Kenneth R. Lofland

Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis.

Changes in maladaptive cognitions may constitute therapeutic processes of multidisciplinary pain programs. A cross-lagged panel design was used to determine whether (a) early-treatment cognitive change predicted late-treatment outcome index change, but not vice versa; and (b) these effects remained significant with depression change controlled. Ninety chronic pain patients, in a 4-week multidisciplinary program, completed measures of catastrophizing, pain helplessness, depression, pain, interference, and activity level at pre-, mid-, and posttreatment. With depression changes controlled, early-treatment catastrophizing and pain helplessness changes predicted late-treatment outcome index changes, but not vice versa; early-treatment depression changes predicted late-treatment activity changes, but not vice versa. Findings advance understanding of pain treatment process and suggest that negative cognition changes may indeed affect improvements in treatment outcome.

Cognitive factors influence outcome following multidisciplinary chronic pain treatment: a replication and extension of a cross-lagged panel analysis

Reducing maladaptive cognitions is hypothesized to constitute an active therapeutic process in multidisciplinary pain programs featuring cognitive-behavioral interventions. A cross-lagged panel design was used to determine whether: a) early-treatment cognitive changes predicted late-treatment pain, interference, activity and mood changes, but not vice versa; b) three cognitive factors made unique contributions to outcome; c) substantial cognitive changes preceded substantial improvements in outcome. Sixty-five chronic pain patients, participating in a 4-week multidisciplinary program, completed measures of pain helplessness, catastrophizing, pain-related anxiety (process factors), pain severity, interference, activity level and depression (outcomes) at pre-, mid- and posttreatment. Results showed that early-treatment reductions in pain helplessness predicted late-treatment decreases in pain and interference, but not vice versa, and that early-treatment reductions in catastrophizing and pain-related anxiety predicted late-treatment improvements in pain severity, but not vice versa. Findings suggested that the three process factors predicted improvements mostly in common. However, little evidence was found that large early-treatment reductions in process variables preceded extensive improvements in pain. Findings replicate those of a recent report regarding cross-lagged effects, and offer support that cognitive changes may indeed influence late-treatment changes in outcomes.

Gender differences in associations between trauma history and adjustment among chronic pain patients

This study examines the relationship between a trauma history and emotional functioning in response to a chronic pain condition. We broadened the traditional study of trauma in chronic pain from sexual and physical abuse to include a variety of traumatic events and experiences that occurred not only during childhood, but during adulthood as well. Seventy-three (51% female, 60% lower back) chronic pain patients were administered the Trauma History Questionnaire (Green, B.L., Trauma History Questionnaire. In B.H. Stamm (Eds.), Measurement of Stress, Trauma and Adaptation, Sidran, Lutherville, MD, 1996, pp. 366-369), the Multidimensional Pain Inventory (Kerns, R.D., Turk, D.C. and Rudy, T.E., The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 23 (1985) 345-356), The Beck Depression Inventory (Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. and Erbaugh, J., An inventory for measuring depression, Arch. Gen Psychiatry, 4 (1961) 561-571), and the Pain Anxiety Symptoms Scale (McCracken, L.M., Zayfert, C., Gross, R.T. The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain, Pain, 50 (1992) 67-73) prior to starting a multidisciplinary pain program. We hypothesized that high levels of emotional distress and anxiety would differentiate patients with a substantial history of trauma from those without, while levels of pain severity and disability would not. A MANOVA revealed a significant Trauma Group (low vs. high) by Gender interaction for the dependent variables, which included both measures of emotional distress and pain severity and disability. Univariate tests showed that the interaction was significant only for emotional distress variables and not for pain severity and disability. Further, the multivariate effect of Trauma Group and the univariate effects for emotional distress variables were significant only among men. Results indicate that a substantial history of trauma may detrimentally impact a chronic pain patients ability to manage their pain effectively, particularly among men.

Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: evaluation of an ironic process model.

OBJECTIVE Evidence for links between anger inhibition or suppression and chronic pain severity is based mostly on studies with correlation designs. Following from ironic process theory, we proposed that attempts to suppress angry thoughts during provocation would increase subsequent pain intensity among chronic low back pain (CLBP) patients, and do so through paradoxically enhanced accessibility of anger. DESIGN CLBP patients (N = 58) were assigned to suppression and nonsuppression conditions while performing a computer maze task with a harassing confederate. A structured pain behavior task (SPBT) followed. MAIN OUTCOME MEASURES Self-reported anger, anxiety, and sadness following maze task. Self-reported pain severity and number of observed pain behaviors during SPBT. RESULTS Patients told to suppress during provocation: (a) reported greater anger following the maze task, reported greater pain intensity during the SPBT, and exhibited more pain behaviors than patients not suppressing; (b) postmaze anger levels significantly mediated group differences on pain behaviors. CONCLUSION Attempts by CLBP patients to suppress anger may aggravate pain related to their clinical condition through ironically increased feelings of anger.

