Nicole E. Andrews

Adult attachment and reports of pain in experimentally-induced pain.

Attachment theory has been proposed as a framework for understanding the development of chronic pain, with evidence supporting the overrepresentation of insecure attachment styles in chronic pain populations and links between insecure attachment and factors known to impact ones ability to cope with pain. The present study sought to extend two earlier studies exploring the relationships between adult attachment and communication of an acute pain experience, in anticipation of providing insight into individual differences in vulnerability in development of chronic pain. It was hypothesised that: (a) fearful attachment would be associated with perceptions of the pain as less intense, and (b) anxious attachment would be associated with lower pain thresholds. A convenience sample of 82 healthy adults completed self‐report measures of attachment, neuroticism, and negative affect prior to taking part in a coldpressor pain inducement task. Results demonstrated that fearful attachment was associated with lower levels of pain intensity throughout the coldpressor task. In addition, dismissing attachment was also associated with less intense pain, as well as increased coldpressor endurance (tolerance) in the presence of a known assessor. These associations were retained after controlling for measures of neuroticism, negative affect, age, and social desirability. The results of this study are consistent with the proposition that fearful and dismissing individuals tend to mask their underlying distress caused by the pain experience, potentially leading to difficulties coping with pain over time.Attachment theory has been proposed as a framework for understanding the development of chronic pain, with evidence supporting the overrepresentation of insecure attachment styles in chronic pain populations and links between insecure attachment and factors known to impact ones ability to cope with pain. The present study sought to extend two earlier studies exploring the relationships between adult attachment and communication of an acute pain experience, in anticipation of providing insight into individual differences in vulnerability in development of chronic pain. It was hypothesised that: (a) fearful attachment would be associated with perceptions of the pain as less intense, and (b) anxious attachment would be associated with lower pain thresholds. A convenience sample of 82 healthy adults completed self-report measures of attachment, neuroticism, and negative affect prior to taking part in a coldpressor pain inducement task. Results demonstrated that fearful attachment was associated with lower levels of pain intensity throughout the coldpressor task. In addition, dismissing attachment was also associated with less intense pain, as well as increased coldpressor endurance (tolerance) in the presence of a known assessor. These associations were retained after controlling for measures of neuroticism, negative affect, age, and social desirability. The results of this study are consistent with the proposition that fearful and dismissing individuals tend to mask their underlying distress caused by the pain experience, potentially leading to difficulties coping with pain over time.

It's very hard to change yourself: an exploration of overactivity in people with chronic pain using interpretative phenomenological analysis

Abstract Overactivity (activity engagement that significantly exacerbates pain) is a common term in the chronic pain literature. Overactivity is accepted clinically as a behaviour that adversely affects an individuals daily functioning and is the target of one of the most widely endorsed pain management strategies among health professionals (ie, activity pacing). Little research, however, has investigated links between overactivity behaviour and indicators of patient functioning, and activity pacing has not been evaluated as a stand-alone treatment specifically for individuals with chronic pain who are habitually overactive. Two studies, using qualitative research designs and interpretative phenomenological analyses, were conducted to provide insight into (1) why certain individuals develop habitual overactivity patterns in response to pain, (2) the impact of overactivity on daily functioning, and (3) the value of activity pacing as a treatment strategy for this population. Findings suggest that overactivity behaviour is complex, influenced by multiple factors, and negatively impacts on multiple quality-of-life domains. Some participants who were followed up 3 to 6 months after a pain management program were able to learn pacing strategies and enact behaviour change with health professional support; however, the majority reported difficulties changing their behaviour after treatment. It is suggested that provision of pacing education, alone, to chronic pain patients who engage in overactivity behaviour may not be effective in eliciting behavioural change. Key factors that participants believed to contribute to the development and maintenance of their overactive behaviour in this study should be considered in future clinical approaches and empirical investigations.

Overactivity in chronic pain: is it a valid construct?

Overactivity is a frequently used term in chronic pain literature. It refers to the phenomenon whereby individuals engage in activity in a way that significantly exacerbates pain, resulting in periods of incapacity. Overactivity, as a construct, has been derived solely from patients’ self-reports, raising concerns about the legitimacy of the construct. Self-reported overactivity reflects an individual’s belief, collected retrospectively, that their earlier activity levels have resulted in increased levels of pain. This may be different to an individual actually engaging in activity in a way that significantly exacerbates pain. In the present study, a five-day observational study design was employed to investigate the validity of overactivity as a construct by examining the relationship between a self-report measure of overactivity, patterns of pain, and objectively measured physical activity over time. A sample of 68 adults with chronic pain completed a questionnaire investigating self-reported habitual engagement in overactivity and activity avoidance behaviour, before commencing five days of data collection. Over the five-day period participants wore an activity monitor, and recorded their pain intensity six times a day using a handheld computer. Associations were found between: 1) high levels of pain and both high overactivity and high avoidance, 2) high levels of overactivity and more variation in pain and objective activity across days, and 3) high levels of overactivity and the reoccurrence of prolonged activity engagement followed by significant pain increases observed in data sets. These results offer some preliminary support for the validity of overactivity as a legitimate construct in chronic pain.

Association between physical activity and sleep in adults with chronic pain: a momentary, within-person perspective.

