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1.  Retaining Critical Therapeutic Elements of Behavioral Interventions Translated For Delivery via the Internet: Recommendations and an Example Using Pain Coping Skills Training 
Evidence supporting the efficacy of behavioral interventions based on principles of cognitive behavioral therapies has spurred interest in translating these interventions for delivery via the Internet. However, the benefits of this dissemination method cannot be realized unless the translated interventions are as effective as possible. We describe a challenge that must be overcome to ensure this occurs—Internet interventions must retain therapeutic components and processes underlying the success of face-to-face interventions on which they are based. These components and processes vary in the ease with which they can be translated to the online environment. Moreover, some are subtle and may be overlooked, despite being recognized as essential to the success of face-to-face interventions. We provide preliminary guidance for retaining critical therapeutic components and processes in the translation process, using Pain Coping Skills Training for osteoarthritis pain to illustrate methods. Directions for future research are also discussed.
doi:10.2196/jmir.3374
PMCID: PMC4285744  PMID: 25532216
psychotherapeutic processes; cognitive behavioral therapy; Internet; eHealth; intervention; treatment efficacy; musculoskeletal pain; osteoarthritis
2.  Spouse Confidence in Self-Efficacy for Arthritis Management Predicts Improved Patient Health 
Background
In addition to patient self-efficacy, spouse confidence in patient efficacy may also independently predict patient health outcomes. However, the potential influence of spouse confidence has received little research attention.
Purpose
The current study examined the influence of patient and spouse efficacy beliefs for arthritis management on patient health.
Methods
Patient health (i.e., arthritis severity, perceived health, depressive symptoms, lower extremity function), patient self-efficacy, and spouse confidence in patients’ efficacy were assessed in a sample of knee osteoarthritis patients (N = 152) and their spouses at three time points across an 18-month period. Data were analyzed using structural equation models.
Results
Consistent with predictions, spouse confidence in patient efficacy for arthritis management predicted improvements in patient depressive symptoms, perceived health, and lower extremity function over 6 months and in arthritis severity over 1 year.
Conclusions
Our findings add to a growing literature that highlights the important role of spouse perceptions in patients’ long-term health.
doi:10.1007/s12160-014-9608-9
PMCID: PMC4331068  PMID: 24604529
Arthritis; Chronic illness; Couples; Longitudinal; Self-efficacy
3.  Cognitive behavioral therapy increases prefrontal cortex gray matter in patients with chronic pain 
Several studies have reported reduced cerebral gray matter (GM) volume/density in chronic pain conditions, but there is limited research on plasticity of the human cortex in response to psychological interventions. We investigated GM changes after cognitive behavioral therapy (CBT) in patients with chronic pain. We used voxel based morphometry (VBM) to compare anatomical MRI scans of 13 patients with mixed chronic pain types before and after an 11-week CBT treatment and to 13 healthy control participants. CBT led to significant improvements in clinical measures. Patients did not differ from healthy controls in GM anywhere in the brain. After treatment, patients had increased GM in bilateral dorsolateral prefrontal (DLPFC), posterior parietal (PPC), subgenual anterior cingulate (ACC)/orbitofrontal, and sensorimotor cortices, as well as hippocampus, and reduced GM in supplementary motor area. In most of these areas showing GM increases, GM became significantly higher than in controls. Decreased pain catastrophizing was associated with increased GM in left DLPFC and ventrolateral prefrontal (VLPFC), right PPC, somatosensory cortex, and pregenual ACC. While future studies with additional control groups will be needed to determine the specific roles of CBT on GM and brain function, we propose that increased GM in the PFC and PPC reflects greater top-down control over pain and cognitive reappraisal of pain, and that changes in somatosensory cortices reflect alterations in the perception of noxious signals.
