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Pain Self-efficacy Mediates the Relationship Between Depressive Symptoms and Pain Severity
Abstract
In this study we examined the relationships between depressive symptoms, pain severity, and pain self-efficacy (PSE) in patients suffering from chronic low back pain (CLBP). We hypothesized that change in depressive symptoms would significantly influence change in pain severity, and that PSE indirectly affect this relationship.
Participants were 109 CLBP patients in a four-week multidisciplinary rehabilitation program for CLBP. They completed measures of PSE, depression, and pain severity at admission and discharge. Structural equation modeling was used to test the significance direct and indirect effects from pre-treatment to post-treatment.
Change in depressive symptoms significantly predicted change in pain severity in affective (β =0.358; 95% CI =0.206 to.480, P =0.006), sensory (β =0.384; 95% CI =0.257 to.523, P =0.002), and evaluative pain (β =0.456; 95% CI =0.285 to.605, P =0.002). The indirect effects of change in PSE partially accounted for the relationship between change in depressive symptoms and change in sensory (β =0.105; 95% CI =0.016 to.241, P =0.023) and evaluative pain (β =0.121; 95% CI =0.010 to.249, P =0.040). The relationship between change in depressive symptoms and change in affective pain was fully accounted for by the indirect effect of change in PSE (β =0.203; 95% CI =0.082 to.337, P =0.002).
These findings suggest that pain management and rehabilitation programs for CLBP should specifically target PSE as a key aspect of treatment.
... DurchdieBerücksichtigungder schmerzspezifischen Selbstwirksamkeit könnten bislang widersprüchliche Befunde zum Einfluss der Depressivität auf schmerzbezogene Kennwerte bei nichtspezifischen CRS besser erklärt werden. So sprechen einige Studien für den negativen Zusammenhang der Depressivität mit der schmerzspezifischen Selbstwirksamkeit [17,26]. In weiteren Studien hing die schmerzspezifische Selbstwirksamkeit ihrerseits mit der wahrgenommenen Beeinträchtigung durch die Schmerzen zusammen [17,21]. ...
... Ein vermittelnder Einfluss der schmerzspezifischen Selbstwirksamkeit wurde vor allem in zwei Studien bei CRS nahegelegt: In einem 1-Jahres-Längsschnitt vermittelten nicht die Angst-Vermeidungs-Kognitionen, sondern die schmerzspezifi-sche Selbstwirksamkeit den ungünstigen Einfluss der Schmerzintensität auf die Schmerzbeeinträchtigung [5]. Für die vorliegende Arbeit ist jedoch folgender Befund sehr relevant: Die schmerzspezifische Selbstwirksamkeit mediierte die Beziehung zwischen hoher Depressivität zu Rehabilitationsbeginn und der erhöhten Schmerzintensität zum Rehabilitationsende [26]. ...
... So wurde geprüft, ob die ungünstigen Effekte der Depressivität zu Rehabilitationsbeginn auf die subjektive Gefährdung der Erwerbsprognose sowie die physische und psychische Arbeitsfähigkeit zur 24-MK durch die schmerzspezifische Selbstwirksamkeit zur 12-MK vermittelt werden. Somit sollte der erste Befund von Skidmore et al. [26] sowohl auf die langfristige Vorhersage als auch auf die arbeitsbezogenen Kennwerte erweitert werden. ...
Background:
The transition from acute to non-specific chronic low back pain (CLBP) is especially associated with psychological factors. However, working mechanisms of psychological factors have been little examined in non-specific CLBP, especially the mediator effect of pain self-efficacy.
Objective:
Does pain self-efficacy mediate the long-term prediction of work-related factors by depressive symptoms?
Methods:
Within the framework of an exploratory secondary analysis, simple mediation analyses were conducted to longitudinally predict prognosis of gainful employment, as well as subjective physical and mental work ability by depressive symptoms mediated by pain self-efficacy in 382 inpatients with non-specific CLBP.
Results:
The findings suggest that depressive symptoms prior to rehabilitation predicted levels of all three work-related factors 24 months after rehabilitation, and pain self-efficacy 12 months after rehabilitation mediated this relationship.
Conclusion:
To improve the success of work-related rehabilitation in the long-term, pain self-efficacy in particular, but also depressive symptoms should be targeted by treatments of non-specific CLBP.
... Individuals experiencing low back pain (LBP) delineate the greatest percentage of people with chronic pain [10]. Chronic low back pain (CLBP), the most common musculoskeletal condition, accounts for approximately half of the United States chronic pain population and has an annual incidence rate that accounts for more than 1/3 of the global health conditions [3,7,[11][12][13][14][15]. Distinct musculoskeletal causes for chronic pain and reported disability are found in 10-20% of the chronic pain population [10,16,17]. ...
... The findings supported the hypotheses that pain self-efficacy clearly influence and potentially mediate the relationships between specific psychosocial factors and reported disability to a greater degree than previously understood. The finding that pain self-efficacy has a mediating role between the three psychosocial factors and reported disability agree with multiple studies that individually investigated these relationships in musculoskeletal pain patients [15,23,35,[60][61][62][63]. ...
... Lower levels of pain selfefficacy present with elevated levels of reported pain and disability at nearly a one-to-one ratio. Likewise, higher levels of pain self-efficacy are related to better functional outcomes [15,35,60,64]. Pain self-efficacy accounts for the interdependent relationship between reported pain levels, psychological factors, and reported disability. ...
Abstract Background Chronic pain and the accompanying level of disability is a healthcare crisis that reaches epidemic proportions and is now considered a world level crisis. Chronic non-specific low back pain (CNLBP) contributes a significant proportion to the chronic pain population. CNLBP occurs with overlapping psychosocial factors. This study was design to investigate specific psychosocial factors and their influence on reported disability in a population with CNLBP. Methods The specific psychosocial factors examined included fear, catastrophizing, depression, and pain self-efficacy. This cross-sectional correlational study investigated the mediating role between pain self-efficacy, the specific psychosocial factors, and reported disability. The study recruited 61 female and 29 male participants from physical therapy clinics. The participants were between 20-to-60 years of age and diagnosed with CNLBP. All participants completed the Fear Avoidance Belief Questionnaire, The Pain Catastrophizing Scale, The Patient Health Questionnaire-9, The Pain Self-Efficacy Questionnaire, and The Lumbar Oswestry Disability Index. The battery of questionnaires measured fear of physical activity, pain catastrophizing, depression, pain self-efficacy, and reported disability. Multivariate regression and mediation analyses was used to analyse the data. Results The principal finding was a strong inverse relationship between pain self-efficacy and reported disability with a p-value
... [5][6][7][8][9] For example, self-efficacy belief has been identified as a mediator in the relationship between depressive symptoms and affective pain intensity, 10 in which individuals with higher selfefficacy were significantly more tolerant of pain and capable of performing daily-life activities. 10 Further, individuals who have a higher level of catastrophizing may perceive and report a higher pain level. 7 Thus, several studies have analyzed the potential link between psychosocial factors such as catastrophizing and fear avoidance and response to treatment in patients with chronic low back pain (CLBP). ...
... Baseline self-efficacy was reported to predict disability outcomes in three studies 10,32,34 with regression coefficient β ranging from 0.21 to 0.37. Further, one study reported an OR of 9.8 of self-efficacy to predict the disability outcomes. ...
... A higher depression score at baseline was a predictor of poor improvement in pain and disability, with regression coefficients β of 0.24 and 0.17, respectively. 10,38 Each study used two different outcome measures, namely the depression symptoms checklist SCL-90 and the hospital anxiety and depression scale. ...
Objective
Previous evidence has recommended conservative interventions as the best treatment in individuals with chronic low back pain (CLBP). However, the influence of psychosocial factors on the treatment outcomes is unclear. Therefore, this systematic review aimed to address the psychosocial factors that influence changes in pain and disability in patients with CLBP after a guideline-based conservative intervention.
Methods
Four electronic databases were systematically searched from inception until September 2020 for prospective studies examining the relationship between psychosocial factors and the outcomes of pain and disability after conservative intervention. All included studies were selected, extracted, and critically evaluated by two independent reviewers.
Results
In total, 15 studies were included in this systematic review. The results support the link between the baseline fear of movement, depression, self-efficacy, and catastrophizing with future functional disability outcomes after conservative interventions. However, these factors were less likely to predict changes in pain intensity outcomes after conservative interventions. Self-efficacy seems to mediate between some of the baseline psychosocial factors (eg, fear) and future pain and disability.
Conclusion
Fear of movement, self-efficacy, catastrophizing and depression were consistently reported to predict disability outcomes irrespective of the type of conservative intervention. This highlights the importance of addressing these factors in conservative management of CLBP.
... Individuals experiencing low back pain (LBP) delineate the greatest percentage of people with chronic pain [10]. Chronic low back pain (CLBP), the most common musculoskeletal condition, accounts for approximately half of the United States chronic pain population and has an annual incidence rate that accounts for more than 1/3 of the global health conditions [3, 7,11,12,13,14,15]. ...
... Lower levels of pain self-e cacy present with elevated levels of reported pain and disability at nearly a one-to-one ratio. Likewise, higher levels of pain self-e cacy are related to better functional outcomes [15,34,60,61]. Pain self-e cacy accounts for the interdependent relationship between reported pain levels, psychological factors, and reported disability. ...
... Pain self-e cacy accounts for the interdependent relationship between reported pain levels, psychological factors, and reported disability. Prior to this understanding, there was only moderate evidence supporting the predictive and in uential role psychosocial factors have over reported disability [15,62]. Self-e cacy contributes to the current understanding of associations between psychosocial factors, functional outcomes, and chronic pain. ...
Background
Chronic pain in all its forms and the accompanying level of disability is a healthcare crisis that reaches epidemic proportions and is considered a world level crisis. Chronic non-specific low back pain contributes a significant proportion of chronic pain. Specific psychosocial factors and their influence on reported disability in a chronic non-specific low back pain (CNLBP) population was researched.
Methods
Psychosocial factors examined include fear, catastrophizing, depression, and pain self-efficacy. This cross-sectional correlational study examined the mediating role between pain self-efficacy and the specific psychosocial factors with reported disability. The study included 90 participants with CNLBP between 20 and 60 years of age. Participants completed the Fear Avoidance Belief Questionnaire, The Pain Catastrophizing Scale, The Patient Health Questionnaire-9, The Pain Self-Efficacy Questionnaire, and The Lumbar Oswestry Disability Index to measure fear of physical activity, pain catastrophizing, depression, pain self-efficacy, and reported disability, respectively. The study used multivariate regression and mediation analyses.
Results
The principal finding of the study was a strong inverse relationship between pain self-efficacy and reported disability. Further, pain self-efficacy was considered a statistic mediator for all psychosocial factors investigated within this data set. Pain self-efficacy was strongly considered to have a mediating role between reported fear of physical activity and disability, reported pain catastrophizing and disability, and reported depression and disability. Additionally, adjusting for age and reported pain levels proved to be statistically significant, and it did not alter the role of pain self-efficacy.
Conclusion
The results identified that pain self-efficacy had a mediating role in the relationship between the specific psychosocial factors of fear, catastrophizing, and depression and reported disability. Pain self-efficacy plays a more significant role in the relationships between specific psychosocial factors and reported disability with CNLBP than previously considered.
... Fear-avoidance behaviours such as this have been evidenced to perpetuate pain behaviours and experiences (Sawchuk and Mayer 2008), and provide one explanation for the transition from acute to chronic pain (Zale and Ditre 2015). Other research highlights that pain self-efficacy, or the beliefs someone holds about their ability to participate in daily activities whilst in pain, is associated with pain catastrophising and avoidance (Nicholas 2007), levels of activity, working endurance (Turner et al. 2005), depressive symptoms, and pain severity (Skidmore et al. 2015). Focus on encouraging protective factors (i.e., selfefficacy, exercise, and good dietary quality) is therefore just as important as reducing risk factors (i.e., smoking, stress, obesity) for prevention of MSK disability. ...
... For those with MSK conditions, perceived lack of control is associated with feelings of helplessness and disadvantageous adaptation to pain (Koleck et al. 2006;Nicassio et al. 1999). Similarly, pain self-efficacy is associated with pain catastrophising and avoidance (Nicholas 2007), depressive symptoms, and severity of pain (Skidmore et al. 2015). Increasing the self-efficacy and thus self-control of individuals with MSK conditions through MECC HCS delivery could have positive impacts on their health and wellbeing, and should be studied further. ...
Aim
To explore the current use and perceptions of the Wessex model of Making Every Contact Count (MECC), incorporating Healthy Conversation Skills (HCS), focussing specifically on physiotherapists supporting people living with musculoskeletal conditions.
Methods
A mixed method, sequential explanatory design was employed. This article reports the first phase of the study, in which an online questionnaire was administered, consisting of items relating to perceived acceptability, appropriateness, feasibility, sustainability, and uptake of MECC HCS. Barriers and facilitators to MECC HCS delivery were additionally explored and mapped to the Theoretical Domains Framework.
Results
Seventy-one professionals responded, including 15 physiotherapists supporting people with MSK conditions. Across professional groups, MECC HCS was found to be highly acceptable, appropriate, and feasible. A significant interaction between perceived sustainability of MECC HCS and the location in which professionals worked was observed. Physiotherapists reported using their MECC HCS at least daily; however, there were discrepancies between the number of their patients they believed could benefit from behaviour change intervention, and the number to whom they reported actually delivering MECC HCS. Perceived barriers and facilitators to MECC HCS implementation mapped mostly to ‘Environmental Context and Resources’ on the Theoretical Domains Framework.
