John W. Burns

Randomized trial of group cognitive behavioral therapy compared with a pain education control for low-literacy rural people with chronic pain.

Summary Cognitive behavioral therapy was compared with pain education within an underserved, low‐socioeconomic status, rural chronic pain population. Both interventions were found to be viable treatment options. ABSTRACT Chronic pain is a common and costly experience. Cognitive behavioral therapies (CBT) are efficacious for an array of chronic pain conditions. However, the literature is based primarily on urban (white) samples. It is unknown whether CBT works in low‐socioeconomic status (SES) minority and nonminority groups. To address this question, we conducted a randomized controlled trial within a low‐SES, rural chronic pain population. Specifically, we examined the feasibility, tolerability, acceptability, and efficacy of group CBT compared with a group education intervention (EDU). We hypothesized that although both interventions would elicit short‐ and long‐term improvement across pain‐related outcomes, the cognitively‐focused CBT protocol would uniquely influence pain catastrophizing. Mixed design analyses of variance were conducted on the sample of eligible participants who did not commence treatment (N = 26), the intention‐to‐treat sample (ITT; N = 83), and the completer sample (N = 61). Factors associated with treatment completion were examined. Results indicated significantly more drop‐outs occurred in CBT. ITT analyses showed that participants in both conditions reported significant improvement across pain‐related outcomes, and a nonsignificant trend was found for depressed mood to improve more in CBT than EDU. Results of the completer analyses produced a similar pattern of findings; however, CBT produced greater gains on cognitive and affect variables than EDU. Treatment gains were maintained at 6‐month follow‐up (N = 54). Clinical significance of the findings and the number of treatment responders is reported. Overall, these findings indicate that CBT and EDU are viable treatment options in low‐SES minority and nonminority groups. Further research should target disseminating and sustaining psychosocial treatment options within underserved populations.

Sleep duration and weight change in midlife women: The SWAN sleep study

Short sleep duration has been associated with higher current BMI and subsequent weight gain. However, most prior longitudinal studies are limited by reliance on self‐reported sleep duration, and none accounted for the potential confounding effect of sleep‐disordered breathing. The associations of sleep duration with current BMI and BMI change were examined among 310 midlife women in the Study of Womens Health Across the Nation (SWAN) Sleep Study (2003‐2005).

Anger management style and hostility among patients with chronic pain: effects on symptom-specific physiological reactivity during anger- and sadness-recall interviews.

Objectives: We examined whether anger-in, anger-out, and hostility predicted symptom-specific muscle tension reactivity during anger induction (but not sadness induction) among patients with chronic low back pain (CLBP). For patients with CLBP, relevant muscles are the lower paraspinals (LPs). Anger-in × hostility and anger-out × hostility interactions were tested to determine whether particularly reactive groups of patients could be identified with a multivariable profile approach. Methods: Ninety-four patients with CLBP underwent anger recall (ARI) and sadness recall (SRI) interviews, whereas LP and trapezius electromyography and systolic blood pressure, diastolic blood pressure, and heart rate were recorded. They completed anger-in, anger-out, hostility, and trait anger measures. Results: Hierarchical regressions were used to test anger-in × hostility and anger-out ×hostility interactions for physiological changes during the ARI and SRI. A significant anger-in × hostility interaction was found for LP change during the ARI (but not SRI) such that high anger-in/high hostility patients evinced the greatest reactivity. Effects for trapezius reactivity were nonsignificant. Significant anger-in × hostility interactions were also found for systolic blood pressure and diastolic blood pressure changes during the ARI such that high anger-in/low hostility patients showed the smallest changes. The anger-out × hostility interaction for diastolic blood pressure change during ARI was also significant such that high anger-out/low hostility patients showed the smallest changes. All effects remained significant with trait anger controlled. Conclusions: A multivariable profile approach may help identify especially vulnerable patient groups. Patients with CLBP who tend to suppress anger and are cynically hostile may be more likely to experience high levels of muscle tension near the site of pain and injury during anger, but not during sadness, than other groups. CLBP = chronic low back pain; EMG = electromyography; AOS = anger-out scale; AIS = anger-in scale; Ho = Cook-Medley Hostility scale; TAS = Trait Anger scale; ARI = anger recall interview; SRI = sadness recall interview; LP = lower paraspinal muscles; SBP = systolic blood pressure; DBP = diastolic blood pressure; HR = heart rate.

