Warren R. Nielson

Toward the development of a motivational model of pain self-management

Adaptive management of chronic pain depends to a large degree on how patients choose to cope with pain and its impact. Consequently, patient motivation is an important factor in determining how well patients learn to manage pain. However, the role of patient motivation in altering coping behavior and maintaining those changes is seldom discussed, and theoretically based research on motivation for pain treatment is lacking. This article reviews theories that have a direct application to understanding motivational issues in pain coping and presents a preliminary motivational model of pain self-management. The implications of this model for enhancing engagement in and adherence to chronic pain treatment programs are then discussed. The article ends with a call for research to better understand motivation as it applies to chronic pain self-management. In particular, there is a need to determine whether (and which) motivation enhancement interventions increase active participation in self-management treatment programs for chronic pain.

Reliability, Standard Error, and Minimum Detectable Change of Clinical Pressure Pain Threshold Testing in People With and Without Acute Neck Pain

STUDY DESIGN Clinical measurement. OBJECTIVES To evaluate the intrarater, interrater, and test-retest reliability of an accessible digital algometer, and to determine the minimum detectable change in normal healthy individuals and a clinical population with neck pain. BACKGROUND Pressure pain threshold testing may be a valuable assessment and prognostic indicator for people with neck pain. To date, most of this research has been completed using algometers that are too resource intensive for routine clinical use. METHODS Novice raters (physiotherapy students or clinical physiotherapists) were trained to perform algometry testing over 2 clinically relevant sites: the angle of the upper trapezius and the belly of the tibialis anterior. A convenience sample of normal healthy individuals and a clinical sample of people with neck pain were tested by 2 different raters (all participants) and on 2 different days (healthy participants only). Intraclass correlation coefficient (ICC), standard error of measurement, and minimum detectable change were calculated. RESULTS A total of 60 healthy volunteers and 40 people with neck pain were recruited. Intrarater reliability was almost perfect (ICC = 0.94-0.97), interrater reliability was substantial to near perfect (ICC = 0.79-0.90), and test-retest reliability was substantial (ICC = 0.76-0.79). Smaller change was detectable in the trapezius compared to the tibialis anterior. CONCLUSIONS This study provides evidence that novice raters can perform digital algometry with adequate reliability for research and clinical use in people with and without neck pain.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Aerobic Fitness Exercises in the Management of Fibromyalgia: Part 1

Background and Purpose: The objective of this study was to create guidelines for the use of aerobic fitness exercises in the management of adult patients (>18 years of age) with fibromyalgia, as defined by the 1990 American College of Rheumatology criteria. Methods: Following Cochrane Collaboration methods, the Ottawa Methods Group found and synthesized evidence from comparative controlled trials and formed the Ottawa Panel, with nominated experts from key stakeholder organizations. The Ottawa Panel then developed criteria for grading the recommendations based on experimental design (I for randomized controlled trials, II for nonrandomized studies) and strength of evidence (A, B, C+, C, D+, D, or D−). From the rigorous literature search, 13 randomized control trials and 3 controlled clinical trials were selected. Statistical analysis was based on Cochrane Collaboration methods. Continuous data were calculated with weighted mean differences between the intervention and control groups, and dichotomous data were analyzed with relative risks. Clinical improvement was calculated using absolute benefit and relative difference in change from baseline. Clinical significance was attained when an improvement of 15% relative to a control was found. Results: There were 24 positive recommendations: 10 grade A, 1 grade B, and 13 grade C+. Of these 24 positive recommendations, only 5 were of clinical benefit. Discussion and Conclusion: The Ottawa Panel recommends aerobic fitness exercises for the management of fibromyalgia as a result of the emerging evidence (grades A, B, and C+, although most trials were rated low quality) shown in the literature.

The Scleroderma Patient-centered Intervention Network (SPIN) Cohort: protocol for a cohort multiple randomised controlled trial (cmRCT) design to support trials of psychosocial and rehabilitation interventions in a rare disease context