Conclusions
The Wessex model of MECC is a promising brief or very brief intervention for physiotherapists supporting individuals with musculoskeletal conditions. Barriers associated with the sustainability of the intervention within organisations must be addressed in order to enhance future implementation. Further rollout of this intervention may be beneficial for meeting the goals of the NHS and Public Health England in prevention of chronic MSK conditions and promotion of musculoskeletal health.
... This study concluded that self-efficacy beliefs partially mediated the relationship between changes in pain and changes in disability over 12 months [37]. In samples of individuals with chronic pain, several studies have supported the conclusions that both self-efficacy beliefs [38] and pain acceptance [39][40][41][42] mediate the improvements in outcome produced by psychological and multidisciplinary pain treatments. However, to our knowledge, no study has tested the mediating effects of multiple positive psychological factors such as pain acceptance, pain self-efficacy, and optimism in the association between pain intensity and pain interference in the same sample with chronic musculoskeletal pain. ...
... Previous observational studies have shown that pain self-efficacy partially mediates the longitudinal association between changes in pain and changes in disability in individuals with chronic low back pain [37], as well as pain self-efficacy and pain acceptance cross-sectionally mediate the association between pain intensity and engagement in valued activities in people with rheumatoid arthritis [35]. Several studies have found that self-efficacy beliefs [38] and pain acceptance [39][40][41][42] mediate the improvement in psychological and multidisciplinary pain treatments in individuals with chronic pain. ...
This study aimed to test the cross-sectional mediating and moderating role that positive
psychological factors play in the association between pain intensity and pain interference in individuals with chronic musculoskeletal pain. A descriptive cross-sectional study using mediation analyses was conducted, including 186 individuals with chronic musculoskeletal pain. We conducted cross-sectional mediation and moderation analyses to determine whether the positive psychological factors mediated or moderated the association between pain intensity and pain interference. Pain acceptance, pain self-e�cacy, and optimism were all significantly and weakly related to pain interference when controlling for pain intensity. Pain self-e�cacy and pain acceptance partially mediated the association between pain intensity and pain interference. On the other hand, the multiple mediation model did not show significant e�ects. The three positive psychological factors were not found to significantly
moderate the association between pain intensity and pain interference. The findings suggest that in chronic musculoskeletal pain patients, the treatments may focus on [i] what they are capable of doing to manage the pain (i.e., pain self-e�cacy) and [ii] being better able to accept the pain as pain waxes and wanes might be also particularly helpful. However, these results must be tested in longitudinal studies before drawing any causal conclusion.
... Each item has four response options, ranging from 0 to 3. The cut-off scores are 8 points for anxiety and 9 for depression. Change in depressive symptoms has been found to significantly predict change in pain severity and intensity [37]. ...
... The scale has 22 items and has been adapted and validated into Brazilian Portuguese [39]. Previous research has suggested that rehabilitation programmes for CLBP should target pain self-efficacy which mediates the relationship between depressive symptoms and pain severity [37]. ...
To investigate the immediate and 1-month effects of functional taping of the lumbar spine for pain intensity and postural control in patients with chronic non-specific low back pain.
Randomised clinical trial.
One hundred and twenty participants aged 18 to 50 years.
Participants will be allocated at random to receive one of three interventions: functional star-shape taping for 7 days, sham functional taping for 7 days or minimal intervention (one session).
The primary outcomes will be pain intensity and postural control. Four measurements of static posturography will be conducted: pre-intervention, immediately after application of the tape, 7 days post-intervention (after removal of the tape) and 1-month follow-up. The secondary outcomes will be low-back-pain-related disability, global perceived effect of treatment and fear avoidance beliefs. Primary and secondary outcomes will be assessed on three occasions: pre-intervention, 7 days post-intervention and at 1-month follow-up. All statistical analyses will be conducted following intention-to-treat principles, and the treatment effects will be calculated using linear mixed models.
The results of this study will determine the effects of functional taping on pain intensity and postural control compared with sham taping and minimal intervention.
NCT02546466.
... Psychosocial factors such as anxiety and catastrophizing are being revealed as crucial contributors to individual differences in pain processing and outcomes. Some researchers have reported the associations between the development of persistent pain catastrophizing and depression or with psychological distress and reduced physical activity [11][12][13][14][15]. This condition may lead to disability worsening individual quality of life [16]. ...
Background: Chronic post-surgical pain is a condition persisting at least three months after surgery. It is estimated that 25-60% of patients who underwent breast cancer removal surgery suffer from post-mastectomy pain syndrome and occurred anxiety, depression, sleep disturbance and catastrophizing. Physical activity can reduce the risk of chronic diseases and has a good impact on mood and cognitive function. Aim of this study was to evaluate the effects of physical activity on the intensity of pain, depression and anxiety in women underwent mastectomy for breast cancer removal. Methods: A prospective observational unicentric cohort study was performed. Patients were female underwent unilateral or bilateral mastectomy. Numerical Rating Scale (NRS), was used to assess pain intensity, Beck’s Depression Inventory (BDI) for depression and Generalized Anxiety Disorders-7 (GAD-7), for anxiety evaluation. Physical activity was assessed by International Physical activity questionnaire (IPAQ). Interleukin (IL)-17, IL-1β, cortisol, adrenocorticotropic hormone (ACTH) and brain-derived neurotrophic factor (BDNF) were also evaluated in the blood of patients. All the evaluation was assessed 3 and 6 months after the surgery. Results: Adequate physical activity reduced intensity of pain, depression and anxiety symptoms in women affected by post-mastectomy pain syndrome. Moreover, adequate active women, showed a reduction of biomarkers of inflammation, cortisol, ACTH and an increase of BDNF. Conclusions: Our results suggest that physical activity can improve quality of life, reducing intensity of pain, inflammatory markers and it can be useful in the reduction of associated anxiety and depression.
... Among those with FM, higher levels of self-efficacy were correlated with lower levels of depression, less FM impact, and reduced external attributions (Van Liew et al., 2019;Moyano et al., 2019;Sahar et al., 2016;Mena et al., 2015;Jackson et al., 2014). Self-efficacy has also been shown to mediate the relationships between depression and indicators of physical health in people with chronic pain (Skidmore et al., 2015;Craig et al., 2013;Arnstein et al., 1999). Barlow and colleagues (2002) found that the self-efficacy beliefs of people with rheumatoid arthritis fully accounted for the effect of depression on physical well-being, suggesting mediation. ...
The purpose of the present study was to determine whether self-efficacy mediated the relationship between perceived disease-specific impact and symptoms of depression in a sample of 600 individuals (Mage = 53.92 years, SD = 11.45 years) with fibromyalgia over 18 months. A 1-1-1 longitudinal multilevel mediation analysis was conducted using participants’ total scores on the Fibromyalgia Impact Questionnaire (FIQ), the Arthritis Self-Efficacy Scale (ASES), and the Center for Epidemiological Studies Depression Scale (CES-D) at four measurement times (baseline, six months, one year, and 18 months later). The results indicated that self-efficacy was a significant partial mediator of the direct negative influence fibromyalgia impact had on depression symptoms at both the within- and between-individual levels over the course of the study. The findings provide further evidence that enhancing self-efficacy beliefs may help buffer the negative psychological consequences of fibromyalgia and suggest that other mechanisms may affect the relationships in the model.
... Notwithstanding this, it is of the utmost importance to stress that the list of putative mediators is by no means complete. We did not consider evaluating catastrophic behavior, pain tolerance, or the severity of depressive symptoms [51]. In fact, pain tolerance and catastrophic behavior have a substantial effect on JPS and limits of the stability [52,53]. ...
(1) Background: Individuals with fibromyalgia syndrome (FMS) may experience proprioceptive and balance impairments. Kinesiophobia is a factor that can mediate the relationship between cervical joint position sense (JPS) and limits of stability. The objectives of this study were to (1) compare the cervical JPS and limits of stability between FMS and asymptomatic individuals, (2) assess the relationship between cervical JPS and limits of stability, and (3) assess the mediation effect of kinesiophobia on the relationship between cervical JPS and limits of stability in FMS individuals. (2) Methods: In this comparative cross-sectional study, 100 individuals with FMS and 100 asymptomatic individuals were recruited. Cervical JPS was assessed using a cervical range of motion device, limits of stability (reaction time, maximum excursion, and direction control) were assessed using dynamic posturography, and FMS individuals’ kinesiophobia was assessed using the Tampa scale of kinesiophobia (TSK). Comparison, correlation, and mediation analyses were performed. (3) Results: The magnitude of the mean cervical joint position error (JPE) was significantly larger in FMS individuals (p < 0.001) compared to the asymptomatic individuals. The limits of the stability test showed that FMS individuals had a longer reaction time (F = 128.74) and reduced maximum excursion (F = 976.75) and direction control (F = 396.49) compared to the asymptomatic individuals. Cervical JPE showed statistically significant moderate-to-strong correlations with reaction time (r = 0.56 to 0.64, p < 0.001), maximum excursion (r = −0.71 to −0.74, p < 0.001), and direction control (r = −0.66 to −0.68, p < 0.001) parameters of the limits of the stability test. (4) Conclusions: Cervical JPS and limits of stability were impaired in FMS individuals, and the cervical JPS showed a strong relationship with limits of stability variables. Moreover, kinesiophobia mediated the relationship between JPS and limits of stability. These factors may be taken into consideration when evaluating and developing treatment strategies for FMS patients.
... Self-efficacy is considered a core component in self-management, yet there is a lack of knowledge about the association between self-efficacy and health-related outcomes in patients with TTH. Low self-efficacy is related to a variety of poor outcomes in both nonsurgical management and postoperative rehabilitation of musculoskeletal conditions [42][43][44]. Several studies have shown that evidence-based interventions can improve self-efficacy and selfmanagement [45][46][47]. In this line, physical activity is a potential self-management treatment and has a positive impact on physical function and disease-related symptoms such as pain [48]. ...
Background:
Chronic tension-type headache is the primary headache with the highest prevalence. The present study is aimed at analyzing the associations between patient self-efficacy and headache impact with pain characteristics, kinesiophobia, anxiety sensitivity, and physical activity levels in subjects with chronic tension-type headache.
Materials and methods:
An observational descriptive study was carried out. A total sample of 42 participants was recruited at university environment with diagnosis of tension-type headache. Headache characteristics (frequency, intensity, and duration), physical activity levels, pain related-self-efficacy, kinesiophobia, anxiety sensitivity, and headache impact were measured.
Results:
The HIT-6 (61.05 ± 6.38) score showed significant moderate positive correlations with the ASI-3 score (17.64 ± 16.22; r = 0.47) and moderate negative correlations with the self-efficacy in the domains of pain management (31.9 ± 10.28; r = -0.43) and coping with symptoms (53.81 ± 14.19; r = -0.47). ASI-3 score had a negative large correlation with self-efficacy in the domains of pain management (r = -0.59), physical function (53.36 ± 7.99; r = -0.55), and coping with symptoms (r = -0.68). Physical activity levels showed positive moderate correlations with the self-efficacy in the domain of physical function (r = 0.41). Linear regression models determined that the self-efficacy and anxiety sensitivity with showed a significant relationship with the HIT-6 score (R 2 = 0.262; p = 0.008) and with the ASI-3 score (R 2 = 0.565; p < 0.001). In addition, no correlations were found between pain intensity, duration or frecuency with psychosocial factors, or headache impact.
Conclusions:
The present study showed that patients with chronic tension-type headache had a great negative impact on daily tasks and physical activity levels, which were associated with higher anxiety levels and lower self-efficacy.
... Prolonged depression affects self-efficacy for coping with and tolerance to pain and physical disability (Nicholas, Coulston, Asghari, and Malhi, 2009). Depression has a distinct moderating role in the relationship between pain self-efficacy and reported disability (Jackson, Wang, Wang, and Fan, 2014;Nicholas, Coulston, Asghari, and Malhi, 2009;Skidmore et al, 2015). Likewise, a decline in self-efficacy that leads to hopelessness, negative affect, reduced energy, physical deconditioning, and reduced social engagement may also result in irreparable depression, pain, and disability. ...
Introduction
The world’s population is experiencing an increasing prevalence of depressive disorders. A comprehensive literature review identifies a schism between current medical interventions and the increasing prevalence. Current treatment paradigms warrant analysis.
Objective
This manuscript theorizes an interdisciplinary team inclusive of physiotherapy as a standard would reverse the increasing prevalence. Physiotherapists’ musculoskeletal expertise and biopsychosocial approach play a valuable role in mental health.
Methods
A clinical narrative review of depression, including parallels with chronic pain, is provided as a substantive foundation. The review includes challenges in primary care as the gateway to mental health. Depression’s underlying mechanisms, standard interventions, current theories, and future paradigms are explored.
Results
A theoretical construct was formulated. This construct identified compromised emotion-regulation and self-efficacy as common dysfunctions that enables and perpetuates depression. Physical activity with cognitive reappraisals positively influences these common dysfunctions and improves general intervention outcomes. The psychologically informed physiotherapist is defined. Physiotherapists can provide functional interventions and cognitive reappraisals that address biopsychosocial needs and build resilience.
Conclusion
Individualized physical and functional activity that facilitate therapeutic alliance, functional improvements, cognitive reappraisals, emotion-regulation and self-efficacy delivered by a physiotherapist provide sustainable behavioral change and completes the interdisciplinary mental health team.
... 45 One study also found that the level of pain self-efficacy is negatively associated with anxiety and depression, which may also affect the QOL. 46 Finally, we detected positive correlations among social support, pain self-efficacy, MCS, and PCS. After controlling for clinicodemographic characteristics, we found that pain self-efficacy may partially mediate the relationship between social support and QOL. ...