Can we improve cognitive-behavioral therapy for chronic back pain treatment engagement and adherence? A controlled trial of tailored versus standard therapy

OBJECTIVE This study evaluated whether tailored cognitive-behavioral therapy (TCBT) that incorporated preferences for learning specific cognitive and/or behavioral skills and used motivational enhancement strategies would improve treatment engagement and participation compared with standard CBT (SCBT). We hypothesized that participants receiving TCBT would show a lower dropout rate, attend more sessions, and report more frequent intersession pain coping skill practice than those receiving SCBT. We also hypothesized that indices of engagement and adherence would correlate with pre- to posttreatment changes in outcome factors. METHOD One hundred twenty-eight of 161 consenting persons with chronic back pain who completed baseline measures were allocated to either TCBT or SCBT using a modified randomization procedure. Participants completed daily ratings of pain coping skill practice and goal accomplishment during treatment, as well as measures of pain severity, disability, and other key outcomes at the end of treatment. RESULTS No significant differences between treatment groups were noted on measures of treatment engagement or adherence. However, these factors were significantly related to some pre- to posttreatment improvements in outcomes, regardless of treatment condition. CONCLUSIONS Participants in this study evidenced a high degree of participation and adherence, but treatment tailored to take into account participant preferences, and that employed motivational enhancement strategies, failed to increase treatment participation over and above SCBT for chronic back pain. Evidence that participation and adherence were associated with positive outcomes supports continued clinical and research efforts focusing on these therapeutic processes.

Associations between daily chronic pain intensity, daily anger expression, and trait anger expressiveness: an ecological momentary assessment study.

Summary Within‐day associations between behavioral anger expression and momentary chronic pain intensity show significant lagged effects, with elevated behavioral anger expression linked to greater subsequent pain intensity. ABSTRACT Links between elevated trait anger expressiveness (anger‐out) and greater chronic pain intensity are well documented, but pain‐related effects of expressive behaviors actually used to regulate anger when it is experienced have been little explored. This study used ecological momentary assessment methods to explore prospective associations between daily behavioral anger expression and daily chronic pain intensity. Forty‐eight chronic low back pain (LBP) patients and 36 healthy controls completed electronic diary ratings of momentary pain and behavioral anger expression in response to random prompts 4 times daily for 7 days. Across groups, greater trait anger‐out was associated with greater daily behavioral anger expression (P < 0.001). LBP participants showed higher levels of daily anger expression than controls (P < 0.001). Generalized estimating equation analyses in the LBP group revealed a lagged main effect of greater behavioral anger expression on increased chronic pain intensity in the subsequent assessment period (P < 0.05). Examination of a trait × situation model for anger‐out revealed prospective associations between elevated chronic pain intensity and later increases in behavioral anger expression that were restricted largely to individuals low in trait anger‐out (P < 0.001). Trait × situation interactions for trait anger suppression (anger‐in) indicated similar influences of pain intensity on subsequent behavioral anger expression occurring among low anger‐in persons (P < 0.001). Overlap with trait and state negative affect did not account for study findings. This study for the first time documents lagged within‐day influences of behavioral anger expression on subsequent chronic pain intensity. Trait anger regulation style may moderate associations between behavioral anger expression and chronic pain intensity.

Common and specific treatment mechanisms in psychosocial pain interventions: The need for a new research agenda.

Jensen’s article [3] in this issue of PAIN synthesizes various conceptualizations of psychosocial treatments for pain into an overarching framework, providing a springboard for future research. The author tackles an important and timely topic. Many psychosocial treatments provide some evidence of efficacy, and Jensen encourages us to take stock of what we have in our armamentarium, document how treatments work, and, as Paul suggested [6], develop principles by which we can find the best treatment for a particular problem given a patient’s unique circumstances. Our commentary intends to amplify some of Jensen’s points and suggest 2 additional areas in need of research. We believe, with Jensen, that commonalities across treatment approaches must be examined. It is tempting to attend to distinctions among the therapies Jensen discusses, debate their relative merits based on apparent differences, and focus on ‘‘building better mousetraps.’’ Doing so has spawned many ‘‘new and improved’’ treatment techniques presumed to offer unique advantages over the ‘‘old.’’ When a certain approach shows efficacy – usually compared to wait-list or attention-placebo control – the inference is that it works because of its ostensible unique qualities. This may not necessarily be the case. Efficacious psychosocial pain treatments all seem to reduce pain and distress and increase physical function. If seemingly different therapies get to the same place, then we may hypothesize that they do so partly because of common features. It may thus prove fruitful to divert some attention away from the study of differences and toward identifying common mechanisms across treatments. Jensen does this to some extent, pointing to possible common brain states achieved with hypnosis, relaxation, and mindfulness. To further this endeavor, we can borrow from a well-established body of theoretical and empirical work. Psychotherapy research has long wrestled with issues regarding common and unique factors of efficacy. Goldfried [2] and others [1] argue that common principles underlie most psychotherapy approaches, and warrant examination and understanding. Two common principles of therapeutic change involve stimulating patient expectations that treatment will help, and establishing a sound therapeutic relationship between patient and therapist. Although Jensen acknowledges that certain psychosocial pain treatments (eg, hypnosis, relaxation) work partly via fostering positive patient expectations, the importance of the therapeutic relationship was not featured in his review. In behavioral medicine, we may have lost appreciation for the centrality of this factor, relegating it to part of ‘‘placebo’’ responses. Results from many studies of psychotherapy process and outcome confirm that the therapeutic

Is reduction in pain catastrophizing a therapeutic mechanism specific to cognitive-behavioral therapy for chronic pain?

