Petra A. Karsdorp

Active avoidance but not activity pacing is associated with disability in fibromyalgia.

ABSTRACT Activity pacing has been suggested as a behavioural strategy that may protect patients with fibromyalgia (FM) against activity dysregulation and disability. The aim of the present study was to empirically test whether the construct of activity pacing is distinct from other behavioural strategies assessed with the Chronic Pain Coping Inventory (CPCI), such as guarding, resting, asking for assistance, relaxation, task persistence, exercise/stretch, seeking social support, and coping self‐statements. The second objective was to test whether pacing was associated with physical disability when controlling for pain catastrophizing, pain severity and the other behavioural strategies as measured with CPCI. A random sample of patients with FM (N = 409) completed the CPCI, the Pain Catastrophizing Scale (PCS), the Physical Index of the Fibromyalgia Impact Questionnaire (FIQ‐PH) and the Pain Disability Index (PDI). The results demonstrated that the Dutch version of the CPCI including the pacing subscale has adequate internal consistency and construct validity. Moreover, guarding and asking for assistance, but not pacing, were associated with disability. These findings are in line with fear‐avoidance models and suggest that specifically active avoidance behaviours are detrimental in FM. The authors recommend developing cognitive‐behavioural and exposure‐based interventions and challenge the idea that pacing as an intervention is essential in pain self‐management programs.

Activity pacing in chronic pain concepts, evidence, and future directions

Background:Activity pacing (AP) is a concept that is central to many chronic pain theories and treatments, yet there remains confusion regarding its definition and effects. Objective:To review the current knowledge concerning AP and integrate this knowledge in a manner that allows for a clear definition and useful directions for future research. Methods:A narrative review of the major theoretical approaches to AP and of the empirical evidence regarding the effects of AP interventions, followed by an integrative discussion. Results:The concept of AP is derived from 2 main traditions: operant and energy conservation. Although there are common elements across these traditions, significant conceptual and practical differences exist, which has led to confusion. Little empirical evidence exists concerning the efficacy of AP as a treatment for chronic pain. Discussion:Future research on AP should be based on a clear theoretical foundation, consider the context in which the AP behavior occurs and the type of pacing problem (“underactivity” vs. “overactivity”), and should examine the impact of AP treatment on multiple clinical outcomes. We provide a provisional definition of AP and specific recommendations that we believe will move the field forward.

Goals matter: Both achievement and pain-avoidance goals are associated with pain severity and disability in patients with low back and upper extremity pain.

&NA; It has been proposed that goal pursuit plays a role in the development of chronic pain disorders. On the basis of (affective) motivational theories, it was hypothesized that both long‐term achievement goals and short‐term hedonic goals would be related to increased levels of pain and disability, particularly in patients with high negative affect. Participants with musculoskeletal pain complaints (N = 299) completed a battery of questionnaires including a novel goal pursuit questionnaire (GPQ) measuring the extent to which participants preferred hedonic goals (mood‐management or pain‐avoidance goals) over achievement goals in various situations. Explorative factor analysis of the GPQ resulted in a reliable pain‐avoidance (α = .88) and mood‐management subscale (α = .76). A nonlinear, U‐shaped relationship was found among the pain‐avoidance scale (but not the mood‐management scale) and pain and disability. This indicated that participants who strongly endorsed either achievement or pain‐avoidance goals also reported higher pain and disability levels while controlling for biographical variables and pain catastrophizing. For pain but not disability, these relationships were only found among patients with high negative affect. For disability, goal pursuit and negative affect were independently related to disability. These findings provide support for the validity of an affective‐motivational approach to chronic pain, suggesting that the experience of pain and the interference of pain on daily life activities depends on goal pursuit and negative affect. Interventions aimed at improving disability in chronic pain should address both patient’s goal pursuit and negative affect. An affective‐motivational approach to chronic pain indicates that achievement and pain‐avoidance goals are associated with pain severity and disability, particularly in patients with high negative affect.

