Jeremy Gauntlett-Gilbert

The role of mindfulness in a contextual cognitive-behavioral analysis of chronic pain-related suffering and disability.

Abstract An increasing number of studies consider the specific processes by which distressing sensations, thoughts, and emotional experiences exert their influence on the daily functioning of those who suffer with chronic pain. Clinical methods of mindfulness and the processes that underlie them appear to have clear implications in this area, but have not been systematically investigated to this point in time. The purpose of the present study was to examine mindfulness in relation to the pain, emotional, physical, and social functioning of individuals with chronic pain. The present study included 105 consecutive patients attending a clinical assessment for treatment of chronic pain. Each completed a standardized battery of questionnaires, including a measure of mindfulness, the Mindful Attention Awareness Scale [Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well‐being. J Pers Soc Psychol 2003;84:822–48]. Correlation analyses indicated that mindfulness was unrelated to age, gender, education, or chronicity of pain, but was significantly related to multiple measures of patient functioning. In multiple regression analyses, after controlling for patient background variables, pain intensity, and pain‐related acceptance, mindfulness accounted for significant variance in measures of depression, pain‐related anxiety; physical, psychosocial, and “other” disability. In each instance greater mindfulness was associated with better functioning. The combined increments of variance explained from acceptance of pain and mindfulness were at least moderate and, in some cases, appeared potentially meaningful. The behavioral processes of mindfulness and their accessibility to scientific study are considered.

Disability in adolescents with chronic pain: Patterns and predictors across different domains of functioning.

Abstract Many children and adolescents experience recurrent pain, but only a few become disabled by it. Research has established that higher pain intensity and worse depression seem to predict poorer functioning in this population. Parent and family variables have been minimally researched. This study investigated functional disability, social/adaptive functioning and school attendance in a population of highly disabled adolescents and their parents seeking help for chronic pain. Adolescents (N = 110) were assessed using the Bath Adolescent Pain Questionnaire [BAPQ; Eccleston C, Jordan A, McCracken LM, Sleed M, Connell H, Clinch J. The Bath Adolescent Pain Questionnaire (BAPQ): Development and preliminary psychometric evaluation of an instrument to assess the impact of chronic pain on adolescents. Pain 2005;118:263–70], a multidimensional instrument designed for a pain population. Pain intensity and depression predicted functional disability. However, social/adaptive functioning was associated with different variables, including parent factors, and school attendance showed no association with pain intensity or anxiety. The results emphasise the need to measure multiple domains of functioning, and show that the connections between pain, physical disability and adaptive functioning are looser than might be predicted.

Mindfulness with Children and Adolescents: Effective Clinical Application

Mindfulness interventions within adult populations are becoming increasingly popular. Research suggests that mindfulness can deliver lasting improvements in self-awareness and emotional stability to adults with severe and chronic conditions. As yet, research within child and adolescent populations is in its initial stages, although mindfulness shows great clinical promise for young people. This article aims to provide an overview of mindfulness to professionals who are working in child or adolescent settings. Initially, it will provide the reader with some orientation to and definitions from the field, before summarizing the current evidence for the utility of the approach. The article recommends specific clinical modifications for mindfulness with children and adolescents, as well as reviewing how to monitor and enhance the development of this skill. Finally, it highlights important differences among mindfulness, relaxation and other meditative techniques.

Acceptance of pain in adolescents with chronic pain: Validation of an adapted assessment instrument and preliminary correlation analyses.

