Egil Andreas Fors

Psychosocial interventions as part of breast cancer rehabilitation programs? Results from a systematic review

Objective: This systematic review aimed to determine the effectiveness of psychoeducation, cognitive behavioural therapy (CBT) and social support interventions used in the rehabilitation of breast cancer (BC) patients.

A Smartphone-Based Intervention With Diaries and Therapist-Feedback to Reduce Catastrophizing and Increase Functioning in Women With Chronic Widespread Pain: Randomized Controlled Trial

Background Internet-based interventions using cognitive behavioral approaches can be effective in promoting self-management of chronic pain conditions. Web-based programs delivered via smartphones are increasingly used to support the self-management of various health disorders, but research on smartphone interventions for persons with chronic pain is limited. Objective The aim of this trial was to study the efficacy of a 4-week smartphone-delivered intervention with written diaries and therapist feedback following an inpatient chronic pain rehabilitation program. Methods A total of 140 women with chronic widespread pain who participated in a 4-week inpatient rehabilitation program were randomized into 2 groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of 1 face-to-face session and 4 weeks of written communication via a smartphone. Participants received 3 smartphone diary entries daily to support their awareness of and reflection on pain-related thoughts, feelings, and activities. The registered diaries were immediately available to a therapist who submitted personalized written feedback daily based on cognitive behavioral principles. Both groups were given access to a noninteractive website after discharge to promote constructive self-management. Outcomes were measured with self-reported questionnaires. The primary outcome measure of catastrophizing was determined using the pain catastrophizing scale (score range 0-52). Secondary outcomes included acceptance of pain, emotional distress, functioning, and symptom levels. Results Of the 140 participants, 112 completed the study: 48 in the intervention group and 64 in the control group. Immediately after the intervention period, the intervention group reported less catastrophizing (mean 9.20, SD 5.85) than the control group (mean 15.71, SD 9.11, P<.001), yielding a large effect size (Cohen’s d=0.87) for study completers. At 5-month follow-up, the between-group effect sizes remained moderate for catastrophizing (Cohen’s d=0.74, P=.003), acceptance of pain (Cohen’s d=0.54, P=.02), and functioning and symptom levels (Cohen’s d=0.75, P=.001). Conclusions The results suggest that a smartphone-delivered intervention with diaries and personalized feedback can reduce catastrophizing and prevent increases in functional impairment and symptom levels in women with chronic widespread pain following inpatient rehabilitation. Trial Registration Clinicaltrials.gov NCT01236209; http://www.clinicaltrials.gov/ct2/show/NCT01236209 (Archived by WebCite at http://www.webcitation.org/6DUejLpPY)

Written online situational feedback via mobile phone to support self-management of chronic widespread pain : a usability study of a Web-based intervention

BackgroundThis pretrial study aimed to develop and test the usability of a four-week Internet intervention delivered by a Web-enabled mobile phone to support self-management of chronic widespread pain.MethodsThe intervention included daily online entries and individualized written feedback, grounded in a mindfulness-based cognitive behavioral approach. The participants registered activities, emotions and pain cognitions three times daily using the mobile device. The therapist had immediate access to this information through a secure Web site. The situational information was used to formulate and send a personalized text message to the participant with the aim of stimulating effective self-management of the current situation. Six women participated and evaluated the experience.ResultsThe intervention was rated as supportive, meaningful and user-friendly by the majority of the women. The response rate to the daily registration entries was high and technical problems were few.ConclusionThe results indicate a feasible intervention. Web-applications are fast becoming standard features of mobile phones and interventions of this kind can therefore be more available than before.Trial registration numberClinicalTrials.gov: NCT01236209

The extent of neurocognitive dysfunction in a multidisciplinary pain centre population. Is there a relation between reported and tested neuropsychological functioning

&NA; A substantial proportion of severe chronic pain patients exhibit impaired neuropsychological function. In the future, this aspect of chronic pain syndromes should be systematically assessed. &NA; Patients with chronic nonmalignant pain syndromes frequently report cognitive dysfunction, in particular with respect to concentration and attention. Such complaints have, in general, been attributed to depressive symptoms. In this study we showed that cognitive complaints in chronic pain patients are significantly associated with objective test performance in the area of inhibitory control after partialling out degree of depressive symptoms. Furthermore, about 20% of the patients performed below cut‐off for clinically significant impairment on tests of basic neurocognitive functioning. A larger proportion of patients with generalized and neuropathic pain performed below this cut‐off, whereas patients with localized pain exhibited impaired function to a lesser degree. Chronic pain patients receiving opioids did not perform worse than patients off opioid treatment. Systematic assessment of basic neurocognitive functions in centres treating chronic pain patients is warranted.