The role of current mood and stop rules on physical task performance: an experimental investigation in patients with work-related upper extremity pain

Patients with work‐related upper extremity pain (WRUED) experience disability in daily life activities. The factors that influence levels of disability are still unclear. Both excessive avoidance and persistence have been suggested, but the affective and motivational processes that underlie these behaviours have not been scrutinized. This study was aimed at examining the role of current mood and stop rules on physical task performance, controlling for gender, pain severity, pain catastrophizing, and pain‐related fear. An additional focus was the role of the interaction between current mood and stop rules as predicted by the novel Mood‐as‐Input (MAI) model. Following MAI, it is the informational value of current mood within a goal context (stop rule), rather than mood per se that predicts behaviour. A 2 (mood)×2 (stop rule)×2 (physical task order) factorial design was used in which 62 WRUED patients performed an upper and lower extremity physical task. A stress interview was used to induce positive and negative mood. Patients received either an “as‐much‐as‐can (AMAC)” stop rule instruction, or a “feel‐like‐discontinuing (FLDC)” stop rule instruction. Results showed that physical task performance was predicted by pain‐related fear, current mood, stop rule. However, the predicted mood×stop rule interaction was not found, and there was no influence of gender, pain severity, and pain catastrophizing on task performance. The findings suggest that not only pain‐related fear, but current mood and goal context factors independently affect physical performance in patients with WRUED.

Pain catastrophizing, threat, and the informational value of mood: Task persistence during a painful finger pressing task

Summary The relationship between pain catastrophizing and task persistence during a painful finger pressing task is modulated by threat context and the informational value of mood. ABSTRACT Pain catastrophizing has shown to predict avoidance behavior in acute and chronic pain, but the literature is inconsistent. The present study tested the hypothesis that current mood and threat context moderate the relationship between pain catastrophizing and performance duration. Affective‐motivational models postulate that negative and positive moods provide information about whether an activity is respectively threatening or safe. Moreover, it has been proposed that stable cognitive schemas about threat influence behavior particularly in threat‐relevant contexts. The present study aimed to establish whether pain catastrophizing is related to less or greater performance duration, when participants experience respectively negative or positive moods, particularly in a high threatening pain context. A 2 mood × 2 threat context between‐subjects factorial design was applied in 89 healthy participants with pain catastrophizing as covariate and performance duration during a painful finger pressing task as dependent variables. As predicted, higher pain catastrophizing was associated with less performance duration when participants experienced negative moods. The opposite was found when participants experienced positive moods. Moreover, these relationships were most pronounced in a high threatening pain context. This study suggests that the relationship between pain catastrophizing and performance duration during painful activities is moderated by situational factors such as current mood and threat context.

Response inhibition predicts painful task duration and performance in healthy individuals performing a cold pressor task in a motivational context

Long‐term avoidance of painful activities has shown to be dysfunctional in chronic pain. Pain may elicit escape or avoidance responses automatically, particularly when pain‐related fear is high. A conflict may arise between opposing short‐term escape/avoidance goals to reduce pain and long‐term approach goals to receive a reward. An inhibitory control system may resolve this conflict. It was hypothesized that reduced response inhibition would be associated with greater escape/avoidance during pain, particularly among subjects with higher pain‐related fear.

Pain catastrophizing moderates the effects of pain-contingent task interruptions

A prominent behavioural consequence of pain is the temporary suspension of current activities with intent to resume them later. Little is known about the effects of such pain‐contingent task interruptions. This experiment examines the influence of pain‐contingent interruptions on the amount of time spent performing a cognitive achievement task: We expected that people would spend more time on task when task performance was interrupted in response to pain (vs. no interruption), and that negative mood and pain catastrophizing would enhance this negative impact.

Chronic pain: Avoidance or endurance?