Perspective
An 11-week CBT intervention for coping with chronic pain resulted in increased gray matter volume in prefrontal and somatosensory brain regions, as well as increased dorsolateral prefrontal volume associated with reduced pain catastrophizing. These results add to mounting evidence that CBT can be a valuable treatment option for chronic pain.
doi:10.1016/j.jpain.2013.07.020
PMCID: PMC3874446  PMID: 24135432
dorsolateral prefrontal cortex; neuroimaging; Voxel-Based Morphometry; pain catastrophizing; CBT
4.  The relationship between pain and eating among overweight and obese individuals with osteoarthritis: An ecological momentary study 
The relationship between pain and overweight/obesity is bidirectional – excess weight can cause pain, yet eating food high in calories, fat and sugar has been shown to alleviate pain. It appears likely that overweight/obese individuals may turn to these types of foods when they experience pain, leading to weight gain; however, this phenomenon has not been examined to date. The authors of this study set out to elucidate the relationship between pain and food intake in obese and overweight patients with osteoarthritis.
BACKGROUND:
Osteoarthritis (OA) patients who are overweight or obese report higher levels of pain compared with their normal-weight OA counterparts. Evidence suggests that overweight or obese OA patients also experience pain relief from eating foods high in calories, fat or sugar. Eating to alleviate pain may be problematic because it can lead to additional weight gain, which may contribute to heightened pain.
OBJECTIVES:
To investigate the relationship between pain and food intake using ecological momentary assessments in a sample of 71 over-weight and obese OA patients.
METHODS:
Participants completed two consecutive days of diary entries in which they recorded their levels of pain, mood and food intake throughout the day. Data were analyzed using generalized estimating equations that modelled pain as a predictor of calorie, fat and sugar intake. All models were adjusted for sex, body mass index, negative mood, time and treatment history.
RESULTS:
Pain significantly predicted calorie (Z=2.57; P=0.01) and fat intake (Z=1.99; P=0.05).
CONCLUSIONS:
Using ecological momentary assessments as a novel approach, the present study provides preliminary data supporting a relationship between pain and food intake among overweight and obese OA patients. Continued advances in our understanding of the relationship between pain and eating behaviour may help to optimize intervention strategies for these patients.
PMCID: PMC4273714  PMID: 24911176
BMI; Eating; Ecological momentary assessments (EMA); Obesity; Osteoarthritis; Pain; Weight
5.  The Effects of a Telehealth Coping Skills Intervention on Outcomes in Chronic Obstructive Pulmonary Disease: Primary Results from the INSPIRE-II Study 
Psychosomatic medicine  2014;76(8):581-592.
Objective
Chronic obstructive pulmonary disease (COPD) is associated with increased morbidity and mortality and reduced quality of life. Novel interventions are needed to improve outcomes in COPD patients. The present study assessed the effects of a telephone-based coping skills intervention on psychological and somatic quality of life and on the combined medical endpoint of COPD-related hospitalizations and all-cause mortality.
Methods
We conducted a dual-site, randomized clinical trial with assessments at baseline and after 16 weeks of treatment. The study population comprised 326 outpatients with COPD aged 38 to 81 years, randomized to Coping Skills training (CST) or to COPD Education (COPD-ED). Patients completed a battery of quality of life (QoL) instruments, pulmonary function tests, and functional measures and were followed for up to 4.4 years to assess medical outcomes.
Results
The CST group exhibited greater improvements in psychological QoL compared to controls (P = .001), including less depression (Cohen’s d=0.22 [95%CI 0.08, 0.36]) and anxiety (d=0.17 [95%CI 0.02, 0.33]), and better overall mental health (d=0.17 [95%CI 0.03, 0.32]), emotional role functioning (d= 0.29 [95%CI 0.10, 0.48]), vitality (d= 0.27 [95%CI 0.11, 0.42]), and social functioning (d= 0.21 [95%CI 0.03, 0.38]). A significant baseline psychological QoL by Treatment group interaction revealed that CST with lower QoL at baseline achieved even greater improvements in psychological QoL compared to COPE-ED. CST participants also exhibited greater improvements in Somatic QoL (P = .042), including greater improvements in pulmonary QoL (d= 0.13 [95%CI 0.01, 0.24]), less fatigue (d= 0.34 [95%CI 0.18, 0.50]), and less shortness of breath (d= 0.11 [95%CI −0.01, 0.23]) and greater improvement in distance walked on the 6 Minute Walk Test (d= 0.09 [95%CI 0.01, 0.16]). However, there was no significant difference in risk of time to COPD-related hospitalization or all-cause mortality between CST (34 events) and COPD-ED (32 events) (P= 0.430).
