Anava A. Wren

Yoga for persistent pain: New findings and directions for an ancient practice

Currently, many clinicians treating persistent pain hear about the benefits of yoga from patients who frequent yoga centers. However, pain clinicians and researchers may not be aware of randomized controlled studies examining the efficacy of yoga for managing persistent pain. The purpose of this review is to highlight recent studies that shed light on the potential role that yoga can play in pain management for a range of conditions that can be chronically painful. The review is divided into three sections: 1) a description of the basic components of yoga-based protocols for pain, b) a review of nine of the thirteen randomized studies located that test yoga’s efficacy for persistent pain, and c) a discussion of key clinical issues and future directions for yoga-based pain research and practice.

Self-compassion in patients with persistent musculoskeletal pain: Relationship of self-compassion to adjustment to persistent pain

CONTEXT Self-compassion entails qualities such as kindness and understanding toward oneself in difficult circumstances and may influence adjustment to persistent pain. Self-compassion may be a particularly influential factor in pain adjustment for obese individuals who suffer from persistent pain, as they often experience heightened levels of pain and lower levels of psychological functioning. OBJECTIVES The purpose of the present study was to examine the relationship of self-compassion to pain, psychological functioning, pain coping, and disability among patients who have persistent musculoskeletal pain and who are obese. METHODS Eighty-eight obese patients with persistent pain completed a paper-and-pencil self-report assessment measure before or after their appointment with their anesthesiologist. RESULTS Hierarchical linear regression analyses demonstrated that even after controlling for important demographic variables, self-compassion was a significant predictor of negative affect (β=-0.48, P<0.001), positive affect (β=0.29, P=0.01), pain catastrophizing (β=-0.32, P=0.003), and pain disability (β=-0.24, P<0.05). CONCLUSION The results of this study indicate that self-compassion may be important in explaining the variability in pain adjustment among patients who have persistent musculoskeletal pain and are obese.

Pain Acceptance, Hope, and Optimism: Relationships to Pain and Adjustment in Patients With Chronic Musculoskeletal Pain

UNLABELLED There is growing interest in the role that positive aspects of psychological adjustment, such as pain acceptance, hope, and optimism, may play in explaining adjustment in persons suffering from persistent pain. This study conducted in obese patients with persistent musculoskeletal pain (N = 89) examined the degree to which pain acceptance and hope explained pain intensity, pain unpleasantness, psychological distress, and pain-related disability, after controlling for the effects of optimism. In correlational analyses, pain acceptance and optimism were associated with psychological distress and pain disability with hope being related to only psychological distress. Pain acceptance, optimism, and hope were not significantly associated with pain. Hierarchical linear regression (HLR) analyses found that pain acceptance remained a significant predictor of psychological distress and pain disability after controlling for optimism, demographic, and medical variables. HLR analyses found that hope was not a significant predictor of psychological distress after controlling for optimism, pain acceptance, and demographic and medical variables. The results of this study are important because they indicate that pain acceptance, hope, and optimism are all related to pain adjustment. They also highlight the importance of controlling for optimism when examining the effects of pain acceptance and hope on pain adjustment. PERSPECTIVE In a sample of obese patients with persistent musculoskeletal pain, pain acceptance was a significant predictor of psychological distress and pain disability even after controlling for optimism, demographic, and medical variables. These results add to the growing literature on the importance of pain acceptance in understanding adjustment to persistent pain.

Feasibility and effectiveness of a brief meditation-based stress management intervention for patients diagnosed with or at risk for coronary heart disease: A pilot study

Extensive research has led to the development of a psychobiological model of cardiovascular disease. This model suggests that psychological factors such as depression, anxiety, hostility, and stress may affect the development and progression of coronary heart disease (CHD). Recent studies have also demonstrated that meditation-based stress reduction programs are useful interventions for patients with various medical and psychological symptoms. The objective of this pilot study was to gather preliminary information regarding the feasibility of implementing a brief meditation-based stress management (MBSM) program for patients with CHD, and those at high risk for CHD, at a major metropolitan hospital that serves a predominately non-local patient population. The secondary aim of this study was to investigate the possibility that such an intervention might reduce depression, as well as perceived stress, anxiety, and hostility, while improving general health scores. The overall feasibility results indicate that this MBSM intervention was highly feasible with regard to both recruitment and retention of participants. In fact, 40% of patients requested further training. In addition, after completion of the 4-week intervention, participants reported significant reductions in depression and perceived stress. In conclusion, the present study demonstrated that the brief meditation-based stress management program was well-received by patients and can successfully be used as a supportive program for patients at risk or diagnosed with CHD.