Chronic musculoskeletal pain poses an important problem in health care and society owing to the large psychological burden and the adverse impact on societal costs. Purely biomedical models seem to be insufficient in explaining the development of chronic pain and disability, and cognitive-behavioural accounts have shown more promising (e.g., Vlaeyen and Linton, 2000). Basically, individuals who catastrophically (mis)interpret pain are likely to experience fear of pain, which is associated with defensive responses including escape, avoidance, and hypervigilance. Paradoxically, defensive responses may ease fear in the short term, but worsen fear and pain in the long term, leading into a vicious circle of avoidance of activities, chronic pain, disuse, and disability. Although there is accumulating evidence supporting such fearavoidance models (Vlaeyen and Linton, 2000), there are unresolved issues that merit further scientific attention. For example, these models do not explain the observed adverse effects of persistence behaviour on pain and disability (Andersen et al., 2007; GarciaCampayo et al., 2007; Van Houdenhove et al., 2001). These findings suggest that the relation between the level of behavioural avoidance and disability is not necessarily linear, and that both excessive avoidance behaviour and excessive persistence behaviour may underlie chronic pain and disability. In the last decade several novel theoretical models have been developed trying to delineate subgroups of patients with chronic pain that are characterized by either excessive avoidance or persistence behaviour (e.g. Van Houdenhove 1986; Hasenbring, 2000). However, evidence for these models is scarce. One of these models is the avoidance-endurance model proposed by Hasenbring et al. (2009) in this issue of EJP. According to this model, two subgroups of patients may be classified based on specific affective, cognitive, and behavioural responses. In line with fear-avoidance models the fear-avoidance group is characterized by fear of pain, catastrophizing thoughts about pain and avoidance behaviour patterns. The endurance group, on the other hand, displays suppression of pain-related thoughts and reports positive affect and persistence behaviour despite the pain. The authors hypothesized that both the avoidance and endurance group may report increased pain levels. However, only the avoidance group may show increased disability levels. The rationale behind this is that the endurance group may withstand the interruptions of pain during daily activities and therefore may show less disability. To support their model, Hasenbring et al. developed a questionnaire based on the Kiel Pain Inventory (KPI) to measure the affective, cognitive, and behavioural components of both avoidance and endurance responses. They tested whether the avoidance and endurance components

Comparing counterconditioning and extinction as methods to reduce fear of movement-related pain

UNLABELLED Cognitive-behavioral treatments for chronic pain typically target pain-related fear; exposure in vivo is a common treatment focusing on disconfirming harm expectancy of feared movements. Exposure therapy is tailored on Pavlovian extinction; an alternative fear reduction technique that also alters stimulus valence is counterconditioning. We compared both procedures to reduce pain-related fear using a voluntary joystick movement paradigm. Participants were randomly allocated to the counterconditioning or extinction group. During fear acquisition, moving the joystick in 2 directions (conditioned stimulus [CS+]) was followed by a painful electrocutaneous stimulus (pain-unconditioned stimulus [US]), whereas moving the joystick in 2 other directions was not (CS-). During fear reduction, 1 CS+ was extinguished, but another CS+ was still followed by pain in the extinction group; in the counterconditioning group, 1 CS+ was extinguished and followed by a monetary reward-US, and another CS+ was followed by both USs (pain-US and reward-US). The results indicate that counterconditioning effectively reduces pain-related fear but that it does not produce deeper fear reduction than extinction. Adding a reward-US to a painful movement attenuated neither fear nor the intensity/unpleasantness of the pain. Both procedures changed stimulus valence. We contend that changing the affective valence of feared movements might improve fear reduction and may prevent relapse. PERSPECTIVE This article reports no immediate differences between counterconditioning and extinction in reducing pain-related fear in the laboratory. Unexpectedly, both methods also altered stimulus valence. However, we cautiously suggest that methods explicitly focusing on altering the affective valence of feared movements may improve the long-term effectiveness of fear reduction and prevent relapse.

Attentional control and the competition between nonpain goals and the threat of pain

Fully understanding attention to pain requires taking into account the motivational context. Both pain‐ and (nonpain) goal‐related information attracts attention. An intriguing question is which attentional bias prevails when pain‐ and goal‐related information co‐occurs? Reduced attentional bias towards pain‐ and goal‐related information was predicted when the other competing information was presented simultaneously. Moreover, trait attentional control was predicted to be associated with stronger attentional bias towards goal‐related information particularly in the presence of pain‐related information.