ABSTRACTMechanisms underlying favorable outcomes of psychosocial interventions for chronic pain are unclear. Theory suggests changes in maladaptive cognitions represent therapeutic mechanisms specific to cognitive-behavioral therapy (CBT). We illustrate the importance of examining whether treatments work either uniquely via mechanisms specified by theory or via mechanisms common to different treatments. Secondary data analysis was conducted to examine the effects of reduction in pain catastrophizing on outcomes following CBT and Pain Education. Generally, reductions in pain catastrophizing were significantly related to outcome improvements irrespective of CBT or Pain Education condition. Results underscore the need to assess whether mechanisms presumed to operate specifically in one treatment do indeed predict outcomes and illustrate the importance of broadening the assessment of mechanisms beyond those specified by theory. Theory-specific, competing, and common mechanisms must all be assessed to determine why our treatments work.

Trait Anger Management Style Moderates Effects of Actual (″State″) Anger Regulation on Symptom-Specific Reactivity and Recovery Among Chronic Low Back Pain Patients

Objectives: We examined whether “state” anger regulation—inhibition or expression—among chronic low back pain (CLBP) patients would affect lower paraspinal (LP) muscle tension following anger-induction, and whether these effects were moderated by trait anger management style. Method: Eighty-four CLBP patients underwent harassment, then they regulated anger under one of two conditions: half expressed anger by telling stories about people depicted in pictures, whereas half inhibited anger by only describing objects appearing in the same pictures. They completed the anger-out and anger-in subscales (AOS; AIS) of the anger expression inventory. Results: General Linear Model procedures were used to test anger regulation condition by AOS/AIS by period interactions for physiological indexes. Significant three-way interactions were found such that: a) high trait anger-out patients in the inhibition condition appeared to show the greatest LP reactivity during the inhibition period followed by the slowest recovery; b) high trait anger-out patients in the expression condition appeared to show the greatest systolic blood pressure (SBP) reactivity during the expression period followed by rapid recovery. Conclusions: Results implicate LP muscle tension as a potential physiological mechanism that links the actual inhibition of anger following provocation to chronic pain severity among CLBP patients. Results also highlight the importance of mismatch situations for patients who typically regulate anger by expressing it. These CLBP patients may be at particular risk for elevated pain severity if circumstances at work or home regularly dictate that they should inhibit anger expression. CLBP = chronic low back pain; EMG = electromyography; AOS = anger-out scale; AIS = anger-in scale; LP = lower paraspinal muscles; SBP = systolic blood pressure; DBP = diastolic blood pressure; HR = heart rate; LIWC = linguistic inquiry and word count.

The continuing evolution of biopsychosocial interventions for chronic pain

In the last several decades, great strides have been made in the treatment of persistent painful conditions. The scope of treatment has shifted from purely biomedical, including approaches built upon cognitive, behavioral, and social psychological principles. This article reports and discusses several key paradigm shifts that fueled this revolutionary change in the management of chronic pain. The progressive development of theoretical metamodels and treatment conceptualizations is presented. Cognitive behavioral therapy (CBT) is the most widely accepted biopsychosocial treatment for chronic pain and is founded upon a rich theoretical tradition. The CBT rationale, and empirical evidence to support its efficacy, is presented. The emergence and promise of mindfulness-based and acceptance-based interventions is also discussed. The article concludes with the assertion that future treatment outcome research should focus on understanding the treatment-specific and common factors associated with efficacy.

What do plasma beta‐endorphin levels reveal about endogenous opioid analgesic function?

Plasma levels of beta‐endorphin (BE), an endogenous opioid analgesic, are often reported as they relate to acute and chronic pain outcomes. However, little is known about what resting plasma BE levels might reveal about functioning of the endogenous opioid antinociceptive system. This study directly examined associations between resting plasma BE and subsequent endogenous opioid analgesic responses to acute pain in 39 healthy controls and 37 individuals with chronic low back pain (LBP). Resting baseline levels of plasma BE were assessed. Next, participants received opioid blockade (8 mg naloxone i.v.) or placebo in a double‐blind, randomized, crossover design. Participants then underwent two acute pain stimuli: finger pressure (FP) pain and ischaemic (ISC) forearm pain. Blockade effects (naloxone minus placebo pain ratings) were derived to index endogenous opioid analgesic function. In placebo condition analyses for both pain stimuli, higher resting BE levels were associated with subsequently greater reported pain intensity (ps < 0.05), with this effect occurring primarily in healthy controls (BE × Participant Type interactions, ps < 0.05). In blockade effect analyses across both pain tasks, higher resting plasma BE predicted less subsequent endogenous opioid analgesia (smaller blockade effects; ps < 0.05). For the ISC task, these links were significantly more prominent in LBP participants (BE × Participant Type Interactions, ps < 0.05). Results suggest that elevated resting plasma BE may be a potential biomarker for reduced endogenous opioid analgesic capacity, particularly among individuals with chronic pain. Potential clinical implications are discussed.