Conclusions
A telehealth coping skills training intervention produced clinically meaningful improvements in quality of life and functional capacity, but no overall improvement in risk of COPD-related hospitalization and all-cause mortality.
Trial Registration
clinicaltrials.gov Identifier NCT00736268
doi:10.1097/PSY.0000000000000101
PMCID: PMC4197099  PMID: 25251888
COPD; stress; depression; coping skills; disease-management
6.  Daily Verbal and Nonverbal Expression of Osteoarthritis Pain and Spouse Responses 
Pain  2013;154(10):2045-2053.
The current study applied a model of pain communication [10] to examine the distinction between verbal and nonverbal pain expression in their prediction of punishing, empathic, and solicitous spouse responses to patient pain. It was hypothesized that on days when patients engaged in more nonverbal expression spouses would respond more positively (i.e., with less punishing, and more solicitous and empathic behavior). The same pattern was predicted for verbal expression. In addition, it was expected that associations between patient nonverbal pain expression and positive spouse responses would be strengthened, and that the association with punishing responses would be weakened, on days when levels of verbal pain expression were higher than usual, regardless of daily pain severity. In a 22-day diary study, 144 individuals with knee osteoarthritis and their spouses completed daily measures of pain expression, spouse responses, health, and affect. The predicted positive main effect of nonverbal expression on empathic and solicitous responses was supported by the data, as was the positive main effect for verbal pain expression. Results from moderation analyses partially supported our hypothesis in that a) patients’ nonverbal pain expression was even more strongly related to empathic and solicitous spouse responses on days of high verbal pain expression, and b) patients were buffered from spouse punishing responses on days when both nonverbal and verbal expression were high. These findings suggest that pain expression in both verbal and nonverbal modes of communication is important for positive and negative spousal responses.
doi:10.1016/j.pain.2013.06.023
PMCID: PMC3778108  PMID: 23791895
Pain expression; spouse responses; osteoarthritis; daily
7.  Validity of an Observation Method for Assessing Pain Behavior in Individuals With Multiple Sclerosis 
Context
Pain is a common and complex experience for individuals who live with multiple sclerosis (MS) that interferes with physical, psychological and social function. A valid and reliable tool for quantifying observed pain behaviors in MS is critical to understanding how pain behaviors contribute to pain-related disability in this clinical population.
Objectives
To evaluate the reliability and validity of a pain behavioral observation protocol in individuals who have MS.
Methods
Community-dwelling volunteers with multiple sclerosis (N=30), back pain (N=5), or arthritis (N=8) were recruited based on clinician referrals, advertisements, fliers, web postings, and participation in previous research. Participants completed measures of pain severity, pain interference, and self-reported pain behaviors and were videotaped doing typical activities (e.g., walking, sitting). Two coders independently recorded frequencies of pain behaviors by category (e.g., guarding, bracing) and inter-rater reliability statistics were calculated. Naïve observers reviewed videotapes of individuals with MS and rated their pain. Spearman correlations were calculated between pain behavior frequencies and self-reported pain and pain ratings by naïve observers.
Results
Inter-rater reliability estimates indicated the reliability of pain codes in the MS sample. Kappa coefficients ranged from moderate agreement (sighing = 0.40) to substantial agreement (guarding = 0.83). These values were comparable to those obtained in the combined back pain and arthritis sample. Concurrent validity was supported by correlations with self-reported pain (0.46-0.53) and with self-reports of pain behaviors (0.58). Construct validity was supported by finding of 0.87 correlation between total pain behaviors observed by coders and mean pain ratings by naïve observers.