Background Individuals with chronic pain consider improved sleep to be one of the most important outcomes of treatment. Physical activity has been shown to have beneficial effects on sleep in the general population. Despite these findings, the physical activity–sleep relationship has not been directly examined in a sample of people with chronic pain. Objective This study aimed to examine the association between objective daytime physical activity and subsequent objective sleep for individuals with chronic pain while controlling for pain and psychosocial variables. Design An observational, prospective, within-person study design was used. Methods A clinical sample of 50 adults with chronic pain was recruited. Participation involved completing a demographic questionnaire followed by 5 days of data collection. Over this period, participants wore a triaxial accelerometer to monitor their daytime activity and sleep. Participants also carried a handheld computer that administered a questionnaire measuring pain, mood, catastrophizing, and stress 6 times throughout the day. Results The results demonstrated that higher fluctuations in daytime activity significantly predicted shorter sleep duration. Furthermore, higher mean daytime activity levels and a greater number of pain sites contributed significantly to the prediction of longer periods of wakefulness at night. Limitations The small sample size used in this study limits the generalizability of the findings. Missing data may have led to overestimations or underestimations of effect sizes, and additional factors that may be associated with sleep (eg, medication usage, environmental factors) were not measured. Conclusions The results of this study suggest that engagement in high-intensity activity and high fluctuations in activity are associated with poorer sleep at night; hence, activity modulation may be a key treatment strategy to address sleep complaints in individuals with chronic pain.

Adult attachment and approaches to activity engagement in chronic pain

Individuals with chronic pain exhibit a wide range of coping mechanisms, some of which are maladaptive (eg, activity avoidance or overactivity). The authors of this study aimed to investigate whether individuals may be predisposed to develop a particular maladaptive coping mechanism based on their attachment style (dismissing, preoccupied, fearful or secure), which represents a core feature of their personality.

The relationship between overactivity and opioid use in chronic pain: a 5-day observational study.

Abstract With increasing concerns about the potential harm of long-term opioid therapy, there is a need for the development and implementation of alternative treatment strategies for patients with chronic pain who have been using opioids for a prolonged period of time. Based on the findings from a recent qualitative investigation that suggested there may be a bidirectional association between opioid reliance and habitual overactivity behaviour (activity engagement that significantly exacerbates pain), this study was designed to quantitatively investigate the association between opioid use and habitual overactivity over a 5-day period in a group of chronic pain patients. Participants provided a list of their prescribed pain medication, completed a self-report measure of habitual overactivity, and then commenced 5 days of data collection. Data collection required participants to wear an activity monitor and to complete a diary that detailed their daily activities and the time at which they took medication. Individuals reporting higher levels of habitual overactivity were more likely to be prescribed opioids. In addition, higher levels of habitual overactivity were associated with more frequent pro re nata (“as needed”) opioid use over the 5 days, and with a discrepancy between the prescribed and actual oral morphine-equivalent daily dose, where more medication was taken than was prescribed. There was no predominant context for pro re nata use. The results of this study support the idea that habitual overactivity behaviour may play a role in the development of reliance on opioid medication and that such an association may provide a potential treatment target for opioid therapy rationalisation.

The Relationship Between Approach to Activity Engagement, Specific Aspects of Physical Function, and Pain Duration in Chronic Pain.

Objectives:To examine: (1) the relationships between habitual approach to activity engagement and specific aspects of physical functioning in chronic pain; and (2) whether or not these relationships differ according to pain duration. Materials and Methods:Outpatients (N=169) with generalized chronic pain completed a set of written questionnaires. Categories of “approach to activity engagement” were created using the confronting and avoidance subscales of the Pain and Activity Relations Questionnaire. An interaction term between “approach to activity engagement” categories and pain duration was entered into analysis with age, sex, pain intensity, the categorical “approach to activity engagement” variable, and pain duration, in 9 ordinal regression models investigating functioning in a variety of daily activities. Results:The “approach to activity engagement” category predicted the personal care, lifting, sleeping, social life, and traveling aspects of physical functioning but, interestingly, not the performance skills used during these activities, that is, walking, sitting, and standing. The interaction term was significant in 2 models; however, the effect of pain duration on associations was the inverse of that theorized, with the relationship between variables becoming less pronounced with increasing duration of pain. Discussion:The results of this study do not support the commonly held notion that avoidance and/or overactivity behavior leads to deconditioning and reduced physical capacity over time. Findings do, however, suggest that a relationship exists between avoidance and/or overactivity behavior and reduced participation in activities. Implications for the clinical management of chronic pain and directions for further research are discussed.

Defining activity pacing: is it time to jump off the merry-go-round?

To the Editor: Many researchers have acknowledged that activity pacing is a poorly defined construct and the various sources of conceptual confusion relating to the term activity pacing have been documented. This has cast doubt about the validity of current activity pacing self-report measures. In response to this, a number of research groups have recently attempted to define activity pacing through varying methodologies and have worked toward developing tools to assess activity pacing. Although this may seem like a positive step toward advancement in the field, each research group has arrived at different conclusions adding to the level of uncertainty about themeaningof the termactivitypacing. In a recent publication, Esteve and colleagues developed a new measure for assessing activity patterns in chronic pain, the Activity Patterns Scale. Three of the 8 subscales of the Activity Patterns Scale purport to measure activity pacing. Each of these activity pacing subscales consist of 3 items relating to a specific activity pacing strategy (ie, breaking activities into smaller tasks, slowing down, and taking frequent short breaks) with the subscales being differentiated by the goal or intended outcome of the behavior (eg, pain reduction vs increasing activity levels). Esteve and colleagues developed their activity pacing subscales on the basis of the conclusions made in Nielson and colleagues’ narrative review. In their publication the authors state that instruments for assessing activity pacing should include 3 activity pacing behaviors, one of which is slowing down. This, however, is in disagreement with the results of 2 recent Delphi surveys. Antcliff and colleagues conducted their Delphi survey to determine items to include in a new activity pacing measure: the Activity Pacing Questionnaire. Items that referred to slowing downwere not endorsed bymost experts, primarily clinicians, who participated in their study