measured by the CAQ-8 was significantly associated with pain-related and general acceptance and with depression, physical and social functioning, mental health, vitality and general health. CONCLUSIONS: The CAQ-8 appears equally adequate as the CAQ as a measure of committed action. Its development ought to facilitate further study of this process of engagement in activity and of the wider psychological flexibility model in relation to chronic pain.

Preoperative assessment in the elderly: evaluation of a new clinical service.

Older people represent the fastest growing sector of society and a growing proportion of those undergoing elective surgery. Older people are at the highest risk of increased length of stay and postoperative complications. We evaluated the development of a nurse-led multidimensional preoperative assessment for older people. An older people's preassessment nurse reviewed consecutive patients undergoing elective surgery who met the inclusion criteria. In the first five months control phase, assessment was not acted on. Following the intervention, patients were referred to appropriate specialties for input. A total of 141 patients were reviewed before and 172 patients reviewed after the introduction of the pilot. Length of stay was reduced from 8.9 to 4.9 days after the introduction of the pilot (P < 0.001). Delays were reduced from 9.9% to 2.3% (P = 0.004) and fewer procedures were cancelled at pre-assessment (17.7% before, 5.2% after; P < 0.001). Serious postoperative complications were reduced from 8.5% to 2.3% (P = 0.01). Coordinated multidisciplinary preoperative assessment in the elderly may reduce complications and length of stay.

Linking of Glycine Receptor Transmembrane Segments Three and Four Allows Assignment of Intrasubunit-Facing Residues.

Glycine receptors (GlyRs) are pentameric ligand-gated ion channels that mediate inhibitory neurotransmission in the brain and spinal cord and are targets of alcohols and anesthetics. The transmembrane (TM) domain of GlyR subunits is composed of four α-helical segments (TM1-4), but there are conflicting data about the orientation of TM3 and TM4 and, therefore, also the proximity of residues (e.g., A288) that are important for alcohol and anesthetic effects. In the present study, we investigated the proximity of A288 in TM3 to residues in TM4 from M404 to K411. We generated eight double mutant GlyRs (A288C/M404C, A288C/F405C, A288C/Y406C, A288C/W407C, A288C/I408C, A288C/I409C, A288C/Y410C, and A288C/K411C), as well as the corresponding single mutants, and expressed them in Xenopus laevis oocytes. To measure glycine responses, we used two-electrode voltage clamp electrophysiology. We built homology models of the GlyR using structures of the nicotinic acetylcholine receptor (nAChR) and a prokaryotic ion channel (Gloeobacter violaceus, GLIC) as templates, and asked which model best fit our experimental data. Application of the cross-linking reagent HgCl(2) in the closed state produced a leftward shift in the glycine concentration-response curves of the A288C/W407C and A288C/Y410C mutants, suggesting they are able to form cross-links. In addition, when HgCl(2) was coapplied with glycine, responses were changed in the A288C/Y406C, A288C/I409C, and A288C/Y410C double mutants, suggesting that agonist-induced rotation of TM4 allows A288C/Y406C and A288C/I409C to cross-link. These results are consistent with a model of GlyR, based on nAChR, in which A288, Y406, W407, I409, and Y410 face into a four-helical bundle.

Applying community-based participatory research principles to the development of a smoking-cessation program for American Indian teens: telling our story

Community-based participatory research provides communities and researchers with opportunities to develop interventions that are effective as well as acceptable and culturally competent. The present project responds to the voices of the North Carolina American Indian (AI) community and the desire for their youth to recognize tobacco addiction and commercial cigarette smoking as debilitating to their health and future. Seven community-based participatory principles led to the AI adaptation of the Not On Tobacco teen-smoking-cessation program and fostered sound research and meaningful results among an historically exploited population. Success was attributed to values-driven, community-based principles that (a) assured recognition of a community-driven need, (b) built on strengths of the tribes, (c) nurtured partnerships in all project phases, (d) integrated the community's cultural knowledge, (e) produced mutually beneficial tools/products, (f) built capacity through co-learning and empowerment, (g) used an iterative process of development, and (h) shared findings/ knowledge with all partners. (AU)

Multimethod assessment of treatment process in chronic low back pain: comparison of reported pain-related anxiety with directly measured physical capacity.

Although cognitive behavioural treatments (CBT) have proven efficacy in improving symptom management, pain-related distress, physical performance and return to work. few studies have examined the relationship between changes in behavioural process variables during treatment and improvement in outcome variables following treatment. We designed a multimethod assessment strategy to test the relative contribution of changes in physical capacity and pain-related anxiety to treatment outcome variables. Low back pain patients (n = 59) were treated with an intensive programme of physical exercise and CBT. Comparisons from pre- to post-treatment showed significant improvement in pain severity, interference, affective distress, activity level, and depression. Improvements in pain-related anxiety were associated with improvements in all outcome variables except interference. Of three physical capacity composite scores, improvement in only one (lumbar extension and flexion capacity) was associated with improvements in all outcome variables except interference. Further analyses demonstrated that the relationship between changes in pain-related anxiety and treatment outcome were independent of changes in physical capacity performance. Changes during treatment in pain-related anxiety may be more important than changes during treatment in physical capacity when predicting the effect of treatment on behavioural outcome measures. These results are discussed in the context of how to improve assessment of the chronic pain patient and improve the effectiveness of multidisciplinary CBT.