It is important to understand the processes that contribute to disability and distress in adolescents with chronic pain. For example, research has identified that when adolescents can positively adapt to the consequences of health condition, rather than attempt to change the condition itself, they also function better and experience less distress. This pattern of behavior is similar to what is referred to as “acceptance” of pain in the adult literature. Although acceptance is consistently associated with positive outcomes in adult studies, there has been less investigation of acceptance in adolescents. This study aimed to examine the reliability and validity of an adolescent‐adapted version of the Chronic Pain Acceptance Questionnaire (CPAQ‐A), and, using this instrument, to carry out a preliminary investigation of acceptance in adolescents with chronic pain. A sample of 122 highly disabled adolescents with chronic pain attending a specialty service completed the adapted CPAQ‐A. They also completed standardized measures of their pain and daily functioning. Results supported the reliability and validity of the CPAQ‐A. Correlation analyses showed that higher levels of acceptance were associated with lower levels of distress and disability, but not with lower pain intensity. Regression analyses were carried out to assess the independent contribution of acceptance after pain intensity and demographic variables were taken into account. In these analyses acceptance accounted for significant variance in disability, psychological distress, and developmental and family functioning. We discuss developmental aspects of acceptance in adolescents and clinical implications of these findings.

Acceptance and Values-Based Treatment of Adolescents With Chronic Pain: Outcomes and Their Relationship to Acceptance

OBJECTIVE Psychological treatments for pediatric chronic pain are moderately effective. However, there have been few studies of the psychological processes associated with treatment response. This study examines the effects of Acceptance and Commitment Therapy (ACT) treatment on a severely disabled group of adolescents with chronic pain, examining relationships between outcome and acceptance. METHODS 98 adolescents with pain, mean age 15.6 years, underwent an uncontrolled trial of 3-week residential ACT treatment. RESULTS Adolescents improved in self-reported functioning and objective physical performance at 3-month follow-up. They were less anxious and catastrophic, attended school more regularly, and used health care facilities less often. Most positive treatment outcomes were associated with improvements in acceptance. CONCLUSIONS An intensive ACT-based pain rehabilitation course was an effective treatment for disabled adolescents with chronic pain. Its results were theoretically consistent--improvements were associated with changes in acceptance and were achieved without pain control or cognitive restructuring techniques.

Young people making sense of pain: cognitive appraisal, function, and pain in 8-16 year old children.

Recurrent pain is a common childhood problem which for some becomes chronic and is associated with severely impaired functioning. Relationships of psychological variables with impaired functioning have rarely been investigated in samples of children reporting pain in non‐clinical settings. The aim of this study was to examine the role of cognitive appraisal in the relationship between chronic pain and level of functioning in a normal school‐attending population of children who report pain as a common experience. Five hundred and sixty one schoolchildren aged between 8 and 16 years and their parents participated in a cross‐sectional interview and questionnaire study. Child functioning was measured in two ways: self‐reported quality of life, and self‐reported functional disability associated with pain. Results showed a consistent pattern across both specific measures of functioning used. Catastrophic appraisals of pain can explain partially the functional impairment found in a sample of normal schoolchildren with chronic pain. Positive expectations about ability, the responsibility to exert control over the pain, and the belief that medication and doctors will help to control the pain, were found to be protective of normal functioning in chronic pain. Cognitive factors were found to mediate but not moderate the relationship between pain and disability, and quality of life.

Role of psychological flexibility in parents of adolescents with chronic pain: development of a measure and preliminary correlation analyses.

&NA; Parent responses to the experiences of adolescents with chronic pain are deemed important. At the same time the best ways to conceptualize, measure, and intervene with these are unclear. The purpose of the present study was to develop a measure of parent responses based on the approach proposed in Acceptance and Commitment Therapy (ACT), an approach that focuses on psychological flexibility. A total of 183 adolescents attending a specialty treatment center for chronic pain, and adults attending with them, provided the data examined in this study. Standard measures of adolescent functioning and parent responses were obtained. In addition, the attending adults, who were mostly mothers, also completed a pool of items for an instrument called the Parent Psychological Flexibility Questionnaire (PPFQ). Preliminary analyses of these items showed an internal consistency of α = 0.91. The total score for parent psychological flexibility was negatively correlated with protective and encouraging parent responses to pain, as predicted. It was also positively correlated with adolescent acceptance of pain and negatively correlated with measures of pain‐related impact on their social, emotional, family, and developmental functioning. Additional analyses showed that the PPFQ yields significant unique information about adolescent functioning independent of age and gender and beyond that provided by another well‐established measure of parent responses. There is increasing evidence for the effectiveness of ACT in the treatment of a range of behavior problems in adults and young people and in training for persons without identified “disorders.” It seems potentially applicable for parent training in the context of adolescent chronic pain. Parent responses effective in promoting psychologically flexible behavior in adolescents with chronic pain are addressed, including the design of an instrument to measure them.