Understanding chronic pain in older adults: abdominal fat is where it is at.

There is growing recognition that obesity and pain are linked and that this linkage may be important in understanding and treating people who suffer from persistent pain. Using a communitybased sample of older adults (age > 70), Ray et al. [6] examined factors (i.e., metabolic syndrome, insulin resistance, inflammation) that might explain the link between obesity markers and chronic pain. After controlling for a variety of potentially confounding variables, they found that central obesity (as indexed by waist circumference) was the most important and most consistent risk factor for chronic pain. The magnitude of this finding was striking in that participants who had a higher degree of central obesity were twice as likely to report chronic pain. The study by Ray et al. [6] has a number of methodological strengths. First, the sample was relatively large (N = 407) and more representative of the general older adult population than participants who might be recruited from specialized pain programs. Second, a number of measures were taken to explore physiological mechanisms that might explain the relationship between obesity and pain (i.e., blood pressure, triglycerides, high density lipoprotein, glucose, insulin, C-reactive protein). Third, the data analysis approach controlled for other co-morbid painful conditions (i.e., osteoarthritis, neuropathy), as well as psychological variables (i.e., cognitive function, anxiety, depression). Finally, the study featured a sophisticated approach to data analysis. The problems of chronic pain and obesity are clearly important for older adults. Ray et al. [6] found that 52% of their communitybased sample of adults over 70 met the International Association for the Study of Pain (IASP) criteria for chronic pain and that 46% met the criteria for obesity. One of the most interesting findings reported by Ray et al. [6] was the strong relationship between central obesity and chronic pain, a finding that could not be explained by physiological variables often associated with obesity and/or chronic pain. Since this study is cross-sectional, it is not clear whether central obesity leads to chronic pain or whether chronic pain leads to central obesity. Regardless, the results suggest that health professionals should more closely monitor simple measures of central obesity, such as waist circumference, when treating older adults who are at risk for pain or obesity. The Ray et al. [6] study is also important in that it suggests a number of interesting directions for future research. First, their findings are based on a cross-sectional design, which leads to a logical next step: a longitudinal study design that tracks central obesity and pain over extended time periods (e.g., 12–36 months). Such a study could shed light on the causal relationships between these two variables and the mechanisms that explain these relationships. Second, future studies should examine a variety of other physiolog-

Holding Back Moderates the Association Between Health Symptoms and Social Well-Being in Patients Undergoing Hematopoietic Stem Cell Transplantation

CONTEXT Holding back, or withholding discussion of disease-related thoughts and emotions, is associated with negative outcomes including lower quality of life, diminished well-being, and relational distress. For patients undergoing hematopoietic stem cell transplantation (HSCT), the degree to which one holds back from discussing illness-related concerns may be an important determinant of social well-being and health; however, this has not been systematically assessed in this population. OBJECTIVES The purpose of the present study was to assess the moderating effects of holding back discussion of disease-related concerns on the relationship between health-related symptoms and social well-being in adult patients undergoing HSCT. METHODS Seventy autologous (n = 55) and allogeneic (n = 15) HSCT patients completed measures of holding back, social well-being, and health symptoms (i.e., pain, fatigue, sleep problems, cognitive problems) both before and after transplantation (i.e., three months after transplantation and six months after transplantation). RESULTS In patients with average to high levels of holding back, health symptoms were significantly related to lower levels of social well-being; however, for patients with low levels of holding back, the relationship between health symptoms and social well-being was not significant. CONCLUSION The results of the present study suggest that the level of holding back may be important in understanding how health-related symptoms relate to social well-being in patients undergoing HSCT. These findings underscore the importance of addressing how patients undergoing HSCT communicate about their disease with others as this may be related to their adjustment to illness and treatment.

The Context of Pain in Arthritis: Self-efficacy for Managing Pain and Other Symptoms

Arthritis pain may be best understood in the context of a biospychosocial model of pain. The biopsychosocial model of pain suggests that adjustment to arthritis pain is multifaceted and is influenced by biological, psychological, and social factors. One psychological construct that appears to be particularly helpful in understanding arthritis pain is patients’ self-efficacy for managing pain and other symptoms. In recent work, investigators have included self-efficacy for managing pain and other symptoms as key outcome measures in behavioral and psychosocial intervention studies. The goal of this article was to review recent intervention studies that have examined the effect of behavioral and psychosocial interventions on self-efficacy for managing pain and other symptoms. Throughout the article, we make several suggestions for future clinical and research considerations regarding the role of self-efficacy for managing pain and other symptoms in the context of arthritis pain.