Purpose
Patients undergoing maintenance hemodialysis (MHD) frequently experience chronic pain, which can severely affect their quality of life (QOL). The objective of this study was to evaluate the prevalence of chronic pain in MHD patients and examine the factors associated with QOL.
Patients and Methods
A cross-sectional questionnaire-based survey was conducted between October 2020 and April 2021, 1204 MHD patients from nine hemodialysis units were screened for chronic pain in Chengdu, China, and 296 MHD patients with chronic pain were enrolled in this study. We analyzed data on clinicodemographic characteristics, pain interference and severity (Brief Pain Inventory), QOL (Medical Outcomes Study 36-item Short Form Health Survey - mental component summary [MCS] and physical component summary [PCS]), pain self-efficacy (Pain Self-Efficacy Questionnaire), and social support (Social Support Rating Scale).
Results
The prevalence of chronic pain in MHD patients was 26.74% in this study. The most common areas of pain were lower back (63.5%), lower limbs (55.0%), and head (33.5%), 36.5% did not implement any measures to relieve it. Of the patients who did receive pain treatment or medication, 56.9% reported that the measures they took had less than half of the pain relief. MHD patients with chronic pain had poor QOL based on scores on the MCS (53 ± 16.76) and PCS (40.56 ± 13.81). Stepwise multiple regression identified age, financial strain, pain interference, social support, and pain self-efficacy as independent predictors of QOL. Pain self-efficacy was significantly associated with social support (r = 0.5, p < 0.01), MCS (r = 0.69, p < 0.01), and PCS (r = 0.8, p < 0.01). The mediating effects of pain self-efficacy were 70.31% on the relationship between social support and MCS, and 75.62% on the relationship between social support and PCS.
Conclusion
Chronic pain is prevalent and undermanaged in Chinese MHD patients, resulting in worse QOL. Healthcare providers should focus on pain management and the impact of psychosocial factors on patient QOL. Further research should deepen our understanding of how pain self-efficacy mediates the relationship between social support and QOL.
... A lack of confidence in being able to manage pain is a significant predictor of chronic pain and associated depression in general [55], and a focal mediator in the present diverse, income-disadvantaged population. The association between changes in depression and affective pain fully accounted for the change in self efficacy in a study of low back pain [56]. Self-efficacy has been postulated to infer resilience to the adverse outcomes of the depression-pain pathway [57]. ...
Background:
Chronic pain is one of the most common reasons adults seek medical care in the US, with prevalence estimates ranging from 11% to 40%. Mindfulness meditation has been associated with significant improvements in pain, depression, physical and mental health, sleep, and overall quality of life. Group medical visits are increasingly common and are effective at treating myriad illnesses, including chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence based integrative medicine, and medical group visits and can be used as adjuncts to medications, particularly in diverse underserved populations with limited access to non-pharmacological therapies.
Objective and design:
The objective of the present study was to use a blended analytical approach of machine learning and regression analyses to evaluate the potential relationship between depression and chronic pain in data from a randomized clinical trial of IMGV in diverse, income disadvantaged patients suffering from chronic pain and depression.
Methods:
The analytical approach used machine learning to assess the predictive relationship between depression and pain and identify and select key mediators, which were then assessed with regression analyses. It was hypothesized that depression would predict the pain outcomes of average pain, pain severity, and pain interference.
Results:
Our analyses identified and characterized a predictive relationship between depression and chronic pain interference. This prediction was mediated by high perceived stress, low pain self-efficacy, and poor sleep quality, potential targets for attenuating the adverse effects of depression on functional outcomes.
Conclusions:
In the context of the associated clinical trial and similar interventions, these insights may inform future treatment optimization, targeting, and application efforts in racialized, income disadvantaged populations, demographics often neglected in studies of chronic pain.
Trial registration:
NCT from clinicaltrials.gov: 02262377.
... The association between changes in depression and affective pain fully accounted for the change in self efficacy in a study of low back pain [42]. Self-efficacy has been postulated to infer resilience to the adverse outcomes of the depressionpain pathway [43]. ...
Background Chronic pain is one of the most common reasons adults seek medical care in the US, with estimates of prevalence ranging from 11% to 40%. Mindfulness meditation has been associated with significant improvements in pain, depression, physical and mental health, sleep, and overall quality of life. Group medical visits are increasingly common and are effective at treating myriad illnesses including chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence based integrative medicine, and medical group visits and can be used as adjuncts to medications, particularly in diverse underserved populations with limited access to non-pharmacological therapies. Objective and Design The objective of the present study was to use a blended analytical approach of machine learning and regression analyses to evaluate the potential relationship between depression and chronic pain in data from a randomized clinical trial of IMGV in socially diverse, low income patients suffering from chronic pain and depression. Methods This approach used machine learning to assess the predictive relationship between depression and pain and identify and select key mediators, which were then assessed with regression analyses. It was hypothesized that depression would predict the pain outcomes of average pain, pain severity, and pain interference. Results Our analyses identified and characterized a predictive relationship between depression and chronic pain interference. This prediction was mediated by high perceived stress, low pain self-efficacy, and poor sleep quality, potential targets for attenuating the adverse effects of depression on functional outcomes. Conclusions In the context of the associated clinical trial and similar interventions, these insights may inform future treatment optimization, targeting, and application efforts in racially diverse, low income populations, demographics often neglected in studies of chronic pain.
... Pacientes com LC e com recursos de enfrentamento menos eficientes apresentaram maior sofrimento psicológico, maior dor e aumento da incapacidade (DiNapoli et al., 2016). Skidmore et al., (2015) verificaram que a relação entre mudança nos sintomas depressivos e na dor foi totalmente explicada pelo efeito indireto de mudanças nas crenças de autoeficácia. Crenças de solicitude e incapacidade encontradas no estudo de Barbosa et al. (2018) já tinham sido relatadas no estudo de Loduca (2014). ...
This study is an integrative review that aimed to gather the main psychological factors associated with depressive symptoms in people with chronic low back pain (CLBP) in articles published between 2009-2018. Scopus, SciELO, ScienceDirect, PubMed and PePSIC bases were used. At the end, 23 studies were selected for bibliometric analysis, methodological topics and content. In all samples of CLBP patients investigated in the selected studies, clinically significant depressive symptoms were found, being more vulnerable to the co-occurrence of these diseases people aged 40 years and over. The main results of this review also identified worsening physical and occupational performance, anxiety, insomnia, low resilience, less efficient coping strategies, beliefs of low self-efficacy, disability and solicitude as factors associated with depressive symptoms in CLBP. It was concluded that people with CLBP show a high burden of psychological distress, a fact that requires redirection of more classical therapeutic strategies aimed at addressing depressive symptoms.
... The association between changes in depression and affective pain fully accounted for the change in self efficacy in a study of low back pain [42]. Self-efficacy has been postulated to infer resilience to the adverse outcomes of the depressionpain pathway [43]. ...
Background
Chronic pain is one of the most common reasons adults seek medical care in the US, with estimates of prevalence ranging from 11% to 40%. Mindfulness meditation has been associated with significant improvements in pain, depression, physical and mental health, sleep, and overall quality of life. Group medical visits are increasingly common and are effective at treating myriad illnesses including chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence based integrative medicine, and medical group visits and can be used as adjuncts to medications, particularly in diverse underserved populations with limited access to non-pharmacological therapies.
Objective and Design
The objective of the present study was to use a blended analytical approach of machine learning and regression analyses to evaluate the potential relationship between depression and chronic pain in data from a randomized clinical trial of IMGV in socially diverse, low income patients suffering from chronic pain and depression.
Methods
This approach used machine learning to assess the predictive relationship between depression and pain and identify and select key mediators, which were then assessed with regression analyses. It was hypothesized that depression would predict the pain outcomes of average pain, pain severity, and pain interference.
Results
Our analyses identified and characterized a predictive relationship between depression and chronic pain interference. This prediction was mediated by high perceived stress, low pain self-efficacy, and poor sleep quality, potential targets for attenuating the adverse effects of depression on functional outcomes.
Conclusions
In the context of the associated clinical trial and similar interventions, these insights may inform future treatment optimization, targeting, and application efforts in racially diverse, low income populations, demographics often neglected in studies of chronic pain.
... The authors hypothesize that poor psychosocial health may be the intermediary between mental health disorders and pain and functional outcomes. To support this hypothesis, a 2015 study by Skidmore et al 46 identified that in patients with chronic low back pain, a change in depressive symptoms predicted changes in pain, and this relationship was mediated by pain selfefficacy. Those patients that were able to increase their confidence to perform activities, despite their current pain, displayed fewer depressive symptoms and reported less pain following a 4-week rehabilitation program. ...
Context:
Femoroacetabular impingement syndrome (FAIS) is a painfully debilitating hip condition disproportionately affecting active individuals. Mental health disorders are an important determinant of treatment outcomes for individuals with FAIS. Self-efficacy, kinesiophobia, and pain catastrophizing are psychosocial factors that have been linked to inferior outcomes for a variety of orthopedic conditions. However, these psychosocial factors and their relationships with mental health disorders, pain, and function have not been examined in individuals with FAIS.
Objective:
(1) To examine relationships between self-efficacy, kinesiophobia, pain catastrophizing, pain, and function in patients with FAIS and (2) to determine if these variables differ between patients with and without a self-reported depression and/or anxiety.
Design:
Cross-sectional.
Setting:
University health center.
Participants:
Fifty-one individuals with FAIS (42 females/9 males; age 35.7 [11.6] y; body mass index 27.1 [4.9] kg/m2).
Main outcome measures:
Participants completed the Pain Self-Efficacy Questionnaire, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, visual analog scale for hip pain at rest and during activity, and the 12-item International Hip Outcome Tool. Self-reported depression and/or anxiety were recorded. The relationships between psychosocial factors, pain, and function were examined using Spearman rank-order correlations. Independent t tests and Mann-Whitney U tests were used to evaluate the effect of self-reported depression and/or anxiety on psychosocial factors, pain and function.
Results:
The 12-item International Hip Outcome Tool was correlated with pain during activity (ρ = -.57, P ≤ .001), Tampa Scale for Kinesiophobia (ρ = -.52, P ≤ .001), and Pain Self-Efficacy Questionnaire (ρ = .71, P ≤ .001). The Pain Self-Efficacy Questionnaire was also correlated with pain at rest (ρ = -.43, P = .002) and pain during activity (ρ = -.46, P = .001). Individuals with self-reported depression and/or anxiety (18/51; 35.3%) had worse self-efficacy and pain catastrophizing (P ≤ .01).
Conclusion:
Self-reported depression and/or anxiety, low self-efficacy, and high kinesiophobia were associated with more hip pain and worse function for patients with FAIS. These findings warrant further examination including psychosocial treatment strategies to improve the likelihood of a successful clinical outcome for this at-risk population.
... Specifically, the pre-intervention score was subjected to linear regression as the independent variable and the post-intervention score as the dependent variable, and the unexplained variance was calculated. Residualized change scores are frequently used in mediation analyses in intervention studies (e.g., Mansell et al., 2016;Skidmore et al., 2015). ...
Can improving employees’ interpersonal listening abilities impact their emotions and cognitions during difficult conversations at work? The studies presented here examined the effectiveness of listening training on customer service employees. It was hypothesized that improving employees’ listening skills would (a) reduce their anxiety levels during difficult conversations with customers, (b) increase their ability to understand the customers’ point of view (i.e., perspective-taking), and (c) increase their sense of competence. The two quasi-experiments provide support for the hypotheses. Study 1 (N = 61) consisted of a pre-post design with a control group and examined the effect of listening training on customer service employees in a Fortune 500 company. Study 2 (N = 33) conceptually replicated the results of Study 1 using listening training conducted in one branch of a company that provides nursing services compared to another branch of the company that did not receive training. The results indicated that listening training had lasting effects on employees' listening abilities, anxiety reduction, and perspective-taking during difficult conversations. The discussion centers on the importance of interpersonal listening abilities to the empowerment wellbeing of employees in the workplace.
... A lack of mediation analysis studies in the area of CR meant that we have to compare our findings with that of other painful disorders. In a heterogeneous group of pain disorders, self-efficacy has been shown to either mediate the relationship from pain intensity to depressive symptoms (Arnstein, Caudill, Mandle, Norris, & Beasley, 1999;Cheng et al., 2018;Craig et al., 2013), or from depressive symptoms to pain intensity (Skidmore et al., 2015). This was in contrast to the present finding that changes in self-efficacy levels were not related to changes in depressive symptoms, but the former was critical in its influence on both neck pain intensity and disability. ...
Background:
Rehabilitation approaches should be based on an understanding of the mechanisms underpinning functional recovery. Yet, the mediators that drive an improvement in post-surgical pain-related disability in individuals with cervical radiculopathy (CR) is unknown. The aim of the present study is to use Bayesian Networks (BN) to learn the probabilistic relationships between physical and psychological factors, and pain-related disability in CR.
Methods:
We analysed a prospective cohort dataset of 201 post-surgical individuals with CR. Fifteen variables were used to build a BN model: age, sex, neck muscle endurance, neck range of motion, neck proprioception, hand grip strength, self-efficacy, catastrophizing, depression, somatic perception, arm pain intensity, neck pain intensity, and disability.
Results:
A one point increase in a change of self-efficacy at six months was associated with a 0.09 point decrease in a change in disability at 12 months (t = -64.09, P < 0.001). Two pathways led to a change in disability: a direct path leading from a change in self-efficacy at six months to disability, and an indirect path which was mediated by neck and arm pain intensity changes at six and 12 months.