Veterans and chronic pain

Summary points 1. Musculoskeletal problems are the commonest reason for medical discharge in all the British armed forces. By definition, these problems are chronic and resistant to treatment. 2. Pain is also common in veterans who have experienced severe injuries (polytrauma), often accompanied by post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) orpostconcussive syndrome. 3. In veterans seeking treatment for chronic pain, PTSD is common. There is also evidence for elevated levels of alcohol misuse in veterans who have been deployed to conflict. However, most veterans do not have pain, PTSD or alcohol problems. 4. Pain clinicians would benefit from training in meeting veterans’ needs, in order to promote their engagement and successful treatment. This should include countering stereotypes, information about the military and support for the assessment and onward referral of PTSD and alcohol problems.

Parental behaviour in paediatric chronic pain: A qualitative observational study

Objectives: Parental behaviour appears to influence the adjustment of children with chronic pain. However, research in this area has failed to produce consistent evidence. Studies have tended to rely on self-report measures derived from adult pain populations. This qualitative, observational research provides descriptive data of parental behaviour in a clinical environment. Design: A qualitative observational study was made of parents and adolescents in a physically stressful setting. Modified grounded theory was used to analyse verbal and non-verbal behaviours. Methods: Eight parent–adolescent dyads seeking treatment for chronic pain were videoed during physical exercise sessions. Verbal and non-verbal behaviours were recorded and transcribed. Results: Four overarching categories emerged: ‘monitoring’, ‘protecting’, ‘encouraging’ and ‘instructing’. These often had both verbal and non-verbal aspects. Within these categories, more precise behavioural groups were also identified. Conclusions: This research identifies categories of parental behaviour that were derived directly from observation, rather than imposed on the basis of results from different populations. Four categories of behaviour were derived, which clarify and extend dimensions used in existing self-report instruments. Careful description of parental behaviours showed features that past research has neglected, and highlighted potential drawbacks of apparently positive parental actions.

The role of physical activity and psychological coping strategies in the management of painful diabetic neuropathy - A systematic review of the literature

BACKGROUND Diabetes is rising in prevalence; painful diabetic neuropathy (PDN) is one complication of diabetes. PDN is primarily managed with medication but analgesic failure is common and people remain in pain and distress. It is unclear whether pain management strategies are appropriate for PDN. OBJECTIVES To establish the effectiveness of physical activity and psychological coping strategies for PDN. DESIGN Systematic literature review. DATA SOURCES Ten online databases. ELIGIBILITY CRITERIA (PARTICIPANTS AND INTERVENTIONS) Controlled trials reporting specific results for PDN, investigating, (a) physical activity or (b) psychological coping strategies and measuring pain as an outcome. The search was restricted to published research with no restriction on language or date of publication. STUDY APPRAISAL METHODS Methodological quality and risk of bias assessed with Cochrane collaboration and NICE checklist for randomised controlled trials. RESULTS Of 1306 titles identified, four studies met the inclusion criteria. Two trials investigated physical activity and two investigated psychological coping interventions. Studies showed pain measures improved or did not worsen compared to controls, but methodological quality was moderate and results need cautious interpretation. LIMITATIONS The studies were of small sample size and used a diverse range of outcome measures. There is high risk of bias from lack of blinding and attrition at follow up. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The research literature in this area is sparse and inconsistent, despite the pressing clinical challenge of PDN. Firm conclusions cannot be drawn from the studies included. Further high quality research is required to match treatment provision to patient requirements.