Conclusion
Results support use of the pain behavior observation protocol for assessing pain behaviors of individuals with MS. Valid assessments of pain behaviors of individuals with MS in could lead to creative interventions in the management of chronic pain in this population.
doi:10.1016/j.jpainsymman.2012.08.006
PMCID: PMC3593957  PMID: 23159684
Multiple sclerosis; pain behaviors; observation protocol; validity
8.  The Impact of Daily Arthritis Pain on Spouse Sleep 
Pain  2013;154(9):1725-1731.
Although chronic pain has been linked to poorer psychosocial well-being in the spouse, the extent to which patient pain affects spouse sleep is unknown. The aim of the present study was to test the hypothesis that greater daily knee pain would be associated with poorer sleep for the spouse that evening. We also tested the hypothesis that this pain contagion is exacerbated in couples who have a close relationship. A total of 138 knee osteoarthritis (OA) patients and their spouse completed baseline interviews and a 22-day diary assessment. Multilevel lagged models indicated that greater knee OA pain at the end of the day was associated with spouses’ poorer overall sleep quality that night and feeling less refreshed after sleep. In contrast, there was no evidence that spouse sleep was related to greater patient pain the next day. The effects of patient pain on spouse sleep were not due to disturbances in patient sleep and were also independent of spouse gender, depressive symptoms, and physical comorbidities; both partners’ negative affect; and the quality of marital interactions throughout the day. As predicted, we also found that patient pain was more strongly related to less refreshing sleep for spouses who were in a close relationship. Findings illustrate that chronic pain may place the spouse’s health at risk, and suggest an important target for couple-oriented interventions.
doi:10.1016/j.pain.2013.05.020
PMCID: PMC3748393  PMID: 23953126
9.  Pain Coping Skills Training and Lifestyle Behavioral Weight Management in Patients with Knee Osteoarthritis: A Randomized Controlled Study 
Pain  2012;153(6):1199-1209.
Overweight and obese patients with osteoarthritis (OA) experience more OA pain and disability than patients who are not overweight. This study examined the long-term efficacy of a combined pain coping skills training (PCST) and lifestyle behavioral weight management (BWM) intervention in overweight and obese OA patients. Patients (N=232) were randomized to a 6-month program of: 1) PCST + BWM; 2) PCST-only; 3) BWM-only; or 4) standard care control. Assessments of pain, physical disability (Arthritis Impact Measurement Scales [AIMS] physical disability, stiffness, activity, and gait), psychological disability (AIMS psychological disability, pain catastrophizing, arthritis self-efficacy, weight self-efficacy), and body weight were collected at four time points (pretreatment, post-treatment, and 6 months and 12 months after the completion of treatment). Patients randomized to PCST+ BWM demonstrated significantly better treatment outcomes (average of all three post-treatment values) in terms of pain, physical disability, stiffness, activity, weight self-efficacy, and weight when compared to the other three conditions (p’s <.05). PCST+BWM also did significantly better than at least one of the other conditions (i.e., PCST-only, BWM-only, or standard care) in terms of psychological disability, pain catastrophizing, and arthritis self-efficacy. Interventions teaching overweight and obese OA patients pain coping skills and weight management simultaneously may provide the more comprehensive long-term benefits.
doi:10.1016/j.pain.2012.02.023
PMCID: PMC3358356  PMID: 22503223
osteoarthritis; pain; coping; physical disability; overweight; obese
10.  Chronic Hepatitis C and Antiviral Treatment Regimens: Where Can Psychology Contribute? 
Objective
To evaluate the existing literature on psychological, social, and behavioral aspects of chronic hepatitis C viral (HCV) infection and antiviral treatment; provide the state of the behavioral science in areas that currently hinder HCV-related health outcomes; and make recommendations for areas in which clinical psychology can make significant contributions.
Methods
The extant literature on HCV and antiviral therapy was reviewed as related to biopsychosocial factors such as mental health, substance/alcohol use, quality of life, coping, stigma, racial disparities, side effects, treatment adherence, integrated care, and psychological interventions.