Predictors of Pain Experienced by Women During Percutaneous Imaging-Guided Breast Biopsies

PURPOSE The purpose of this study was to evaluate pain experienced during imaging-guided core-needle breast biopsies and to identify factors that predict increased pain perception during procedures. METHODS In this institutional review board-approved, HIPAA-compliant protocol, 136 women undergoing stereotactically or ultrasound-guided breast biopsy or cyst aspiration were recruited and provided written informed consent. Participants filled out questionnaires assessing anticipated biopsy pain, ongoing breast pain, pain experienced during biopsy, catastrophic thoughts about pain during biopsy, anxiety, perceived communication with the radiologist, chronic life stress, and demographic and medical information. Procedure type, experience level of the radiologist performing the biopsy, number of biopsies, breast density, histology, and tumor size were recorded for each patient. Data were analyzed using Spearmans ρ correlations and a probit regression model. RESULTS No pain (0 out of 10) was reported by 39.7% of women, mild pain (1-3 out of 10) by 48.5%, and moderate to severe pain (≥4 out of 10) by 11.8% (n = 16). Significant (P < .05) predictors of greater biopsy pain in the probit regression model included younger age, greater prebiopsy breast pain, higher anticipated biopsy pain, and undergoing a stereotactic procedure. Anticipated biopsy pain correlated most strongly with biopsy pain (β = .27, P = .004). CONCLUSIONS Most patients report minimal pain during imaging-guided biopsy procedures. Women experiencing greater pain levels tended to report higher anticipated pain before the procedure. Communication with patients before biopsy regarding minimal average pain reported during biopsy and encouragement to make use of coping strategies may reduce patient anxiety and anticipated pain.

Optimism and pain: a positive move forward.