A comparison of blacks and whites seeking treatment for chronic pain.

OBJECTIVE: Most conceptualizations of chronic pain acknowledge the importance of culture and social circumstances. Cultural and social influences may differ for persons of different racial or ethnic groups, and this circumstance may lead them to experience and adjust differently to pain. The current study compared adjustment to chronic pain by blacks and whites seeking treatment for chronic pain. SUBJECTS AND MEASURES: Fifty-seven black and 207 white patients completed measures of anxiety, depression, disability, pain, and physical symptoms during their initial visit to a university pain clinic. RESULTS: Comparisons showed that the groups did not differ with regard to age, sex, education, chronicity of pain, pain location, work status, previous surgeries, medical diagnosis, medication, wage replacement, or involvement in litigation. However, the black group reported higher pain severity, more avoidance of activity, more fearful thinking, more physical symptoms, and greater physical and psychosocial disability. The groups remained significantly different with regard to avoidance, fearful thinking, and physical symptoms after pain severity was statistically controlled for; however, they did not remain different on disability. CONCLUSIONS: These results show that blacks and whites with chronic pain experience pain differently. Several factors may underlie these differences, including family situation, health care experiences, or other unmeasured behavioral, environmental, or social influences. Other investigators should attempt to replicate these findings and more closely examine variables that may explain them.

Temporal stability of the Minnesota Multiphasic Personality Inventory (MMPI) in patients undergoing lumbar fusion: a poor predictor of surgical outcome.

In this prospective study, the Minnesota Multiphasic Personality Inventory (MMPI) was administered to patients before and after lumbar spines fusion to investigate the stability of MMPI scores after surgical intervention and to attempt to correlate MMPI scale scores with outcome data. Sixty-eight patients were included. Testing was performed before surgery and at a mean of 1.5 years after surgery. Clinical outcome ratings were assigned by using criteria of pain relief and analgesic use. In addition, demographic variables known to affect outcome were analyzed. Sixty percent of the patients had a successful clinical outcome. Positive outcome correlated with the demographic factors of occupation (homemaker) and solid fusion. MMPI scales were stable across time, with no difference between groups. Independent t tests were used to study preoperative MMPI scores with respect to clinical outcome. Unsatisfactory outcomes were associated with higher scores on scales 1, 3, and 10 before surgery. Postoperative testing revealed significant outcome correlations--higher scores on scales 1, 2, 3, 5, 7, and 8 associated with an unsatisfactory outcome. However, discriminant function analysis of preoperative MMPI data was able to classify outcomes correctly in only 58.8% of the cases. The utility of the MMPI as a predictor of outcome after surgical intervention is quite limited. Use of group data and testing before and after surgery does not appear to influence this conclusion. Although the scores as a group were stable across time, the amount of variance in outcome that could not be accounted for by using MMPI scales as predictors was unacceptably large.

Assessing depression in systemic lupus erythematosus: determining reliable change.

Systemic lupus erythematosus (SLE) can follow an unpredictable course. Clinicians and researchers use various self-report inventories to track aspects of the patient's functioning during the course of the illness (e.g. health status, pain, fatigue, quality of life and psychological status). These self-report inventories are used to measure improvement or deterioration as a function of the natural history of the disease process, or as a function of response to treatment. Proper interpretation of scores derived from these inventories requires an understanding of their psychometric properties, in particular, their reliability. It is important to calculate reliable change difference scores for tests commonly used in rheumatology so clinicians can determine if a change score is a reliable indicator of improvement or deterioration in individual patients (i.e. the change score is not likely to be due to measurement error). The purpose of this article is to illustrate the use of the reliable change difference scores when assessing depression in patients with SLE using the Beck Depression Inventory (BDI).

Predicting complaints of impaired cognitive functioning in patients with chronic pain.

Patients with chronic pain often complain of difficulties with cognitive functioning. Previous studies suggest that these occur with no history of head trauma or neurological disease. This study examined potential predictors of cognitive complaints in 275 consecutive patients referred to a university pain management center. Patients completed a brief set of self-report measures of problems with cognitive functioning, biographical information, pain severity, pain location, depression, anxiety, sleep quality, medication use, and litigation status during their first visit to the clinic. The most frequently reported cognitive complaints included forgetfulness (23.4%), minor accidents (23.1%), difficulty finishing tasks (20.5%), and difficulty with attention (18.7%). Fifty-four percent of patients reported at least one problem with cognitive functioning. Correlation analyses showed that using antidepressants, pain severity, pain-related anxiety, and depression were moderately associated with total cognitive complaints. Regression analyses showed that depression accounted for the largest unique proportion of variance in cognitive complaints (DeltaR2 = 29%). Given the high frequency of complaints of impaired cognitive functioning, this realm of functioning deserves routine assessment. When these complaints are encountered, a careful evaluation considering a range of neurological, social, and emotional influences is in order.