Conclusions:
This is the first study to apply BN modelling to understand the mechanisms of recovery in post-surgical individuals with CR. Improvements in pain-related disability was directly and indirectly driven by changes in self-efficacy levels. The present study provides potentially modifiable mediators that could be the target of future intervention trials. BN models could increase the precision of treatment and outcome assessment of individuals with CR.
... Because the change between the two measurements was the focal interest in this third experiment, we calculated residualized change scores for self-set goal and employee performance. Residualized change controls for baseline score is frequently used in mediation analysis (e.g., George et al., 2008;Mansell et al., 2016;Skidmore et al., 2015). As can be seen in Figure 8, the interaction term, CSE × Condition on self-set goal, was significant [b = 0.42,SE = 0.15,t = 2.88,p = .005,95% ...
An understudied issue in the goal priming literature is why the same prime can provoke different responses in different people. The current research sheds light on this issue by investigating whether an individual difference variable, core self-evaluations (CSE), accounts for different responses from the same prime. Based on the findings of experiments showing that individuals with high CSE have higher performance after consciously setting a task-related goal than individuals with lower CSE, two hypotheses were tested: (1) Individuals who score high on CSE perform better following a subconsciously primed goal for achievement than do individuals who score low on CSE, and (2) this effect is mediated by a self-set goal. Two laboratory experiments (n = 207, 191) and one field experiment (n = 62) provided support for the hypotheses. These findings suggest that personality variables such as the CSE can provide an explanation for the "many effects of the one prime problem".
... This suggests that, consistent with the motivational model, positive personal experience with pain self-management techniques such as exercise may improve self-efficacy and exercise participation while reducing fear of movement, which may lead to improvements in physical functioning, depression, and pain. The sentiment that self-efficacy is an important part of treatment is echoed by Skidmore and colleagues [33]. These investigators reported that increases in pain self-efficacy mediated the relationship between reduction in depressive symptom severity and reduction in pain intensity among patients participating in a 4-week multidisciplinary pain rehabilitation program. ...
Purpose of Review
The purpose of this review is to evaluate and summarize recent empirical research investigating motivational factors for management of chronic pain and headache disorders.
Recent Findings
Research on motivation for non-pharmacological treatment of chronic pain and headache disorders has identified factors that influence initiation of and adherence to treatment. To address common factors that inhibit initiation of treatment (i.e., cost, time commitment), several electronic treatments have been developed. Self-efficacy is the most commonly studied psychosocial influence on treatment adherence, with evidence that it is positively correlated with adherence. Other studies have sought to improve adherence to treatment using motivational interviewing interventions.
Summary
There is currently limited research on how to enhance motivation for initial adherence to non-pharmacological treatment for chronic pain and headache disorders. Instead of enhancing motivation, researchers have looked to reduce barriers to treatment with electronic health treatments; however, many of these studies have focused on intervention feasibility, rather than efficacy or effectiveness. Numerous studies have identified a relationship between self-efficacy and treatment adherence. Although motivational interviewing interventions have been shown to improve adherence to treatment, there is little evidence that they improve treatment outcomes. Recommendations for further investigation include improving interventions to enhance accessibility and adherence to treatment with the goal of improving outcomes, as well as identifying ways to improve treatment initiation and adherence in patients who are currently engaged in long-term opioid therapy.
... Future work should examine how trait levels and variability in low-arousal affect influence pain coping. Another major limitation is that previous experience with pain was not assessed, and as such, well-established relationships between pain self-efficacy and outcomes could not be examined (Skidmore et al., 2015). Finally, the sample was not ethnically diverse. ...
Over 70% of older adults report chronic or acute pain, and pain threatens affective wellbeing. The strategies older adults use to maintain affective wellbeing following acute pain remain unknown. Specific strategies that can be used to manage pain include recalling, recognizing, and responding to positive stimuli and prioritizing close over knowledgeable social partners. The study tested whether older adults used positivity-enhancing strategies and maintained affective wellbeing following acute pain better than younger adults. Fifty older (ages 65–85) and 50 younger (ages 18–30) pain-free adults experienced a control and a pain condition and were given the chance to employ positivity-enhancing strategies. Older and younger adults similarly used positivity-enhancing strategies following pain. Younger adults demonstrated reduced preference for knowledgeable social partners after experiencing pain. Pain-related affective changes were similar between age groups. Older and younger adults may cope with acute pain similarly, highlighting future directions for exploring age differences in pain coping.
... 25 This differs from raw change as it allows the confounding effect of baseline score to be controlled for. Residualized change scores have been used previously in mediation studies, 26,27 and are obtained from the residual values of linear regression analysis where the follow-up score is entered as the outcome and baseline score as the predictor. Posttreatment scores for the outcome measure were used. ...
Background:
Many interventions for the treatment of low back pain exist, but the mechanisms through which such treatments work are not always clear. This situation is especially true for biopsychosocial interventions that incorporate several different components and methods of delivery.
Objective:
The study objective was to examine the indirect effects of the Cognitive Patient Education (COPE) intervention via illness perceptions, back pain myths, and pain catastrophizing on disability outcome.
Design:
This study was a secondary analysis of the COPE randomized controlled trial.
Methods:
Mediation analysis techniques were employed to examine the indirect effects of the COPE intervention via residualized change (baseline - posttreatment) in the 3 variables hypothesized to be targeted by the COPE intervention on posttreatment disability outcome. Pain intensity at baseline, pain duration, clinician type, and a treatment-mediator interaction term were controlled for in the analysis.
Results:
Preliminary analyses confirmed that changes in pain catastrophizing and illness perceptions (not back pain myths) were related to both allocation to the intervention arm and posttreatment disability score. The treatment exerted statistically significant indirect effects via changes in illness perceptions and pain catastrophizing on posttreatment disability score (illness perceptions standardized indirect effect = 0.09 [95% CI = 0.03 to 0.16]; pain catastrophizing standardized indirect effect = 0.05 [95% CI = 0.01 to 0.12]). However, the inclusion of an interaction term led to the indirect effects being significantly reduced, with the effects no longer being statistically significant.
Limitations:
This study presents a secondary analysis of variables not identified a priori as being potentially important treatment targets; other, unmeasured factors could also be important in explaining treatment effects.
Conclusions:
The finding that small indirect effects of the COPE intervention via changes in illness perceptions and pain catastrophizing on posttreatment disability could be estimated indicates that these variables may be viable treatment targets for biopsychosocial interventions; however, this finding must be viewed in light of the adjusted analyses, which showed that the indirect effects were significantly reduced through the inclusion of a treatment-mediator interaction term.
... 35 36 Furthermore, self-efficacy is considered to be a stronger mediator of the relationship between pain behaviour, pain intensity and disability than psychological factors such as kinesiophobia and pain catastrophising. [37][38][39] However, the role of self-efficacy as an outcome measure and as mediator in CSP has not been studied yet. Knowing and understanding which psychological factors are specifically involved in the prognosis of CSP is challenging to facilitate clinical decision-making and, if necessary, timely, and specific consultation with-or referral to-other healthcare providers. ...
Introduction
Shoulder pain is a highly prevalent condition. Psychological factors could play an essential role in the prognosis of chronic shoulder pain (CSP). The aims of the study will be to analyse the level of association between psychological factors and pain-disability at baseline and prospectively to assess their prognostic role; to evaluate the association of pain catastrophising and kinesiophobia at baseline and prospectively in the relationship between pain intensity and disability, or between self-efficacy and disability in patients with CSP; to explore the association of self-efficacy at baseline and prospectively in the relationship between pain intensity and disability, in comparison with kinesiophobia and pain catastrophising.
Methods and analysis
The study is a longitudinal, prospective cohort study with a 12-month follow-up. It will be conducted in 4 primary-care centres and one hospital of the province of Malaga, Spain. 307 participants aged between 18 and 70 years suffering from CSP (3 months or more) will be included. Primary outcomes will include pain, disability and self-efficacy, whereas kinesiophobia, pain-related fear, pain catastrophising, anxiety, depression, patient expectations of recovery, age, gender, duration/intensity of symptoms, educational level and other factors will be predictive measures. Follow-up: baseline, 3, 6 and 12 months.
Ethics and dissemination
The local ethics committee (The Costa del Sol Ethics Committee, Malaga, 28042016) has approved this protocol. Dissemination will occur through presentations at National and International conferences and publications in international peer-reviewed journals.
Trial registration number
NCT02738372; pre-results
... The review findings support existing theories regarding the factors associated with adaptive psychological functioning despite the enduring nature of pain. In line with existing mediation research whereby the presence of positive psychological constructs facilitate greater coping and adjustment (Skidmore et al. 2015;Wright et al. 2011), pre and post-intervention changes in self-efficacy ) and hope (Howell et al. 2015) were associated with significant improvements in psychological well-being. Although increased levels of optimism have also been found to be related to greater adjustment in individuals with chronic pain (Wright et al. 2011), only one study (Flink et al. 2015) included this variable, with no significant changes in optimism observed following intervention. ...
Chronic pain is a multi-faceted, pervasive condition associated with significant psychosocial impairment. Positive psychological interventions (PPIs) are increasingly delivered in clinical settings, with recent research offering evidence supporting the application of PPIs in predominantly mental-health contexts. To date, no review has considered the impact of PPIs applied in physical-health settings. The aim of this systematic review is to collate the available evidence and identify psychosocial factors that can be improved via PPIs for individuals with chronic non-cancer pain. Particularly, the review focuses upon study outcomes considered to be conceptually-aligned with the aims of such interventions. A systematic search of five electronic databases was conducted utilising terms relating to chronic pain, positive psychological constructs and intervention outcomes. A total of 3289 articles were considered as part of the identification process. Eight studies were included in the final review upon de-duplication and application of the review exclusion criteria. The effects of PPIs and methodological quality of studies varied greatly, though improvements in psychological well-being, hope, pain self-efficacy, happiness and life-satisfaction were evident. The results demonstrate PPIs can have beneficial effects for individuals living with chronic non-cancer pain. Methodological limitations, clinical implications and recommendations regarding future research are discussed.
Chronic pain is a substantial health problem with a high prevalence of comorbid depression. To understand the link between chronic pain and depression, cognitive factors including pain catastrophising and pain self-efficacy have been theorised as significant contributing variables. There is relatively strong evidence that pain catastrophising mediates the relationship between pain severity and depression symptoms. There is also emerging evidence that the mediation role of pain catastrophising may vary as a function of pain self-efficacy. However, it is unknown whether this model will apply in a tertiary pain clinic sample. Thus, this study aimed to examine the respective moderating and mediating roles of pain self-efficacy and pain catastrophising on the association between pain severity and depressive symptoms in a large clinical sample of Australian adults living with chronic pain. Participants (n = 1195) completed all questionnaire measures prior to their first appointments at one tertiary pain service. As expected, the PROCESS path analysis showed that pain catastrophising mediated the relationship between pain severity and depressive symptoms. Further, there was support for the moderating effect of pain self-efficacy; as pain self-efficacy decreased, the relationship strengthened between both pain severity and pain catastrophising, as well as pain catastrophising and depressive symptoms. These findings may have important clinical implications including how relationships between these factors may be considered in the provision of care for those with chronic pain. Notably, these measures could be used in triaging processes to inform treatment decisions.
Background: Chronic post-surgical pain is a condition persisting for not less than 3 months after surgical intervention. It is evaluated that 25–60% of women who underwent breast cancer excision suffer from post-mastectomy pain syndrome, and anxiety, depression, sleep disturbance, and catastrophizing. Physical activity can reduce the risk of chronic diseases and has a good impact on mood and cognitive function. The aim of this study was to estimate the influence of physical activity on the intensity of pain, depression, and anxiety in women who underwent mastectomy for breast cancer removal. Methods: A prospective observational unicentric cohort study was performed. Patients were females who underwent unilateral or bilateral mastectomy. The Numerical Rating Scale (NRS) was used to measure pain intensity, Beck’s Depression Inventory (BDI) for depression, and Generalized Anxiety Disorders-7 (GAD-7) for anxiety evaluation. Physical activity was assessed by the International Physical Activity Questionnaire (IPAQ). Interleukin (IL)-17, IL-1β, cortisol, adrenocorticotropic hormone (ACTH), and brain-derived neurotrophic factor (BDNF) were also evaluated in the blood of patients. All evaluations were assessed 3 and 6 months after the surgery. Results: Adequate physical activity reduced the intensity of pain, depression, and anxiety symptoms in women affected by post-mastectomy pain syndrome. Moreover, adequately active women showed a reduction in biomarkers of inflammation, cortisol, ACTH, and an increase of BDNF. Conclusions: Our results suggest that physical activity can improve the quality of life, reduce the intensity of pain and inflammatory markers, and be useful in the reduction of associated anxiety and depression.
Chronic pain is a costly and debilitating problem in the US, and its burdens are exacerbated among socially disadvantaged and stigmatized groups. In a cross-sectional study of Black Veterans with chronic pain at the Atlanta VA Health Care System (N=380), we used path analysis to explore the roles of racialized discrimination in healthcare settings, pain self-efficacy, and pain-related fear avoidance beliefs as potential mediators of pain outcomes among Black Veterans with and without an EHR-documented mental health diagnosis. In unadjusted bivariate analyses, Black Veterans with a mental health diagnosis (n=175) reported marginally higher levels of pain-related disability and significantly higher levels of pain interference compared to those without a mental health diagnosis (n=205). Path analyses revealed that pain-related disability, pain intensity, and pain interference were mediated by higher levels of racialized discrimination in healthcare and lower pain self-efficacy among Black Veterans with a mental health diagnosis. Pain-related fear avoidance beliefs did not mediate pain outcomes. These findings highlight the need to improve the quality and effectiveness of healthcare for Black patients with chronic pain through the implementation of anti-racism interventions within healthcare systems. Results further suggest that Black patients with chronic pain who have a mental health diagnosis may benefit from targeted pain management strategies that focus on building self-efficacy for managing pain. PERSPECTIVE: Racialized healthcare discrimination and pain self-efficacy mediated differences in pain-related disability, pain intensity, and pain interference among Black Veterans with and without a mental health diagnosis. Findings highlight the need for anti-discrimination interventions within healthcare systems in order to improve the quality of care for Black patients with chronic pain.