Results
For reasons that have not been well elucidated, individuals infected with HCV experience psychological and somatic problems and report poor health-related quality of life. Preexisting conditions, including poor mental health and alcohol/substance use, can interfere with access to and successful completion of HCV treatment. Perceived stigma is highly prevalent and associated with psychological distress. Racial disparities exist for HCV prevalence, treatment uptake, and treatment success. During HCV treatment, patients experience exacerbation of symptoms, treatment side effects, and poorer quality of life, making it difficult to complete treatment. Despite pharmacological advances in HCV treatment, improvements in clinical and public health outcomes have not been realized. The reasons for this lack of impact are multifactorial, but include suboptimal referral and access to care for many patients, treatment-related side effects, treatment nonadherence, and lack of empirically-based approaches.
Conclusions
Biomedical advances in HCV and antiviral treatment have created a fertile field in which psychologists are uniquely positioned to make important contributions to HCV management and treatment.
doi:10.1037/a0029030
PMCID: PMC3504622  PMID: 22730952
Interferon; Psychosocial; Coping; Adherence; Multidisciplinary
11.  A Pilot Cluster Randomized Trial of a 20-Week Tai Chi Program in Elders With Cognitive Impairment and Osteoarthritic Knee: Effects on Pain and Other Health Outcomes 
Context
Because Tai Chi (TC) is beneficial to elders without cognitive impairment (CI), it also may benefit elders with CI. But elders with CI have generally been excluded from TC studies because many measurement tools require verbal reports and some elders with CI are unable to provide.
Objectives
To tested the efficacy of a TC program in improving pain and other health outcomes in community-dwelling elders with knee osteoarthritis (OA) and CI.
Methods
This pilot cluster-randomized trial was conducted between January 2008 and June 2010 (ClinicalTrials.gov Identifier: NCT01528566). The TC group attended Sun style TC classes, three sessions a week for 20 weeks; the control group attended classes providing health and cultural information for the same length of time. Measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, physical function and stiffness subscales, the Get Up and Go test, the Sit-to-Stand test and the Mini-Mental State Examination (MMSE), administered at baseline, every four weeks during the intervention and at the end of the study (post-test).
Results
Eight sites participated in either the TC group (four sites, 28 participants) or the control group (four sites, 27 participants). The WOMAC pain (P=0.006) and stiffness scores (P=0.010) differed significantly between the two groups at post-test, whereas differences between the two groups in the WOMAC physical function score (P=0.071) and the MMSE (P=0.096) showed borderline significance at the post-test. WOMAC pain (P=0.001), physical function (P=0.021) and stiffness (P≤0.001) scores improved significantly more over time in the TC group than in controls. No adverse events were found in either group.
Conclusion
Practicing TC can be efficacious in reducing pain and stiffness in elders with knee OA and CI.
doi:10.1016/j.jpainsymman.2012.04.009
PMCID: PMC3543500  PMID: 23017610
Tai Chi; osteoarthritis; knee; pain; physical function; cognitive function
12.  Daily Spousal Influence on Physical Activity in Knee Osteoarthritis 
Background
Physical activity is critical for the management of knee osteoarthritis, and the spouse may play a role in encouraging or discouraging physical activity.
Purpose
To examine four types of spousal influence—spouses' daily activity, autonomy support, pressure, and persuasion--on the daily physical activity of adults living with knee osteoarthritis.
Methods
A total of 141 couples reported their daily experiences for 22 days using a handheld computer, and wore an accelerometer to measure moderate activity and steps.
Results
Spouses' autonomy support for patient physical activity, as well as their own level of activity, was concurrently associated with patients' greater daily moderate activity and steps. In addition, on days when male patients perceived that spouses exerted more pressure to be active, they spent less time in moderate activity.
Conclusions
Couple-oriented interventions for knee osteoarthritis should target physical activity in both partners and spousal strategies for helping patients stay active.
doi:10.1007/s12160-012-9442-x
PMCID: PMC3594506  PMID: 23161472
couples; physical activity; daily diary; arthritis; autonomy support; social control
13.  Development of the NIH PROMIS® Sexual Function and Satisfaction Measures in Patients with Cancer 
The journal of sexual medicine  2013;10(0 1):43-52.