There is growing evidence that optimism is linked to lower pain sensitivity and better adjustment to pain [1,2,5,10,12,16]. To date, however, the evidence for optimism’s effects on pain has come solely from cross-section studies. The paper by Hannssen et al. in this issue of Pain is noteworthy because, to our knowledge, it the first study to manipulate optimism experimentally and examine its effects on pain [11]. The authors obtained pain ratings from healthy volunteers exposed to a cold pressor task. Prior to the cold pressor task, half of the participants were randomly assigned to a manipulation designed to enhance optimism (writing about and then visualizing their best possible self), while the others received a control condition. The Best Possible Self manipulation produced significantly lower reports of pain during the cold pressor task. Furthermore, changes in situational pain catastrophizing mediated the effects of the Best Possible Self manipulation on pain. This paper has several important methodological strengths. First, the authors included a manipulation check, demonstrating that the Best Possible Self manipulation led to expected changes in positive affect as well as positive and negative future expectations. Second, the authors examined two possible mechanisms (i.e., expected pain intensity, situational pain catastrophizing) that might be responsible for the observed effects. Third, the authors utilized a number of well-validated measures. Finally, the intervention was quite brief and based on an optimism induction that has been used in prior studies [15,17]. Optimism is typically thought to be a trait-like variable, an enduring disposition that is unlikely to change over time [18]. Optimism, like other traits, is assumed to play a particularly important role in determining how one might respond to stressful events, such as pain. One of the most interesting findings of this study is that a very brief lab-based intervention, designed to enhance optimism, exerted significant effects on pain. Unlike many interventions for managing pain, which focus on decreasing maladaptive, learned patterns of coping and appraisal, the Best Possible Self task encouraged participants to focus on the positives in life. This creative manipulation likely led participants to focus on their strengths, sources of resilience, characteristics that they would like to develop and nurture, and on positive connections with others. As noted above, exposure to this manipulation was quite brief: participants wrote about their best possible self for only 15 minutes and then visualized this story for another five minutes. Despite this brevity, the manipulation not only altered positive mood and future expectations but also reports of cold pressor pain. We expect that the paper by Hanssen et al. will stimulate future research on optimism and pain. A number of future directions could be explored. First, the methods used in this paper could serve as a model for future lab-based studies of causal processes that explain the relationship between optimism-enhancing treatments and the pain experience. For example, such research could examine more positive psychological mechanisms (e.g., self-efficacy) that might explain the effects of the Best Possible Self intervention. This field of research clearly needs to move from cross-sectional correlational studies to controlled experimental research that sheds light on the causal relationships between optimism and pain. Second, additional experimental studies are needed to more definitely evaluate the association of other positive adjustment factors that have been linked to pain (e.g., pain acceptance, hope, positive mood) and the pain experience. Third, there is a need to determine whether the effects reported by Hanssen et al. can be replicated in clinical populations having persistent pain, in which individuals may have more entrenched ways of coping with pain. New theories of positive emotion could help guide and direct a future program of research in this field. Frederickson’s Broaden-and-Build theory of positive emotion highlights the potential benefits of positive emotions in health and well-being [6]. According to this theory, interventions designed to enhance positive emotion can have an undoing effect (i.e. physiologically reversing the effects of negative emotions), as well as lead to the broadening of thoughts and actions that over time can build psychological resources (e.g., resiliency, learning), cognitive resources, (e.g., mindfulness), social resources (e.g., friendship, social support, engaging in more healthy, adaptive behaviors with others) and physical resources (e.g., coordination, strength, immune functioning) [6–9]. This theory, for example, could provide a theoretical explanation for why the optimism-enhancing intervention that Hanssen et al. used led to less situational pain catastrophizing (i.e., the broadening effects of visualizing the best possible self counteracted the potential narrow focus inherent in pain catastrophizing). Future studies that are informed by the Broaden-and-Build theory might include measures of the undoing effect, as well as measures that capture both the broadening and building effects of positive emotion. Finally, it is possible that the results of this study have implications for clinical research. There is a small but growing body of research showing that interventions designed to enhance positive adjustment can benefit patients suffering from persistent pain. These interventions include mindfulness meditation [4], loving-kindness meditation [3], acceptance-based treatments [14], yoga [19], and certain forms of cognitive-behavioral therapy [13]. As a group, these interventions are more intensive than the brief Best Possible Self induction and are also more broad in their focus. As a result, they are more likely to have sustained effects on pain as well as enhance positive adjustment factors that might buffer individuals from the negative effects of living with pain. An interesting direction for future clinical research would be to directly compare interventions focused on cultivating positive resources for managing pain (e.g., optimism, pain acceptance, positive mood, self-efficacy) to those focused on reducing maladaptive coping responses (e.g., engaging in catastrophizing). In sum, we need to pay more attention to the role that positive adjustment factors, such as optimism, play in the pain experience. The most positive move forward at this time is to break from the tradition of correlational studies that simply show an association between these positive adjustment factors and pain, and move toward studies like Hanssen et al. that focus on causal mechanisms underpinning the effects of optimism and related factors. This new focus on causal mechanisms not only will inform lab-based research programs, but will also likely lead to the development and refinement of novel clinical interventions that can cultivate optimism and other positive resources for coping with pain.

Pain, physical functioning, and overeating in obese rheumatoid arthritis patients: do thoughts about pain and eating matter?

BackgroundObese rheumatoid arthritis (RA) patients have higher levels of pain, disability, and disease activity than do nonobese patients with RA. Patients’ health-related thoughts about arthritis and weight may be important to consider in obese patients with RA who face the dual challenge of managing RA and weight. ObjectivesThe objective of this study was to examine the relationships of pain catastrophizing, self-efficacy (ie, confidence) for arthritis management and self-efficacy for weight management to important outcomes in obese patients with RA. We expected that after controlling for demographic and medical variables, higher levels of pain catastrophizing and lower levels of confidence would account for significant and unique variance in pain, physical functioning, and overeating. MethodsParticipants had a diagnosis of RA and a body mass index of 28 kg/m2 or greater and completed self-report questionnaires assessing pain, physical functioning, overeating, pain catastrophizing, self-efficacy for arthritis management, self-efficacy for weight management, and a 6-minute walk test. ResultsPain catastrophizing, self-efficacy for arthritis, and self-efficacy for weight management were significantly and uniquely related to RA-related outcomes. Pain catastrophizing was a significant independent predictor of pain severity (&bgr; = 0.38); self-efficacy for arthritis was a significant independent predictor of self-report physical functioning (&bgr; = −0.37) and the 6-minute walk performance (&bgr; = 0.44), and self-efficacy for weight management was a significant independent predictor of overeating (&bgr; = −0.58). ConclusionsPain catastrophizing, self-efficacy for arthritis, and self-efficacy for weight management each contributed uniquely to relate to key outcomes in obese patients with RA. Clinicians should consider assessment of thought processes when assessing and intervening with patients who face dual health challenges; unique intervention approaches may be needed for addressing the challenges of arthritis and weight.