Knee Osteoarthritis (OA) is a prevalent musculoskeletal condition, commonly resulting in pain and disability. However, pain and disability in this population are poorly related with the degree of structural joint damage. Underlying pain mechanisms, including activity-related pain and sensitization assessed via Quantitative Sensory Testing (QST), may better predict pain and functional outcomes of those with knee OA. Therefore, the aim of this study was to explore whether activity-related pain and sensitization assessed via QST predict future pain, function, fatigue, physical performance and quality of life outcomes in those living in the community with knee OA. Eighty-six participants with knee OA were recruited in Dunedin, New Zealand. Those eligible to participate underwent baseline testing including QST as well as measures of activity-related pain including Movement-evoked Pain (MEP) and Sensitivity to Physical Activity (SPA). Outcome measures exploring pain, function, fatigue and quality of life outcomes were collected at baseline, and two follow-up periods (two and nine weeks). Univariable linear regression models were developed followed by multivariable linear regression models for each prognostic marker adjusting for age, gender, BMI, OA duration, baseline pain intensity and socioeconomic status. Activity-related measures of pain, including MEP and SPA, demonstrated predictive associations with pain and functional outcomes prospectively in those with knee OA. Therefore, those demonstrating activity-related pain are at future risk of greater pain, disability and reduced quality of life. Larger, externally validated longitudinal studies are required which include individuals with more severe knee OA.
Background
High baseline pain self-efficacy (PSE) predicts a better outcome for people attending physiotherapy for musculoskeletal shoulder pain. A potential contributing factor is that PSE moderates the relationship between some treatment modalities and outcome. Our aim was to investigate whether there is a difference in outcome between participants with high compared to low PSE receiving manual therapy, acupuncture, and electrotherapy.
Methods
Participants were stratified into high or low baseline (i) PSE, (ii) shoulder pain and disability index (SPADI), and (iii) did or did not receive the treatment. Whether the effect of treatment differs for people with high compared to low PSE was assessed using the 95% confidence interval of the difference of difference (DoD) at a 5% significance level ( p < 0.05).
Results
Six-month SPADI scores were consistently lower (less pain and disability) for those who did not receive passive treatments compared to those who did (statistically significant in 7 of 24 models). However, DoD was statistically insignificant.
Conclusion
PSE did not moderate the relationship between treatment and outcome. However, participants who received passive treatment experienced equal or more pain and disability at 6 months compared to those who did not. Results are subject to confounding by indication but do indicate the need for further appropriately designed research.
Level of Evidence
Level of evidence II-b.
Purpose:
This study evaluated the relationship between pain and depressive symptoms through pain self-efficacy and pain catastrophizing in breast cancer patients with pain.
Design:
Secondary analysis of a randomized trial investigating a cognitive-behavioral pain management protocol.
Sample:
Females (N = 327) with stage I-III breast cancer and report of at least moderate pain.
Methods:
Pain severity, pain self-efficacy, pain catastrophizing, and depressive symptoms were measured. The proposed model was assessed using structural equation modeling.
Results:
Higher pain severity was significantly related to lower pain self-efficacy and higher pain catastrophizing. Lower pain self-efficacy and higher pain catastrophizing were significantly related to more depressive symptoms. Higher pain severity was significantly associated with more depressive symptoms through lower pain self-efficacy and higher pain catastrophizing. The association between pain severity and depressive symptoms was not significant when specified as a direct effect.
Conclusion:
Pain severity related to depressive symptoms in breast cancer patients via pain self-efficacy and pain catastrophizing.
Implications for psychosocial providers:
Measurement of pain self-efficacy and pain catastrophizing should be incorporated into comprehensive pain assessments for women with breast cancer, as these variables may be relevant therapeutic targets. Psychosocial symptom management interventions should include strategies that increase pain self-efficacy and decrease pain catastrophizing because these pain-related cognitive variables appear to drive the relationship between pain severity and depressive symptoms.
Low back pain (LBP) can be less disabling in those who are physically active. This study analyzed the association between physical activity (PA)- and LBP-related disability in older people with LBP, exploring if this association was mediated by depressive symptoms. The authors analyzed the relationship between PA levels and disability using the short version of the International Physical Activity Questionnaire and the Roland–Morris Disability Questionnaire, respectively, collected at baseline from the Brazilian Back Complaints in the Elders study. The authors investigated depressive symptoms as a mediator of this association using the Center of Epidemiologic Studies Depression scale. PA was inversely associated with disability. This association was smaller when considering the indirect effect through depressive symptoms. Thus, depressive symptoms partially mediated the association between PA and disability in older adults with LBP, and higher levels of PA were associated with less depressive symptoms and disability.
Purpose: Psychosocial variables are known risk factors for the development and chronification of low back pain (LBP). Psychosocial stress is one of these risk factors. Therefore, this study aims to identify the most important types of stress predicting LBP. Self-efficacy was included as a potential protective factor related to both, stress and pain. Participants and Methods: This prospective observational study assessed n = 1071 subjects with low back pain over 2 years. Psychosocial stress was evaluated in a broad manner using instruments assessing perceived stress, stress experiences in work and social contexts, vital exhaustion and life-event stress. Further, self-efficacy and pain (characteristic pain intensity and disability) were assessed. Using least absolute shrinkage selection operator regression, important predictors of characteristic pain intensity and pain-related disability at 1-year and 2-years follow-up were analyzed. Results: The final sample for the statistic procedure consisted of 588 subjects (age: 39.2 (± 13.4) years; baseline pain intensity: 27.8 (± 18.4); disability: 14.3 (± 17.9)). In the 1-year follow-up, the stress types “tendency to worry”, “social isolation”, “work discontent” as well as vital exhaustion and negative life events were identified as risk factors for both pain intensity and pain-related disability. Within the 2-years follow-up, Lasso models identified the stress types “tendency to worry”, “social isolation”, “social conflicts”, and “perceived long-term stress” as potential risk factors for both pain intensity and disability. Furthermore, “self-efficacy” (“internality”, “self-concept”) and “social externality” play a role in reducing pain-related disability. Conclusion: Stress experiences in social and work-related contexts were identified as important risk factors for LBP 1 or 2 years in the future, even in subjects with low initial pain levels. Self-efficacy turned out to be a protective factor for pain development, especially in the long-term follow-up. Results suggest a differentiation of stress types in addressing psychosocial factors in research, prevention and therapy approaches.
Purpose
Psychosocial variables are known risk factors for the development and chronification of low back pain (LBP). Psychosocial stress is one of these risk factors. Therefore, this study aims to identify the most important types of stress predicting LBP. Self-efficacy was included as a potential protective factor related to both, stress and pain.
Participants and Methods
This prospective observational study assessed n = 1071 subjects with low back pain over 2 years. Psychosocial stress was evaluated in a broad manner using instruments assessing perceived stress, stress experiences in work and social contexts, vital exhaustion and life-event stress. Further, self-efficacy and pain (characteristic pain intensity and disability) were assessed. Using least absolute shrinkage selection operator regression, important predictors of characteristic pain intensity and pain-related disability at 1-year and 2-years follow-up were analyzed.
Results
The final sample for the statistic procedure consisted of 588 subjects (age: 39.2 (±13.4) years; baseline pain intensity: 27.8 (±18.4); disability: 14.3 (±17.9)). In the 1-year follow-up, the stress types “tendency to worry”, “social isolation”, “work discontent” as well as vital exhaustion and negative life events were identified as risk factors for both pain intensity and pain-related disability. Within the 2-years follow-up, Lasso models identified the stress types “tendency to worry”, “social isolation”, “social conflicts”, and “perceived long-term stress” as potential risk factors for both pain intensity and disability. Furthermore, “self-efficacy” (“internality”, “self-concept”) and “social externality” play a role in reducing pain-related disability.
Conclusion
Stress experiences in social and work-related contexts were identified as important risk factors for LBP 1 or 2 years in the future, even in subjects with low initial pain levels. Self-efficacy turned out to be a protective factor for pain development, especially in the long-term follow-up. Results suggest a differentiation of stress types in addressing psychosocial factors in research, prevention and therapy approaches.
Background:
Before an intervention can be implemented to improve pain-related self-efficacy, assessment is required. The aim of the present study was to provide a systematic review on which self-efficacy scales are being used among patients with back pain and to evaluate their psychometric properties.
Methods:
A systematic search was executed in January 2019 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 checklist served as a guide for conducting the study. Electronic databases included CINAHL, MEDLINE, PubMed, PsycINFO, PSYNDEX, and Sport Discus. Publications in English or German language that focused on adult patient population suffering from back pain and provided validation or reliability measures on pain-related self-efficacy were included.
Results:
A total of 3,512 records were identified resulting in 671 documents after duplicates were removed. 233 studies were screened full-text and a total of 47 studies addressing 19 different measures of pain-related self-efficacy were included in the quality analysis. The most commonly used instruments were the Pain Self-Efficacy Questionnaire and the Chronic Pain Self-Efficacy Scale. All studies reported internal consistency but many studies lacked other aspects of reliability and validity.
Conclusion:
Further research should focus on assessing validity and interpretability of these questionnaires, especially in pain-related target groups. Researchers should select questionnaires that are most appropriate for their study aims and back pain population and contribute to further validation of these scales to best predict future behavior and develop intervention programs. This systematic review aids selection of pain-related assessment tools in back pain both in research and practice.
Individuals with chronic pain commonly report significant functional impairment and reduced quality of life. Despite this, little is known about psychological processes and mechanisms underpinning enhancements in well-being within this population. The study aimed to investigate whether (1) increased levels of pain intensity and interference were associated with lower levels of mental well-being, (2) increased positive goal engagement was associated with higher levels of mental well-being and (3) whether the relationships between pain characteristics and mental well-being were mediated by increased positive goal engagement. A total of 586 individuals with chronic pain participated in the cross-sectional, online study. Participants completed self-report measures to assess pain intensity and interference, mental well-being and goal motivation variables. Results showed that pain interference and positive goal engagement were associated with mental well-being. Moreover, the relationship between pain interference and mental well-being was partially mediated by positive goal engagement. The results provide tentative evidence for the protective role of positive goal engagement in enabling individuals with chronic pain to maintain a sense of mental well-being. The study develops the biopsychosocial model of chronic pain by examining the roles and relationships of relevant yet previously unexplored psychological constructs. The promotion of mental well-being through the enhancement of positive goal engagement is discussed, offering a platform for further research and clinical interventions.
Persistent Post-Mastectomy Pain (PPMP) is a common condition that can follow surgeries for breast cancer, the most common cancer for women. Because of the frequency of PPMP and its potential severity, it has received increasing research attention in recent years. This manuscript reviews the recent research literature. It begins with a brief history and data bearing on its prevalence. It then reviews medical, surgical, demographic, and psychosocial risk factors that have been identified, as well associal, psychological, and functional sequelae that have been linked to PPMP. Research on current pharmacological, psychological, and rehabilitative approaches to treatment is considered, as are the implications of the research for best practices. Itconcludes with a discussion of directions that future research and treatment might take to reduce the incidence and impact of PPMP on breast cancer survivors.
Perspective:
This article describes current research literature involving mechanisms, risks, and treatments related to post-mastectomy pain syndrome. Implications of research findings for pre- and post-surgical approaches to pain management, current treatments, and promising research directions also are discussed.
Evidence suggests that self-efficacy can play an essential role as a protective factor as well as a mediator in the relationship between pain and disability in people suffering from chronic musculoskeletal pain. This study systematically reviewed and critically appraised the role of self-efficacy on the prognosis of chronic musculoskeletal pain. Study selection was on the basis of longitudinal studies testing the prognostic value of self-efficacy in chronic musculoskeletal pain. The Newcastle-Ottawa Scale, the Cochrane Collaboration's tool, and the Methodological Index for Non-Randomized Studies checklist were used to evaluate the risk of bias of included studies. A total of 27 articles met the inclusion criteria. Our results suggest that higher self-efficacy levels are associated with greater physical functioning, physical activity participation, health status, work status, satisfaction with the performance, efficacy beliefs, and lower levels of pain intensity, disability, disease activity, depressive symptoms, presence of tender points, fatigue, and presenteeism. Despite the low quality of evidence of included studies, clinicians should be encouraged identify people with chronic musculoskeletal pain who present low self-efficacy levels before prescribing any therapy. It may help clinicians in their clinical decision-making and timely and specific consultations with—or referral to—other health care providers.
Perspective
This article presents promising results about the role of self-efficacy on the prognosis of chronic musculoskeletal pain. However, because of the low quality of evidence of included studies, these findings should be taken with caution, and further research is needed.