Introduction
We describe the development and validation of the PROMIS Sexual Function and Satisfaction (PROMIS SexFS) measures version 1.0 for cancer populations.
Aim
To develop a customizable self-report measure of sexual function and satisfaction as part of the U.S. National Institutes of Health PROMIS® Network.
Methods
Our multidisciplinary working group followed a comprehensive protocol for developing psychometrically robust patient reported outcome (PRO) measures including qualitative (scale development) and quantitative (psychometric evaluation) development. We performed an extensive literature review, conducted 16 focus groups with cancer patients and multiple discussions with clinicians, and evaluated candidate items in cognitive testing with patients. We administered items to 819 cancer patients. Items were calibrated using item response theory and evaluated for reliability and validity.
Main Outcome Measures
The PROMIS Sexual Function and Satisfaction (PROMIS SexFS) measures version 1.0 include 79 items in 11 domains: interest in sexual activity, lubrication, vaginal discomfort, erectile function, global satisfaction with sex life, orgasm, anal discomfort, therapeutic aids, sexual activities, interfering factors, and screener questions.
Results
In addition to content validity (patients indicate that items cover important aspects of their experiences) and face validity (patients indicate that items measure sexual function and satisfaction), the measure shows evidence for discriminant validity (domains discriminate between groups expected to be different), convergent validity (strong correlations between scores on PROMIS and scores on conceptually-similar older measures of sexual function), as well as favorable test-retest reliability among people not expected to change (inter-class correlations from 2 administrations of the instrument, 1 month apart).
Conclusions
The PROMIS SexFS offers researchers a reliable and valid set of tools to measure self-reported sexual function and satisfaction among diverse men and women. The measures are customizable; researchers can select the relevant domains and items comprising those domains for their study.
doi:10.1111/j.1743-6109.2012.02995.x
PMCID: PMC3729213  PMID: 23387911
patient-reported outcome measures; sexual function; satisfaction; cancer; quality of life; male and female sexual dysfunction
14.  Effects of coping skills training and sertraline in patients with non-cardiac chest pain: A randomized controlled study 
Pain  2011;152(4):730-741.
Non-cardiac chest pain (NCCP) is a common and distressing condition. Prior studies suggest that psychotropic medication or pain coping skills training (CST) may benefit NCCP patients. To our knowledge, no clinical trials have examined the separate and combined effects of CST and psychotropic medication in the management of NCCP. This randomized clinical trial examined the separate and combined effects of CST and antidepressant medication (sertraline) in participants with non-cardiac chest pain. A sample of individuals diagnosed with NCCP was randomly assigned to one of four treatments: (1) CST plus sertraline (CST + sertraline), (2) CST plus placebo (CST + placebo), (3) sertraline alone, or (4) placebo alone. Assessments of pain intensity, pain unpleasantness, anxiety, pain catastrophizing, depression, and physical disability were collected prior to treatment, and at 10- and 34-weeks following randomization. Data analyses revealed that CST and sertraline either alone or in combination significantly reduced pain intensity and pain unpleasantness. The combination of CST plus sertraline may have the greatest promise in that, when compared to placebo alone, it not only significantly reduced pain but also pain catastrophizing and anxiety. Overall, these findings support the importance of further research on the effects of CST and sertraline for non-cardiac chest pain.
doi:10.1016/j.pain.2010.08.040
PMCID: PMC3894605  PMID: 21324590
Non-cardiac chest pain; Pain; Pain catastrophizing; Coping skills training; Sertraline; Anxiety
15.  Hope in the Context of Lung Cancer: Relationships of Hope to Symptoms and Psychological Distress 
Context
Hope may be important in explaining the variability in how patients adjust to lung cancer.