A Smartphone-Based Intervention With Diaries and Therapist Feedback to Reduce Catastrophizing and Increase Functioning in Women With Chronic Widespread Pain. Part 2: 11-month Follow-up Results of a Randomized Trial

Background Internet-based interventions are increasingly used to support self-management of individuals with chronic illnesses. Web-based interventions may also be effective in enhancing self-management for individuals with chronic pain, but little is known about long-term effects. Research on Web-based interventions to support self-management following participation in pain management programs is limited. Objective The aim is to examine the long-term effects of a 4-week smartphone-intervention with diaries and therapist-written feedback following an inpatient chronic pain rehabilitation program, previously found to be effective at short-term and 5-month follow-ups. Methods 140 women with chronic widespread pain, participating in a 4-week inpatient rehabilitation program, were randomized into two groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of one face-to-face individual session and 4 weeks of written communication via a smartphone, consisting of three diaries daily to elicit pain-related thoughts, feelings, and activities, as well as daily personalized written feedback based on cognitive behavioral principles from a therapist. Both groups were given access to an informational website to promote constructive self-management. Outcomes were measured with self-reported paper-and-pencil format questionnaires with catastrophizing as the primary outcome measure. Secondary outcomes included daily functioning and symptom levels, acceptance of pain, and emotional distress. Results By the 11-month follow-up, the favorable between-group differences previously reported post-intervention and at 5-month follow-up on catastrophizing, acceptance, functioning, and symptom level were no longer evident (P>.10). However, there was more improvement in catastrophizing scores during the follow-up period in the intervention group (M=-2.36, SD 8.41) compared to the control group (M=.40, SD 7.20), P=.045. Also, per protocol within-group analysis showed a small positive effect (Cohen’s d=.33) on catastrophizing in the intervention group (P=.04) and no change in the control group from the smartphone intervention baseline to 11-month follow-up. A positive effect (Cohen’s d=.73) on acceptance was found within the intervention group (P<.001) but not in the control group. Small to large negative effects were found within the control group on functioning and symptom levels, emotional distress, and fatigue (P=.05) from the intervention baseline to the 11-month follow-up. Conclusion The long-term results of this randomized trial are ambiguous. No significant between-group effect was found on the study variables at 11-month follow-up. However, the within-group analyses, comparing the baseline for the smartphone intervention to the 11-month data, indicated changes in the desired direction in catastrophizing and acceptance in the intervention group but not within the control group. This study provides modest evidence supporting the long-term effect of the intervention. Trial Registration Clinicaltrials.gov NCT01236209; http://www.clinicaltrials.gov/ct2/show/NCT01236209 (Archived by WebCite at http://www.webcitation.org/6FF7KUXo0)

Psychosocial factors and risk of chronic widespread pain: an 11-year follow-up study--the HUNT study.

Summary Chronic widespread pain develops over a long‐term period for a substantial group of healthy people. Both psychosocial and lifestyle factors influence the risk of chronic widespread pain onset. ABSTRACT Few studies have used prospective designs in large population surveys to assess the risk of developing chronic widespread pain (CWP). We wanted to examine 1) how many people without CWP developed it after 11 years, and 2) how anxiety, depression, alcohol use, smoking, sleeping problems, and body mass index (BMI) were associated with this development. This study was based on a representative population‐based Norwegian cohort attending both the second (1995 to 1997) and the third (2006 to 2008) wave of the Nord‐Trøndelag Health Study (HUNT2 and HUNT3, respectively). Only those adults attending both surveys (N = 28,367) were included. Approximately 19,000 individuals without CWP in HUNT2 were assessed for later CWP development in HUNT3, where we looked for symptoms of anxiety, depression, monthly frequency of alcohol use, smoking, sleeping problems, and BMI. Data were analyzed with logistic regression adjusted for age, sex, education, marital status, physical exercise, and pain symptoms not meeting the CWP criteria at baseline. After 11 years, 12% of those without CWP developed CWP. Anxiety and depression, former and current smoking status, BMI < 18.5 kg/m2, BMI ≥ 25 kg/m2, and sleeping problems were all associated with an increased risk of CWP. High and moderate levels of alcohol use were associated with a reduced risk of CWP. In summary, this study indicates that CWP develops over a long‐term period for a substantial group of healthy people, and that both psychosocial and lifestyle factors influence the risk of CWP onset.