Opioid drugs, including prescription as well as heroin, have come to the national spotlight due to the unprecedented rate of overdose and addiction. The Centers for Disease Control and Prevention (CDC) has termed this problem as an "epidemic" that has reached record numbers of deaths in 2014. Approximately half of these deaths are the result from prescribed opioids. Also on the rise are the numbers of individuals who are diagnosed with chronic pain and are treated with opioids, methadone and buprenorphine. Individuals currently taking opioids for chronic pain confound the treatment of acute pain after traumatic injury. Goals of treatment include effective pain relief, prevention of opioid withdrawal, and managing the associated behavioral and psychological factors with drug addiction and dependence. The CDC has put forth guidelines on how to treat chronic pain but has yet to provide recommendations on how to treat acute pain in this unique population. The purpose of this literature review is to provide resources to treat pain, given a tolerant opioid-dependent patient. © 2017 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
Interventions developed to improve disability outcomes for low back pain (LBP) often show only small effects. Mediation analysis was used to investigate what led to the effectiveness of the Stratified Targeted Treatment (STarT) Back trial, a large primary care-based trial that treated patients consulting with LBP according to their risk of a poor outcome. The high-risk subgroup, randomized to receive either psychologically-informed physiotherapy (n = 93) or current best care (n = 45), was investigated to explore pain-related distress and pain intensity as potential mediators of the relationship between treatment allocation and change in disability. Structural equation modeling was used to generate latent variables of pain-related distress and pain intensity from measures used to identify patients at high risk (fear-avoidance beliefs, depression, anxiety, and catastrophizing thoughts). Outcome was measured using the Roland–Morris Disability Questionnaire. Change in pain-related distress and pain intensity were found to have a significant mediating effect of .25 (standardized estimate, bootstrapped 95% confidence interval, .09–.39) on the relationship between treatment group allocation and change in disability outcome. This study adds to the evidence base of treatment mediation studies in pain research and the role of distress in influencing disability outcome in those with complex LBP.
Perspective
Mediation analysis using structural equation modeling found that change in pain-related distress and pain intensity mediated treatment effect in the STarT Back trial. This type of analysis can be used to gain further insight into how interventions work, and lead to the design of more effective interventions in future.
Arnau RC, Meagher MW, Norris MP, Bramson R. Psychometric evaluation of the Beck Depression Inventory-II with primary care medical patients. Health Psychol. 2001 Mar;20(2):112-9.
This study evaluated the psychometric characteristics of the Beck Depression Inventory-II (BDI-II; A. T. Beck, R. A. Steer, & G. K. Brown, 1996) in a primary care medical setting. A principal-components analysis with Promax rotation indicated the presence of 2 correlated factors, Somatic-Affective and Cognitive, which explained 53.5% of the variance. A hierarchical, second-order analysis indicated that all items tap into a second-order construct of depression. Evidence for convergent validity was provided by predicted relationships with
subscales from the Short-Form General Health Survey (SF-20; A. L. Stewart, R. D. Hayes, & J. E. Ware, 1988). A receiver operating characteristic analysis demonstrated criterion-related validity: BDI-II scores predicted a diagnosis of major depressive disorder (MDD), as determined by the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ). This study
demonstrated that the BDI-II yields reliable, internally consistent, and valid scores in a primary care medical setting, suggesting that use of the BDI-II in this setting may improve detection and treatment of depression in these medical patients.
PMID: 11315728
The criterion validity of the Beck Depression Inventory-II (BDI-II; A. T. Beck, R. A. Steer, & G. K. Brown, 1996) was investigated by pairing blind BDI-II administrations with the
major depressive episode portion of the Structured Clinical Interview for
DSM-IV Axis I Disorders (SCID-I; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1997) in a sample of 137 students receiving treatment at a university counseling center. Student BDI-II scores correlated strongly (
r=.83) with their number of SCID-I depressed mood symptoms. A BDI-II cut score of 16 yielded a sensitivity rate of 84% and a false-positive rate of 18% in identifying depressed mood. Receiver operating characteristic analyses were used to produce cut scores for determining severity of depressed mood. In a second study, a sample of 46 student clients were administered the BDI-II twice, yielding test-retest reliability of .96. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study evaluated the psychometric characteristics of the Beck Depression Inventory-II (BDI-II; A. T. Beck, R. A. Steer, & G. K. Brown, 1996) in a primary care medical setting. A principal-components analysis with Promax rotation indicated the presence of 2 correlated factors, Somatic-Affective and Cognitive, which explained 53.5% of the variance. A hierarchical, second-order analysis indicated that all items tap into a second-order construct of depression. Evidence for convergent validity was provided by predicted relationships with subscales from the Short-Form General Health Survey (SF-20; A. L. Stewart, R. D. Hayes, & J. E. Ware, 1988). A receiver operating characteristic analysis demonstrated criterion-related validity: BDI-II scores predicted a diagnosis of major depressive disorder (MDD), as determined by the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ). This study demonstrated that the BDI-II yields reliable, internally consistent, and valid scores in a primary care medical setting, suggesting that use of the BDI-II in this setting may improve detection and treatment of depression in these medical patients.
Here is the reference for this chapter.
MacKinnon, D. P., Cheong, J., Pirlott, A. G. (2012) In Cooper, H., Camic, P. M., Long, D. L., Panter, A. T., Rindskopf, D., Sher, K. J. (Eds.) (2012). APA handbook of research methods in psychology, Vol 2: Research designs: Quantitative, qualitative, neuropsychological, and biological., (pp. 313-331). Washington, DC, US: American Psychological Association.
Introduction: To evaluate the psychometric characteristics of the Beck Depression Inventory - Second Edition (BDI-II) with an ethnically diverse sample of college students. Methods: The BDI-II was completed by a group of 502 college students (54% women) with an ethnic distribution of African-American (n=49, 10%), Asian-American (n =33, 7%), Hispanic (n = 113, 22%), Native-American (n = 10, 2%), and White (n=297, 59%). Psychometric characteristics of the inventory with the ethnically diverse group were compared to the results published in the test manual for nonclinical samples composed predominantly of European and White participants. Results: Using confirmatory factor analyses, a three-factor model that identified negative attitude, performance difficulty, and somatic dimensions, provides a better fit of the data than does the two-factor model. Similar psychometric characteristics were found between the ethnically diverse student sample and the standardization sample. Based on multivariate analysis of variance, White students had higher scores on the item of agitation compared to Asian-American students and on the items of worthlessness and irritability compared to Hispanic students. Conclusion: The results of the psychometric analyses suggest that the BDI-II is suitable as a screening instrument for depression in college populations of diverse ethnicity. (PsycINFO Database Record (c) 2005 APA, all rights reserved) (journal abstract)
P. A. Frazier, A. P. Tix, and K. E. Barron (2004) highlighted a normal theory method popularized by R. M. Baron and D. A. Kenny (1986) for testing the statistical significance of indirect effects (i.e., mediator variables) in multiple regression contexts. However, simulation studies suggest that this method lacks statistical power relative to some other approaches. The authors describe an alternative developed by P. E. Shrout and N. Bolger (2002) based on bootstrap resampling methods. An example and step-by-step guide for performing bootstrap mediation analyses are provided. The test of joint significance is also briefly described as an alternative to both the normal theory and bootstrap methods. The relative advantages and disadvantages of each approach in terms of precision in estimating confidence intervals of indirect effects, Type I error, and Type II error are discussed.
To determine the nature of depressive symptoms in a sample of patients with chronic pain, and to examine the relationship between depressive symptoms and physical disability due to pain.
Cross-sectional study of 812 patients with complete datasets from a total of 2419 patients with pain who were referred to the Pain Management Research Institute at Royal North Shore Hospital, Sydney, between January 2000 and December 2007.
Pain severity and distress, physical disability, depressive symptoms, pain self-efficacy, catastrophising, fear of movement/(re)injury, use of unhelpful self-management strategies, sense of control over life, and perceived support from significant others, assessed by the West Haven-Yale Multidimensional Pain Inventory, modified version of the Roland Morris Disability Questionnaire, the depression subscale of the Depression Anxiety Stress Scales, Pain Self-Efficacy Questionnaire, Pain-Related Self-Statements Scale, Tampa Scale of Kinesiophobia, and Pain Self-Management Checklist.
After controlling for the effects of age, sex and duration of pain, depressive symptoms were most strongly correlated with a combination of catastrophising, sense of control over life, physical disability, pain self-efficacy beliefs, higher use of unhelpful self-management strategies and lower perceived social support. Depressive symptoms also correlated with physical disability, but to a lesser extent than other variables, including fear of re-injury, low self-efficacy for activity and pain severity. The depressive symptoms that were rated as most frequently experienced reflected sadness, lack of initiative and lack of ability to experience pleasure.
In patients with chronic pain, depressive symptoms are correlated more strongly with cognitive variables than pain severity and pain distress, while physical disability is correlated more strongly with cognitive, behavioural and pain variables than depressive symptoms. Furthermore, depressive symptoms are characterised predominantly by mood-related symptoms, which suggests differences in the experience of depression in patients with chronic pain compared with those presenting with mental disorders.
In this experiment, we tested for opioid and nonopioid mechanisms of pain control through cognitive means and the relation of opioid involvement to perceived coping efficacy. Subjects were taught cognitive methods of pain control, were administered a placebo, or received no intervention. Their pain tolerance was then measured at periodic intervals after they were administered either a saline solution or naloxone, an opiate antagonist that blocks the effects of endogenous opiates. Training in cognitive control strengthened perceived self-efficacy both to withstand and to reduce pain; placebo medication enhanced perceived efficacy to withstand pain but not reductive efficacy; and neither form of perceived self-efficacy changed without any intervention. Regardless of condition, the stronger the perceived self-efficacy to withstand pain, the longer subjects endured mounting pain stimulation. The findings provide evidence that attenuation of the impact of pain stimulation through cognitive control is mediated by both opioid and nonopioid mechanisms. Cognitive copers administered naloxone were less able to tolerate pain stimulation than were their saline counterparts. The stronger the perceived self-efficacy to reduce pain, the greater was the opioid activation. Cognitive copers were also able to achieve some increase in pain tolerance even when opioid mechanisms were blocked by naloxone, which is in keeping with a nonopioid component in cognitive pain control. We found suggestive evidence that placebo medication may also activate some opioid involvement. Because placebos do not impart pain reduction skills, it was perceived self-efficacy to endure pain that predicted degree of opioid activation.
A computer and a hand search of the literature recovered 33 papers from which 25 trials suitable for meta-analysis were identified. We compared the effectiveness of cognitive-behavioural treatments with the waiting list control and alternative treatment control conditions. There was a great diversity of measurements which we grouped into domains representing major facets of pain. Effect sizes, corrected for measurement unreliability, were estimated for each domain. When compared with the waiting list control conditions cognitive-behavioural treatments were associated with significant effect sizes on all domains of measurement (median effect size across domains = 0.5). Comparison with alternative active treatments revealed that cognitive-behavioural treatments produced significantly greater changes for the domains of pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Differences on the following domains were not significant; mood/affect (depression and other, non-depression, measures), cognitive coping and appraisal (negative, e.g. catastrophization), and social role functioning. We conclude that active psychological treatments based on the principle of cognitive behavioural therapy are effective. We discuss the results with reference to the complexity and quality of the trials.
Research has demonstrated the importance of psychological factors in coping, quality of life, and disability in chronic pain. Furthermore, the contributions of psychology in the effectiveness of treatment of chronic pain patients have received empirical support. The authors describe a biopsychosocial model of chronic pain and provide an update on research implicating the importance of people's appraisals of their symptoms, their ability to self-manage pain and related problems, and their fears about pain and injury that motivate efforts to avoid exacerbation of symptoms and further injury or reinjury. They provide a selected review to illustrate treatment outcome research, methodological issues, practical, and clinical issues to identify promising directions. Although there remain obstacles, there are also opportunities for psychologists to contribute to improved understanding of pain and treatment of people who suffer from chronic pain. The authors conclude by noting that pain has received a tremendous amount of attention culminating in the passage of a law by the U.S. Congress designating the period 2001-2011 as the "The Decade of Pain Control and Research."
Mediation is said to occur when a causal effect of some variable X on an outcome Y is explained by some intervening variable M. The authors recommend that with small to moderate samples, bootstrap methods (B. Efron & R. Tibshirani, 1993) be used to assess mediation. Bootstrap tests are powerful because they detect that the sampling distribution of the mediated effect is skewed away from 0. They argue that R. M. Baron and D. A. Kenny's (1986) recommendation of first testing the X --> Y association for statistical significance should not be a requirement when there is a priori belief that the effect size is small or suppression is a possibility. Empirical examples and computer setups for bootstrap analyses are provided.
Pain is easily one of the most common health problems today. According to Bishop (1994), up to 80% of all visits to physicians involve pain-related complaints. This paper illustrates the use of hypnosis in the treatment of chronic low back pain. The use of hypnosis is described in terms of ecosystemic thinking and three case studies are used to illustrate this approach. The data from the case histories suggest that this way of thinking could lead to new possibilities for the application of hypnosis in the treatment of chronic low back pain.
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
This immensely practical volume describes the rationale, development, and utilization of cognitive-behavioral techniques in promoting health, preventing disease, and treating illness, with a particular focus on pain management. An ideal resource for a wide range of practitioners and researchers, the book's coverage of pain management includes theoretical, research, and clinical issues, and includes illustrative case material.
Readers who want a less mathematical alternative to the EQS manual will find exactly what they're looking for in this practical text. Written specifically for those with little to no knowledge of structural equation modeling (SEM) or EQS, the author's goal is to provide a non-mathematical introduction to the basic concepts of SEM by applying these principles to EQS, Version 6.1. The book clearly demonstrates a wide variety of SEM/EQS applications that include confirmatory factor analytic and full latent variable models.