Introduction Psychosocial and rehabilitation interventions are increasingly used to attenuate disability and improve health-related quality of life (HRQL) in chronic diseases, but are typically not available for patients with rare diseases. Conducting rigorous, adequately powered trials of these interventions for patients with rare diseases is difficult. The Scleroderma Patient-centered Intervention Network (SPIN) is an international collaboration of patient organisations, clinicians and researchers. The aim of SPIN is to develop a research infrastructure to test accessible, low-cost self-guided online interventions to reduce disability and improve HRQL for people living with the rare disease systemic sclerosis (SSc or scleroderma). Once tested, effective interventions will be made accessible through patient organisations partnering with SPIN. Methods and analysis SPIN will employ the cohort multiple randomised controlled trial (cmRCT) design, in which patients consent to participate in a cohort for ongoing data collection. The aim is to recruit 1500–2000 patients from centres across the world within a period of 5 years (2013–2018). Eligible participants are persons ≥18 years of age with a diagnosis of SSc. In addition to baseline medical data, participants will complete patient-reported outcome measures every 3 months. Upon enrolment in the cohort, patients will consent to be contacted in the future to participate in intervention research and to allow their data to be used for comparison purposes for interventions tested with other cohort participants. Once interventions are developed, patients from the cohort will be randomly selected and offered interventions as part of pragmatic RCTs. Outcomes from patients offered interventions will be compared with outcomes from trial-eligible patients who are not offered the interventions. Ethics and dissemination The use of the cmRCT design, the development of self-guided online interventions and partnerships with patient organisations will allow SPIN to develop, rigourously test and effectively disseminate psychosocial and rehabilitation interventions for people with SSc.

Biopsychosocial approaches to the treatment of chronic pain.

Background: Biopsychosocial treatments address the range of physical, psychological, and social components of chronic pain. Objective: This review sought to determine how effective unimodal and multimodal biopsychosocial approaches are in the treatment of chronic pain. Methodology: The literature search identified three systematic reviews of the literature and 21 randomized controlled trials to provide the evidence for this review. Results: The systematic reviews and 12 randomized controlled trials reported on chronic low back pain. Other randomized controlled trials studied fibromyalgia (three trials) and back or other musculoskeletal disorders (five trials). Biopsychosocial components reviewed were electromyogram feedback and hypnosis as unimodal approaches, and behavioral and cognitive-behavioral treatments and back school, or group education, as multimodal approaches for chronic low back pain. For other chronic pain disorders, cognitive-behavioral treatments were reviewed. Comparisons were hindered by studies with heterogeneous subjects, varied comparison groups, different cointerventions and follow-up times, variable outcomes, and a range of analytic methods. Conclusions: Multimodal biopsychosocial treatments that include cognitive-behavioral and/or behavioral components are effective for chronic low back pain and other musculoskeletal pain for up to 12 months (level 2). There is limited evidence (level 3) that electromyogram feedback is effective for chronic low back pain for up to 3 months. The remaining evidence of longer-term effectiveness and of effectiveness of other interventions was inadequate (level 4a) or contradictory (level 4b). Future studies of cognitive-behavioral treatments should be condition specific, rather than include patients with different pain conditions.

Relationship between changes in coping and treatment outcome in patients with Fibromyalgia Syndrome.

&NA; The present study utilized a sample of 198 individuals with Fibromyalgia Syndrome (FMS) to examine the association between treatment process variables (beliefs, coping strategies) and treatment outcomes (pain severity, activity level, emotional distress and life interference) related to a 4‐week multidisciplinary fibromyalgia treatment program. Multiple regression analyses were utilized to evaluate these relationships pretreatment to posttreatment as well as from pretreatment to 3‐ and 6‐month follow‐ups. The results indicated that outcomes were most closely related to: (1) an increased sense of control over pain, (2) a belief that one is not necessarily disabled by FM, (3) a belief that pain is not necessarily a sign of damage, (4) decreased guarding, (5) increased use of exercise, (6) seeking support from others, (7) activity pacing and (8) use of coping self‐statements. These findings are consistent with a cognitive‐behavioural model of fibromyalgia, and suggest targets for therapeutic change.

An activity pacing scale for the chronic pain coping inventory: development in a sample of patients with fibromyalgia syndrome.

&NA; Patients with fibromyalgia syndrome (FS) experience a decreased ability to participate in both vocational and avocational activities. Although many treatment programs advocate activity pacing techniques, ‘pacing’ is a poorly understood concept for which there are no available measures. The present study describes a brief six‐item pacing scale that can be administered as part of the Chronic Pain Coping Inventory (CPCI). Preliminary data indicate that this scale is a valid, reliable index of the pacing construct that is associated with physical impairment in patients with FS and is unrelated to simple task persistence.

Further evaluation of the pain stages of change questionnaire : is the transtheoretical model of change useful for patients with chronic pain?