The Relationship Between Self-Efficacy and Disability in Chronic Low Back Pain Patients

This study examined the reliability of an adapted version of the Arthritis Self-Efficacy Scale in a sample of 59 chronic low back pain patients. The present study also investigated the relationship between self-efficacy and measures of disability. Regression analyses indicated a significant negative relationship between self-efficacy and low back pain disability. That is, patients who report higher levels of self-efficacy have higher activity levels (R2=0.34,P<0.01), work more hours (R2=0.25,P<0.01), and have lower levels of psychological distress (R2=0.29,P<0.01), pain severity (R2=0.46,P<0.01), and pain behavior (R2=0.27,P<0.01) after controlling for the demographic variables of gender, duration of back pain, and having a lawyer on retainer. The results support the use of the Back Pain Self-Efficacy Scale (BPSES) as a general measure of self-efficacy in the chronic low back pain population.

Attentional Strategy Moderates Effects of Pain Catastrophizing on Symptom-Specific Physiological Responses in Chronic Low Back Pain Patients

In the present study, we examined whether experimentally-manipulated attentional strategies moderated relations between pain catastrophizing and symptom-specific physiological responses to a cold-pressor task among sixty-eight chronic low back patients. Patients completed measures of pain catastrophizing and depression, and were randomly assigned to sensory focus, distraction or suppression conditions during a cold pressor. Lumbar paraspinal and trapezius EMG, and cardiovascular responses to the cold pressor were assessed. Attentional strategies moderated the relation between pain catastrophizing and lumbar paraspinal muscle, but not trapezius muscle or cardiovascular responses. Only for participants in the suppression condition was catastrophizing related significantly to lumbar paraspinal muscle responses. Depressed affect did not account for this relation. These findings indicate that ‘symptom-specific’ responses among pain catastrophizers with chronic low back depend on how they attend to pain-related information. Specifically, it appears that efforts to suppress awareness of pain exaggerate muscular responses near the site of injury.

Use of cluster analysis to validate IHS diagnostic criteria for migraine and tension-type headache.

Cluster analysis was used to validate headache diagnostic criteria of the International Headache Society (IHS). Structured diagnostic interviews were conducted on 443 headache sufferers from a community sample, which was randomly split to allow replication. Hierarchical cluster analysis of symptoms in both subsamples revealed two distinct (P<.001) clusters: (1) unilateral pulsating pain, pain aggravated by activity, and photophobia and phonophobia, and (2) bilateral pressing/tightening pain, mild to moderate intensity, and absence of nausea/vomiting. These clusters were consistent with IHS migraine and tension‐type classifications, respectively. Replication using a non‐hierarchical clustering technique, k‐means cluster analysis, revealed a migrainelike patient cluster, reflecting more frequent pulsating, unilateral pain; more severe pain; and pain aggravated by activity; nausea, vomiting, photophobia, and phonophobia. A tensionlike patient cluster was also identified, reflecting more frequent pressing/tightening pain, mild to moderate pain, bilateral location, and absence of nausea/vomiting. These patient clusters were consistent across subsamples. International Headache Society diagnoses corresponded with classification based upon statistically derived clusters (P<.001). These results indicate that headache symptoms cluster empirically in a manner consistent with IHS criteria for migraine and tension‐type headaches. Criterion overlap problems regarding pain intensity and duration were identified. Overall, these data support migraine and tension‐type headache as distinct entities, and provide support for the IHS diagnostic criteria with minor modifications.

The predictive value of abbreviated migraine diagnostic criteria.

Objective.—To determine the operating characteristics and predictive value of abbreviated criteria for the diagnosis of migraine headache.

The Variable Responding Scale for Detection of Random Responding on the Multidimensional Pain Inventory

This study developed a scale for detecting random responding on the Multidimensional Pain Inventory (MPI). Ninety-five undergraduates (derivation sample) completed the MPI randomly, as did 2 cross-validation samples, 34 chronic pain patients (pain) and 115 health care professionals (health care). Up to 71% of random profiles appeared valid. For comparison in validity scale development, a clinical MPI sample (N = 507) was split into derivation and cross-validation samples. Given that responses to similar items should be consistent in nonrandom protocols, 8 pairs of highly intercorrelated items were selected. Absolute differences between pairs were summed into a variable responding (VR) scale; scores were contrasted across clinical and random groups. On the basis of derivation sample results, VR scale cut scores (from 12 to 17) were tested and found to discriminate accurately (p <.001) between the cross-validation clinical and the healthcare and pain random responding samples. The potential clinical utility of the VR scale to identify random MPI protocols is supported.

Patterns of pain descriptor usage in African Americans and European Americans with chronic pain.

This study examined ethnic differences in the use of pain descriptors, comparing standardized pain assessment data from African American and European American patients with heterogeneous chronic pain syndromes. The measure was the Short-Form McGill Pain Questionnaire (SF-MPQ) including the embedded Visual Analog Scale (VAS). Exploratory factor analyses of SF-MPQ data identified differences in factor structure with the VAS loading on a different factor for each group. A 5-factor solution was obtained from the African American group and a 4-factor solution was obtained from the European American group. There was little overlap in the pattern matrices for African American and European American groups. Results suggest that the VAS is as sensitive to ethnic differences as other traditional pain measures.