Objective. To identify risk factors for the development of depression in persons with rheumatoid arthritis (RA).Methods. Subjects were divided into depressed versus nondepressed groups on the basis of the Center for Epidemiologic Studies-Depression Scale; a range of psychological, pain-related, disease-related, and demographic variables were analyzed to predict depression. Both cross-sectional and longitudinal predictive models were examined.Results. A series of analyses, including multiple logistic regression, found that the optimal predictors of depression in RA were average daily stressors, confidence in one's ability to cope, and degree of physical disability. The model was successfully cross-validated on separate data sets (i.e., same subjects at different time points).Conclusion. All of the identified risk factors for depression in RA are preventable to some extent and, therefore, should be addressed in comprehensive, rheumatology team care.
Objective. To examine how self-efficacy for arthritis pain relates to the perception of controlled laboratory pain stimuli.
Methods. Forty patients with osteoarthritis completed self-report measures of self-efficacy for arthritis pain. They then participated in a single experimental session in which measures of thermal pain threshold and tolerance were collected, as well as measures of the perceived intensity and unpleasantness of a range of thermal pain stimuli.
Results. Correlational analyses revealed that patients reporting high self-efficacy for arthritis pain rated the thermal pain stimuli as less unpleasant than those reporting low self-efficacy. When subjects scoring very high and very low in self-efficacy were compared, it was found that subjects scoring high on self-efficacy for arthritis pain had significantly higher pain thresholds and pain tolerance than those scoring low on self-efficacy.
Conclusions. These results in dicate that self-efficacy for arthritis pain is related to judgments of thermal pain stimuli. Implications for the understanding of arthritis pain and for future laboratory research are discussed.
The neuromatrix theory of pain proposes that pain is a multidimensional experience produced by characteristic “neurosignature” patterns of nerve impulses generated by a widely distributed neural network—the “body-self neuromatrix”—in the brain. These neurosignature patterns may be triggered by sensory inputs, but they may also be generated independently of them. Acute pains evoked by brief noxious inputs have been meticulously investigated by neuroscientists, and their sensory transmission mechanisms are generally well understood. In contrast, chronic pain syndromes, which are often characterized by severe pain associated with little or no discernable injury or pathology, remain a mystery. Furthermore, chronic psychological or physical stress is often associated with chronic pain, but the relationship is poorly understood. The neuromatrix theory of pain provides a new conceptual framework to examine these problems. It proposes that the output patterns of the body-self neuromatrix activate perceptual, homeostatic, and behavioral programs after injury, pathology, or chronic stress. Pain, then, is produced by the output of a widely distributed neural network in the brain rather than directly by sensory input evoked by injury, inflammation, or other pathology. The neuromatrix, which is genetically determined and modified by sensory experience, is the primary mechanism that generates the neural pattern that produces pain. Its output pattern is determined by multiple influences, of which the somatic sensory input is only a part, that converge on the neuromatrix.
To provide information on the use of the Beck Depression Inventory-II (BDI-II) with adolescents, the BDI-II was administered to 105 male and 105 female outpatients between 12 and 18 years old who were seeking psychiatric treatment. The internal consistency of the BDI-II was high (coefficient = .92). The mean BDI-II total score of the girls was approximately 5 points higher than that of the boys (p .001), and age (years) was positively correlated with the BDI-II total scores (r = .18, p .01). An iterated principal-factor analysis identified three factors, but only the Cognitive and Somatic-Affective factors were generalizable.
Unlabelled:
Both race and socioeconomic status (SES) contribute to disparities. We assessed the relative roles of neighborhood socioeconomic status (nSES) and race in the chronic pain experience for young adults (<50 years old). Data from a tertiary care pain center was matched to 2000 US Census data to examine the role of race and nSES on chronic pain and its sequelae in 3,730 adults (9.7% black, 61% female) 18 to 49 years old (37 ± 8 years). Blacks had significantly more pain and disability and lived in lower SES neighborhoods. Living in a lower SES neighborhood was associated with increased sensory, affective, and "other" pain, pain-related disability, and mood disorders. Race was independently associated with affective and "other" pain on the McGill Pain Questionnaire scales, and both disability factors. Racial disparities in sensory pain and mood disorders were mediated by nSES. In every case, race and neighborhood SES played important roles in the outcomes for chronic pain. Age was related to both disability outcomes. Gender was associated with voluntary disability and mood disorders, with men displaying worse outcomes.
Perspective:
Important racial- and SES-related variability in pain related outcomes in young adults with chronic pain were defined. Black race was associated with neighborhood SES, and black race plays an important role in pain outcomes beyond neighborhood SES.
Multicentre controlled study.
To investigate if individuals with and without spinal cord injury (SCI) differ in biopsychosocial variables according to the International Classification of Functioning, Disability and Health (ICF).
Participants were recruited through three major SCI rehabilitation centres in Switzerland.
A convenience sample of people with SCI (N=102) and a matched non-SCI sample (N=73) were compared according to secondary conditions, pain, depressive symptoms, participation, social support, self-efficacy, self-esteem, coping and sense of coherence. Difference tests and multivariate logistic regression analyses to predict the likelihood of group membership were calculated.
People with SCI reported more health conditions, higher levels of anxiety and depressive symptoms, worse pain and pain interference, lower level of participation and social support, lower self-efficacy, self-esteem and task- and emotion-oriented coping. The two samples did not differ in satisfaction with social support, in use of avoidance-oriented coping and in sense of coherence. Health conditions, pain interference, participation and age were found to be significant predictors of the likelihood of group membership. In the logistic regression models, the number of health conditions, limitations due to health conditions, pain interference, participation, task-oriented coping and age are significant predictors of group membership, accounting for 55% of variation.
Health conditions, pain interference and participation seemed to be the areas of biopsychosocial functioning that are substantially influenced by SCI. Potential buffering resources seem to be diminished in individuals with SCI. In rehabilitation practice, prevention of secondary conditions, treatment of pain, enhancement of participation and strengthening resources should be addressed.
This article is a report of a Norwegian-revised study on the effectiveness of a follow-up multidisciplinary management programme for chronic pain to investigate the change processes associated with treatment.
Substantial evidence supports the use of Cognitive Behavioural Therapy approaches to chronic pain. As relapse is often reported, follow-up sessions should be included.
A follow-up quasi-experimental design was performed, and a previous control group was used. The study initially included 117 participants, and 104 of the sample completed the 6- and 12-month follow-up programme. The 6-month follow-up consisted of therapeutic dialogue and education combined with physical activity. At the 12-month follow-up, a telephonic consultation was conducted. The data collection period was between September 2006 and January 2008. The statistical and clinical significance were considered.
Findings suggest that this follow-up programme can potentially maintain the positive results of the basic programme in terms of reduced pain perception, improved health-related quality of life, and movement towards self-management.
These results are consistent with the ultimate goal of Cognitive Behavioural Therapy approaches, which is to help patients with chronic pain to cope more effectively and to improve their health-related quality of life and functioning. To maintain treatment improvements and advance nursing, there is a clear need for research that tests the efficacy of follow-up interventions that are designed to prevent drop out and relapse.
Pain patients with comorbid depression have reduced quality of life and more disturbances than patients without such comorbidity.
The aim of this study was to investigate cross-sectional and longitudinal associations of depression and chronic pain.
The authors followed a sample of patients who took part in a cognitive-behavior treatment protocol for chronic pain.
Higher depression levels at pretreatment were associated with higher pain intensity and higher pain disability at pretreatment. Depression at pretreatment did not affect treatment outcome. Changes in depression from pretreatment to posttreatment accounted for variance in changes in pain intensity and pain disability.
The authors concluded that reducing pain-related depression could be a central therapeutic mechanism in cognitive-behavioral treatment of chronic back pain.
Our purpose was to examine the effects of self-efficacy on the pain behaviors exhibited by patients with rheumatoid arthritis (RA). Seventy-two patients with RA were assessed using a standardized videotaping procedure for rating specific pain behaviors such as limps, facial grimaces, and guarded movements. Patients also completed questionnaires measuring self-efficacy and depression. Hierarchical regression was used to assess the relationship between self-efficacy and pain behavior after the effects of demographic characteristics and disease activity were statistically controlled. Higher self-efficacy was found to be related to fewer pain behaviors. In contrast, depression was found to be unrelated to pain behavior. Our results indicate that the pain behaviors that patients with RA exhibit are related to their self-efficacy, not solely to their disease activity.
A short form of the McGill Pain Questionnaire (SF-MPQ) has been developed. The main component of the SF-MPQ consists of 15 descriptors (11 sensory; 4 affective) which are rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate or 3 = severe. Three pain scores are derived from the sum of the intensity rank values of the words chosen for sensory, affective and total descriptors. The SF-MPQ also includes the Present Pain Intensity (PPI) index of the standard MPQ and a visual analogue scale (VAS). The SF-MPQ scores obtained from patients in post-surgical and obstetrical wards and physiotherapy and dental departments were compared to the scores obtained with the standard MPQ. The correlations were consistently high and significant. The SF-MPQ was also shown to be sufficiently sensitive to demonstrate differences due to treatment at statistical levels comparable to those obtained with the standard form. The SF-MPQ shows promise as a useful tool in situations in which the standard MPQ takes too long to administer, yet qualitative information is desired and the PPI and VAS are inadequate.
Given the lack of objective physical measures for assessing fibromyalgia syndrome (FS), the role of pain assessment is particularly important. The role of psychological factors is controversial among FS patients. This study was designed to better understand the relationship between pain behaviors and psychological variables. Specifically, this study (1) refined a pain behavior observation (PBO) methodology for use with FS patients, (2) determined whether stretching is a valid pain behavior, and (3) assessed whether psychological variables including self-efficacy and/or depression can predict pain behaviors after controlling for disease severity and age. The 73 FS subjects meeting the American College of Rheumatology classification system completed questionnaires measuring self-efficacy, depression, and pain. Trained physicians conducted tender-point examinations. Subjects were video-taped using a standardized procedure. Two trained raters independently coded all pain behaviors. Kappa coefficients and correlations among pain behaviors and self-reported pain indicated that the PBO method was both reliable and valid. However, the newly defined pain behavior 'stretching' was found to be negatively associated with self-reported pain. Hierarchical multiple regression (MR) analyses revealed that depression did not predict pain behavior over and above myalgic scores and age; however, in 3 separate MR analyses, self-efficacy for function, pain, and other symptoms each predicted pain behavior over and above myalgic scores and age. This study indicated that the original pain behavior scoring methodology is appropriate for use with the FS population and should not be modified to include the pain behavior 'stretching'. Self-efficacy was related to pain behavior while depression was not among this FS sample.
To identify risk factors for the development of depression in persons with rheumatoid arthritis (RA).
Subjects were divided into depressed versus nondepressed groups on the basis of the Center for Epidemiologic Studies-Depression Scale; a range of psychological, pain-related, disease-related, and demographic variables were analyzed to predict depression. Both cross-sectional and longitudinal predictive models were examined.
A series of analyses, including multiple logistic regression, found that the optimal predictors of depression in RA were average daily stressors, confidence in one's ability to cope, and degree of physical disability. The model was successfully cross-validated on separate data sets (i.e., same subjects at different time points).
All of the identified risk factors for depression in RA are preventable to some extent and, therefore, should be addressed in comprehensive, rheumatology team care.
This manuscript describes the development and initial validation of a self-report questionnaire designed to assess an individual's readiness to adopt a self-management approach to their chronic pain condition. Theory and preliminary empirical work informed the development of a pool of items that were administered to a sample of individuals reporting chronic pain. Analyses of the data support a four factor measure that is consistent with the transtheoretical model of change and associated stages of change model. Each of the four factors, precontemplation, contemplation, action, and maintenance, was found to be internally consistent and stable over time. There was also substantial support for each factor's discriminant and criterion-related validity.
To clarify the relationships between physical, and psychosocial components of chronic pain, a path analytic model was tested conceptualizing self efficacy as a mediator of disability. In turn, disability was hypothesized to mediate depression. This model could help explain the circumstances under which disability develops and why so many chronic pain patients become depressed. Questionnaires from 126 chronic pain patients (without prior depression) were reviewed from three pain clinics. Hypothesized and alternate models were tested using separate regression equations to identified models which best fit these data. Regression analysis supported that self efficacy partially mediates the relationship between pain intensity and disability. This model accounted for 47% of the explained variance in disability (P < 0.001). Six additional variables that were significantly related to disability in preliminary analysis, added to the explained variance in disability (R2 = 0.56), with gender and pain location paths remaining significant. In separate regression analyses, disability was found to partially mediate the relationship between pain intensity and depression (b = 0.47-0.33). This model accounted for 26% of the explained variance in depression. The addition of self efficacy to this model supported it as a stronger mediator (R2 = 0.32), and suggested that support for disability as a mediator of depression was a spurious finding. Both pain intensity and self efficacy contribute to the development of disability and depression in patients with chronic pain. Therefore, the lack of belief in ones own ability to manage pain, cope and function despite persistent pain, is a significant predictor of the extent to which individuals with chronic pain become disabled and/or depressed. Nevertheless, these mediators did not eliminate the strong impact that high pain intensity has on disability and depression. Therefore, therapy should target multiple goals, including: pain reduction, functional improvement and the enhancement of self efficacy beliefs.
The main aspects of the most common models describing depression in chronic pain patients are reviewed. It is suggested that dualistic thinking provides neither a satisfactory model of chronic pain, nor of depression, and relies on questionable assumptions of homogeneous, diagnostically defined entities. Models of depression based in cognitive psychology, although apparently more suitable, cannot be applied to populations of pain patients without clarifying the relationship between pain and depression. Furthermore, commonly used depression measurement instruments are criticized for criterion contamination, lack of external reference, and lack of sensitivity when applied to these groups, all of which further obscure the relationship. Finally, we suggest more promising directions for research in this area.