&NA; Patient readiness to adopt new beliefs and coping responses to pain may predict response to multidisciplinary or cognitive‐behavioral pain treatments that emphasize changes in beliefs and coping behaviors. According to the transtheoretical model of change, individuals go through specific stages in the process of changing maladaptive behaviors. Based on this model, Kerns et al. (1997) (Kerns RD, Rosenberg R, Jamison RN, Caudill MA, Haythornthwaite J. Readiness to adopt a self‐management approach to chronic pain: the Pain Stages of Change Questionnaire (PSOCQ). Pain 1997;72:227–234) developed a measure of readiness to adopt a self‐management approach to pain problems (the Pain Stages of Change Questionnaire; PSOCQ) and provided preliminary data supporting the validity of the measure. The current study sought to further evaluate the PSOCQ by determining the generalizability of these preliminary findings and the ability of the PSOCQ to classify persons with chronic pain into specific stages of readiness to self‐manage pain. One hundred ten patients with diverse chronic pain problems, and 119 patients with fibromyalgia completed the PSOCQ and two measures of pain‐related beliefs and coping prior to entry into two separate multidisciplinary pain programs. The internal consistency and concurrent validity of the PSOCQ subscales were largely replicated, supporting the validity of the subscales as measures of readiness to self‐manage pain. However, the PSOCQ demonstrated less utility as a tool for classifying individuals into one of four specific stages of readiness to adopt a self‐management approach. This result may be due to the classification procedure used in the current study, the characteristics of the samples in the study, specific limitations of the measure, and/or limitations in the applicability of the transtheoretical model of change to patients with chronic pain.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Strengthening Exercises in the Management of Fibromyalgia: Part 2

Background and Purpose: The objective of this study was to create guidelines for the use of strengthening exercises in the management of adult patients (>18 years of age) with fibromyalgia (FM), as defined by the 1990 American College of Rheumatology criteria. Methods: Following Cochrane Collaboration methods, the Ottawa Methods Group found and synthesized evidence from comparative controlled trials and formed the Ottawa Panel, with nominated experts from key stakeholder organizations. The Ottawa Panel then developed criteria for grading the recommendations based on experimental design (I for randomized controlled trials, II for nonrandomized studies) and strength of evidence (A, B, C+, C, D+, D, or D−). From the rigorous literature search, 5 randomized controlled trials were selected. Statistical analysis was based on Cochrane Collaboration methods. Continuous data were calculated with weighted mean differences between the intervention and control groups, and dichotomous data were analyzed with relative risks. Clinical improvement was calculated using absolute benefit and relative difference in change from baseline. Clinical significance was attained when an improvement of 15% relative to a control was found. Results: There were 5 positive recommendations: 2 grade A and 3 grade C+. All 5 were of clinical benefit. Discussion and Conclusion: The Ottawa Panel recommends strengthening exercises for the management of fibromyalgia as a result of the emerging evidence (grades A, B, and C+, although most trials were rated low quality) shown in the literature.

Readiness to adopt the self-management approach to cope with chronic pain in fibromyalgic patients

&NA; The effectiveness of cognitive‐behavior therapy aimed at helping patients with the acquisition of self‐management skills to cope with pain, is thought to depend partly on the patients’ willingness to adopt a self‐management approach. Some patients may not believe that self‐management will be helpful while others have decided to adopt it and others already apply the self‐management skills in their daily lives. The present study explored the concept of ‘Readiness to change’ in a population of Dutch fibromyalgic patients. A self‐report questionnaire was completed by 321 patients. Factor analysis revealed three scales, each assessing the characteristic of one stage of readiness to change, the Precontemplation, Contemplation and Action scale. Firstly, the reliabilities of these scales were 0.61, 0.86 and 0.61, respectively, and only the latter two scales correlated significantly (r=0.14). Secondly, the scales were validated using subscales from the Multidimensional Pain Inventory, beliefs on the credibility of the self‐management approach and subscales from the Illness Perception Questionnaire. These subscales explained 5, 22 and 8% of the variance of the scores on the Precontemplation, Contemplation and the Action scales, respectively. Thirdly, on the basis of the three scale scores, over 80% of the fibromialgia patients could be classified into one of five potentially psychological relevant subgroups: Precontemplation, Contemplation, Preparation, Action and Relapse. The data suggest that improvements in operationalizations of the Precontemplation and Action dimensions of readiness to change are needed and that the theoretical foundation of readiness to change needs further development.