Protocol for the Cognitive Interventions and Nutritional Supplements (CINS) trial: A randomized controlled multicenter trial of a brief intervention (BI) versus a BI plus cognitive behavioral treatment (CBT) versus nutritional supplements for patients with long-lasting muscle and back pain

BackgroundBrief intervention programs are clinically beneficial, and cost efficient treatments for low back pain, when offered at 8-12 weeks, compared with treatment as usual. However, about 30% of the patients do not return to work. The European Guidelines for treatment of chronic low back pain recommends Cognitive Behavioral Therapy (CBT), but conclude that further research is needed to evaluate the effectiveness of CBT for chronic low back pain.Methods/DesignThe aim of the multicenter CINS trial (Cognitive Interventions and Nutritional Supplements) is to compare the effectiveness of 4 different interventions; Brief Intervention, Brief Intervention and CBT, Brief Intervention and nutritional supplements of seal oil, and Brief Intervention and nutritional supplements of soy oil. All participants will be randomly assigned to the interventions. The nutritional supplements will be tested in a double blind design. 400 patients will be recruited from a population of chronic low back pain patients that have been sick listed for 2-10 months. Four outpatient clinics, located in different parts of Norway, will participate in recruitment and treatment of the patients.The Brief Intervention is a one session cognitive, clinical examination program based on a non-injury model, where return to normal activity and work is the main goal, and is followed by two booster sessions. The CBT is a tailored treatment involving 7 sessions, following a detailed manual. The nutritional supplements consist of a dosage of 10 grams of either soy or seal oil (capsules) per day for 3 months, administered in a double blind design. All patients will be followed up with questionnaires after 3, 6 and 12 months, while sick leave data will be collected up to at least 24 months after randomization. The primary outcome of the study is sick leave and will be based on register data from the National Insurance Administration. Secondary outcomes include self-reported data on disability, pain, and psychological variables.ConclusionsTo our knowledge, the CINS trial will be the largest, randomized trial of psychological and nutritional interventions for chronic low back pain patients to date. It will provide important information regarding the effectiveness of CBT and seal oil for chronic low back pain patients.Trial Registrationhttp://www.clinicaltrials.gov, with registration number NCT00463970.

Impact of self-administered relaxation and guided imagery techniques during final trimester and birth

The objective of this study was to test if and how self-administered practice of relaxation techniques, positive affirmation and guided imagery, in the final part of pregnancy had an impact on giving birth. Further to see if the use of a simple method, a CD with a booklet, with no previous training or specific support of the participants (neither required nor delivered), affected the birth experience. Outcome measures were monitored both during and after delivery: During delivery, pain and anxiety were measured at different stages of birth. Post-delivery Wellbeing (Edmonton Scale 0-10, where 10 is the worst possible feeling of Wellbeing), pain, anxiety, Apgar score, duration of birth, complications and anesthesia/analgesic were recorded. Those in the CD-intervention group also reported how many times they had practiced the techniques. The study employed a randomized controlled trial. Results show that the CD-intervention group had a significantly better score on total Wellbeing, as measured by the ESAS (0-10) Edmonton Scale.

Patients with problematic opioid use can be weaned from codeine without pain escalation

Background: Brief treatments for chronic non‐malignant pain patients with problematic opioid use are warranted. The aims of the present study were to investigate (1) whether it is possible to withdraw codeine use in such patients with a brief cognitive‐behavioural therapy (CBT), (2) whether this could be done without pain escalation and reduction in quality of life and (3) to explore the effects of codeine reduction on neurocognitive functioning.

Cognitive Interventions and Nutritional Supplements (The CINS Trial): A Randomized Controlled, Multicenter Trial Comparing a Brief Intervention with Additional Cognitive Behavioral Therapy, Seal Oil, and Soy Oil for Sick-Listed Low Back Pain Patients

Study Design. A randomized controlled trial. Objective. The aim of this study was to evaluate whether a tailored and manualized cognitive behavior therapy (CBT) or nutritional supplements of seal oil and soy oil had any additional benefits over a brief cognitive intervention (BI) on return to work (RTW). Summary of Background Data. Brief intervention programs are clinically beneficial and cost-effective for patients with low back pain (LBP). CBT is recommended for LBP, but evidence on RTW is lacking. Seal oil has previously been shown to have a possible effect on muscle pain, but no randomized controlled trials have so far been carried out in LBP patients. Methods. Four hundred thirteen adults aged 18 to 60 years were included. Participants were sick-listed 2 to 10 months due to LBP. Main outcome was objectively ascertained work participation at 12-month follow-up. Participants were randomly assigned to BI (n = 100), BI and CBT (n = 103), BI and seal oil (n = 105), or BI and soy oil (n = 105). BI is a two-session cognitive, clinical examination program followed by two booster sessions, while the CBT program is a tailored, individual, seven-session manual-based treatment. Results. At 12-month follow-up, 60% of the participants in the BI group, 50% in the BI and CBT group, 51% in the BI and seal oil group, and 53% in the BI and soy oil group showed reduced sick leave from baseline, and had either partly or fully RTW. The differences between the groups were not statistically significant (&khgr;2 = 2.54, P = 0.47). There were no significant differences between the treatment groups at any of the other follow-up assessments either, except for a significantly lower sick leave rate in the BI group than the other groups during the first 3 months of follow-up (&khgr;2 = 9.50, P = 0.02). Conclusion. CBT and seal oil had no additional benefits over a brief cognitive intervention on sick leave. The brief cognitive intervention alone was superior in facilitating a fast RTW. Level of Evidence: 2