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.
A path analytic model conceptualizing self efficacy as a mediator of disability was tested. This model could help explain the circumstances under which disability develops more in some chronic pain patients than in others.
Questionnaires from 479 chronic pain patients were collected prior to an initial consultative visit with a pain specialist at three pain clinics. These patients represented three separate samples. One sample from a tertiary care hospital (n = 226), one from a community-based clinic (n = 137) and a third sample from combined settings, but excluding patients with a history of depression prior to the onset of their pain (n = 116). Hypothesized and alternative models were tested to identify the model best fitting these data.
Regression analysis supported self efficacy as a mediator of the relationship between pain intensity and disability (p < 0.001) in all three groups. This model was best supported in the group with no prior depression (accounting for 47% of the explained variance in disability). The 'no-prior depression' group was different than the other samples in that depression did not contribute to disability in this sample where prior depression was not controlled for.
Self efficacy in an important variable contributing to the disability of chronic pain patients. Therefore, evaluating and bolstering the patient's belief in their own abilities may be an important component of therapy.
The Beck Depression Inventory-II (BDI-II) was administered to 416 consecutive male admissions to a 28-day residential chemical dependence treatment program as part of a routine intake procedure. Psychometric analyses revealed that the BDI-II scores were internally consistent in this treatment-seeking population based on coefficient alpha. The mean BDI-II score for patients in this study was higher than that noted for other clinical samples in previous studies. The use of the BDI-II for clinical decision making with chemically dependent individuals is discussed in light of this elevated distribution of scores. Confirmatory factor-analytic examinations of the instrument revealed that a three-factor model, with cognitive, affective, and somatic symptoms loading as separate factors, provided the most adequate account of the data. In total, the study supported the use of the BDI-II for the assessment of depression in chemically dependent male patients entering a residential treatment program at a VAMC facility, provided population-specific normative data is utilized for making clinical decisions.
This study examined the relationship between pain self-efficacy beliefs and a range of pain behaviours, as measured by the pain behaviour questionnaire (PBQ), using a prospective design. A heterogeneous sample of 145 chronic pain patients completed sets of questionnaires on four occasions over a nine-month period. Multiple hierarchical regression analyses revealed that the subjects' confidence in their ability to perform a range of tasks despite pain (assessed at baseline), was predictive of total pain behaviour and avoidance behaviour over the nine-month study period. This finding was particularly significant because the analyses controlled for the possible effects of pain severity (at each measurement occasion), pain chronicity, age, gender, physical disability, depression, neuroticism and catastrophising. These findings suggest that pain self-efficacy beliefs are an important determinant of pain behaviours and disability associated with pain, over and above the effects of pain, distress and personality variables. In particular, higher pain self-efficacy beliefs are predictive of reduced avoidance behaviours over an extended period.
In this article an overview is given on the attempts of understanding and treating chronic pain from the psychodynamic view and the perspective of behavioural medicine.
Pain cannot be reliably measured. Assessment of pain depends on verbal description, nonverbal expressions, specific tests and our empathy. From this perspective pain is a matter of subjective experience and communication. Several phenomena (e.g. phantom limb pain, stress analgesia, the pain-relieving effects of relaxation, hypnosis, placebo, etc., pain in spite of a non-existing injury) obviously show that psychological factors like distraction, relaxation, fear, depression, former pain experiences as well as family and cultural influences modulate the way pain is experienced. Different parts of the CNS are involved in the modulation of pain-experience. Referring to cognitive and emotional processes, the importance of the the neocortex and and the limbic system are to be underlined.
Chronic pain (as a category of ICD-10) presupposes a continuous, torturing pain, which sometimes even cannot be explained sufficiently by an organic damage. Psychosocial problems such as emotional conflicts, misleading thoughts, etc. are recognizable and can be brought into connection with the pain the patient experiences.
The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) and the Reynolds Adolescent Depression Scale (RADS; Reynolds, 1987) were administered to 56 female and 44 male psychiatric inpatients whose ages ranged from 12 to 17 years old. The Cronbach coefficient alpha(s) for the BDI-II and RADS were, respectively, .92 and .91 and indicated comparably high levels of internal consistency. The correlation between the BDI-II and RADS total scores was .84,p <.001. Binormal receiver-operating-characteristic analyses indicated that both instruments were comparably effective in differentiating inpatients who were and were not diagnosed with a major depressive disorder; the areas under the ROC curves for the BDI-II and RADS were, respectively, .78 and .76. The results (a) indicate that the BDI-II and the RADS have similar psychometric characteristics and (b) support the convergent validity of the BDI-II for assessing self-reported depression in adolescent inpatients.
The Beck Depression Inventory (BDI) is widely used to assess depression in chronic pain despite doubts about its structure and therefore its interpretation. This study used a large sample of 1947 patients entering chronic pain management to establish the structure of the BDI. The sample was randomly divided to conduct separate exploratory (EFA) and confirmatory factor analyses (CFA). EFA produced many satisfactory two-factor solutions. The series of CFA generated showed reasonable fit for ten of those solutions. All included a first factor identified as negative view of the self (items: failure, guilt, self-blame, self-dislike, punishment and body image change), and a second factor identified as somatic and physical function (items: work difficulty, loss of appetite, loss of libido, fatigability, insomnia and somatic preoccupation). The remaining items (suicidal ideation, social withdrawal, dissatisfaction, sadness, pessimism, crying, indecisiveness, weight loss, irritability) loaded infrequently or not at all in the CFA solutions. They did not form a coherent factor but comprised items associated with negative affect. When compared with published data from samples of depressed patients drawn from mental health settings the mean item scores for items reflecting the negative view of the self were consistently statistically lower that that observed in samples; there was no consistent difference between the samples on the items reflecting somatic and physical function; but the mean scores for the remaining affect items were significantly greater in the mental health samples. This version of depression is strikingly different from the psychiatric model of depression (e.g. DSM-IV or ICD-10), which is primarily defined by affective disturbance, and secondarily supported by cognitive and somatic symptoms. The finding is consistent with a reconsideration of what constitutes depression in the presence of chronic pain. It also has important clinical implications: it may provide a way to distinguish depressed patients with typical cognitive biases, who require specific treatment for depression alongside pain management.
Chronic pain is a prevalent and costly problem. This review addresses the question of the clinical effectiveness and cost-effectiveness of the most common treatments for patients with chronic pain.
Representative published studies that evaluate the clinical effectiveness of pharmacological treatments, conservative (standard) care, surgery, spinal cord stimulators, implantable drug delivery systems (IDDSs), and pain rehabilitation programs (PRPs) are examined and compared. The cost-effectiveness of these treatment approaches is also considered.
Outcome criteria including pain reduction, medication use, health care consumption, functional activities, and closure of disability compensation cases are examined. In addition to clinical effectiveness, the cost-effectiveness of PRPs, conservative care, surgery, spinal cord stimulators, and IDDSs are compared using costs to return a treated patient to work to illustrate the relative expenses for each of these treatments.
There are limitations to the success of all the available treatments. The author urges caution in interpreting the results, particularly in comparisons between treatments and across studies, because there are broad differences in the pain syndromes and inclusion criteria used, the drug dosages, comparability of treatments, the definition of "chronic" used, the outcome criteria selected to determine success, and societal differences. None of the currently available treatments eliminates pain for the majority of patients. Pain rehabilitation programs provide comparable reduction in pain to alternative pain treatment modalities, but with significantly better outcomes for medication use, health care utilization, functional activities, return to work, closure of disability claims, and with substantially fewer iatrogenic consequences and adverse events. Surgery, spinal cord stimulators, and IDDSs appear to have substantial benefits on some outcome criteria for carefully selected patients. These modalities are, however, expensive. Pain rehabilitation programs are significantly more cost effective than implantation of spinal cord stimulators, IDDSs, conservative care, and surgery, even for selected patients. Research is needed to identify which patients are most likely to benefit from the available treatments and to study combinations of the available treatments since none of them appear capable of eliminating pain or significantly improving functional outcomes for all treated.
First, to identify what physical performance differences existed between a group of disabled individuals with chronic pain and a control group of pain-free individuals with comparable disabilities; and second, to test a psychosocial model designed to evaluate which psychosocial constructs were predictive of performance in disabled individuals with chronic pain.
Case-comparison study.
Ambulatory university laboratory.
A community sample of 62 individuals with lower limb amputations or paraplegia, 31 with chronic pain and 31 pain-free.
Standardized lifting and wheel-turning tasks.
Static strength, endurance, lifting speed, lateral and anterior-posterior sway, and multidimensional psychosocial measures. RESULTS Disabled individuals with chronic pain had decreased endurance for both the lifting (p <0.001) and the wheel-turning (p <0.05) tasks. A psychosocial model of physical performance also was evaluated. Using confirmatory factor analysis, 31 measures were used to validate 8 theoretical constructs: emotional functioning, pain intensity, pain cognitions, physical functioning, social functioning, task-specific self-efficacy, performance outcome, and performance style. Regression analyses indicated that more than 90% of the variance in performance was predicted by psychosocial factors, with self-efficacy, perceived emotional and physical functioning, pain intensity, and pain cognitions showing the highest associations.
Chronic pain was found to significantly reduce the performance in individuals with lower limb amputations and paraplegia. A strong association was found between performance and psychosocial factors in disabled individuals with chronic pain. These findings extend the existing literature by validating that psychosocial models of chronic pain can be applied to the disabled population, with results similar to those of other chronic pain samples.
Back pain is ubiquitous and probably plagues almost everyone in all cultures and ethnic groups at some time (around 20% annually), and in up to 50% of these at least once a year. The WHO-COPCORD epidemiologic investigations have established its prevalence even in countries that had been unaware of its frequency in their populace, and factors involving type of work and training probably accounted for this misperception. Medical journals are replete with articles addressing diagnosis and treatment, but the majority fail to meet the standards needed for metaanalysis or comparison. A task force of the Agency for Health Care Policy and Research of the United States Department of Health and Human Services screened more than 10,000 abstracts, eliminated the majority of these studies and papers, and still was unable to recommend the best approach even to acute back pain; the problem of subacute and chronic back pain is even more formidable. Yet back pain has been identified as perhaps the major cause of disability and absenteeism from the workplace worldwide. WHO chiefly addressed subacute back pain, as most acute back pain is self-limited and ends spontaneously, almost regardless of the treatment. Subacute pain is the intermediate stage toward chronic pain, which defies most treatments. Specific causes for back pain, such as infections, tumors, osteoporosis, spondyloarthropathies, and trauma, actually represent a minority of such pain syndromes, qualifying for specific therapeutic approaches. A major problem in defining the burden of disease for back pain has been a dearth of agreed-upon outcome measures by which to judge the various interventions, and this was the task that the WHO Low Back Pain Initiative took upon itself. Among measures recommended to be included in all studies, so that valid comparisons could be made, were measurement of pain by visual analog scales, somatic perception, the Oswestry disability and modified Zung questionnaires, and a modified Schober test of spinal mobility. These measures are needed for studies, not for diagnosis or treatment of individual patients. They have been translated into various major languages and validated by back-translations, and applied in comparative studies in various cultures to medical, chiropractic, and other common interventions. The importance of such scientifically sound studies cannot be overemphasized, as the costs of health care are mounting everywhere and it therefore becomes imperative to develop cost-effective approaches. All the more so as conversion of acute back pain to chronic back pain is often iatrogenic, with strong psychosocial factors as well, so that not only what to do but also what not to do become important public health issues. The general lack of attention to back pain by governments and organizations probably results from the fact that it is perceived as a syndromic presentation with myriad causes rather than as a specific disease entity. Even if the "disease" names classify like presentations but are not necessarily etiologically discrete, syndromic diagnoses that subsume a variety of causes receive less attention; international rankings of common disabilities and public health problems tend to emphasize the named disorders rather than the grouped disorders. Moreover, back pain is often self-treated with nonprescription medications or alternative therapies, and by nonmedical practitioners or treatments in many parts of the world. Validation of outcomes therefore not only reduces invalidism and direct costs but also reduces the indirect costs of absenteeism and medical care.
Low back pain is a leading cause of disability. It occurs in similar proportions in all cultures, interferes with quality of life and work performance, and is the most common reason for medical consultations. Few cases of back pain are due to specific causes; most cases are non-specific. Acute back pain is the most common presentation and is usually self-limiting, lasting less than three months regardless of treatment. Chronic back pain is a more difficult problem, which often has strong psychological overlay: work dissatisfaction, boredom, and a generous compensation system contribute to it. Among the diagnoses offered for chronic pain is fibromyalgia, an urban condition (the diagnosis is not made in rural settings) that does not differ materially from other instances of widespread chronic pain. Although disc protrusions detected on X-ray are often blamed, they rarely are responsible for the pain, and surgery is seldom successful at alleviating it. No single treatment is superior to others; patients prefer manipulative therapy, but studies have not demonstrated that it has any superiority over others. A WHO Advisory Panel has defined common outcome measures to be used to judge the efficacy of treatments for studies.
We examined the psychometric properties of the Beck Depression Inventory-Second Edition (BDI-II) [Beck et al., 1996, San Antonio: The Psychological Corporation]. Four hundred fourteen undergraduate students at two public universities participated. A confirmatory factor analysis supported the BDI-II two-factor structure measuring cognitive-affective and somatic depressive symptoms. In addition, the internal consistency was high and the concurrent validity of the BDI-II was supported by positive correlations with self-report measures of depression and anxiety. These findings replicate prior research supporting the validity and reliability of the BDI-II in a college sample.