Objectives
The aim of this study was to examine how hope, as conceptualized by Snyder and colleagues, is associated with multiple indices of adjustment to lung cancer. This theoretical model of hope suggests that people with high levels of hope are able to think about the pathways to goals (pathways) and feel confident that they can pursue those pathways to reach their goals (agency).
Methods
We hypothesized that higher levels of hope, as measured by Snyder et al.’s hope scale, would be related to lower levels of pain and other lung cancer symptoms (i.e., fatigue, cough) and lower psychological distress (i.e., depression). Participants in this study included patients with a diagnosis of lung cancer (n = 51). All participants provided demographic and medical information and completed measures of hope, lung cancer symptoms, and psychological distress.
Results
Data analyses found that hope was inversely associated with major symptoms of cancer (i.e., pain, fatigue, cough) and psychological distress (i.e., depression), even after accounting for important demographic and medical variables (i.e., age, cancer stage).
Conclusion
The findings of this cross-sectional study highlight the potential importance of hope in understanding adjustment to lung cancer. Future longitudinal research could help reveal how hope and adjustment interact over the course of cancer survivorship.
doi:10.1016/j.jpainsymman.2010.01.014
PMCID: PMC2921459  PMID: 20579840
Hope; lung cancer; pain
16.  Optimism and pain: A positive move forward 
Pain  2012;154(1):7-8.
doi:10.1016/j.pain.2012.10.005
PMCID: PMC3753086  PMID: 23159574
17.  Disease Severity and Domain Specific Arthritis Self-Efficacy: Relationships to Pain and Functioning in Rheumatoid Arthritis Patients 
Arthritis care & research  2010;62(6):848-856.
Objective
Examining the degree to which disease severity and domains of self-efficacy (pain, function, other symptoms) explain pain and functioning in rheumatoid arthritis patients.
Methods
Patients (N=263) completed the Arthritis Impact Measurements Scales-2 to assess pain and functioning (physical, affective, and social), the Arthritis Self-Efficacy Scale to assess three self-efficacy domains (pain, physical function, other); disease severity was assessed with C-reactive protein, physician's rating, abnormal joint count. Structural equation modeling was used to examine hypotheses: 1) does disease severity have a direct relationship with pain and each area of functioning, 2) does disease severity have a direct relationship with each arthritis self-efficacy domain, and 3) do the self-efficacy domains mediate the relationship between disease severity and RA pain and each area of functioning.
Results
Disease severity was related to pain, physical functioning, and each self-efficacy domain (β's=.28-.56; p's<.001). Each self-efficacy domain was related to its respective domain of functioning (e.g., self-efficacy for pain was related to pain) (β's=.36-.54; p's<.001). Self-efficacy mediated the relationship between disease severity and pain and functioning (β's=.12-.19; p's<.001). Self-efficacy for pain control and to perform functional tasks accounted for 32-42% of disease severity's total effect on their respective outcomes (e.g., self-efficacy for pain control accounted for 32% of disease severity's total effect on pain). Variance accounted for by the total model was 52% for pain, 53% for physical functioning, and 44% for affective and social functioning.
Conclusions
Disease severity and self-efficacy both impact RA functioning and intervening in these areas may lead to better outcomes.
doi:10.1002/acr.20127
PMCID: PMC2885011  PMID: 20535796
18.  A primary care-based interdisciplinary team approach to the treatment of chronic pain utilizing a pragmatic clinical trials framework 
Chronic pain affects at least 116 million adults in the USA and exacts a tremendous cost in suffering and lost productivity. While health systems offer specialized pain services, the primary care setting is where most patients seek and receive care for pain. Primary care-based treatment of chronic pain by interdisciplinary teams (including behavioral specialists, nurse case managers, physical therapists, and pharmacists) is one of the most effective approaches for improving outcomes and managing costs. To ensure robust integration of such services into sustainable health-care programs, evaluations must be conducted by researchers well versed in the methodologies of clinical trials, mixed methods and implementation research, bioinformatics, health services, and cost-effectiveness. Recent national health policy changes, in addition to the increasing recognition of the high prevalence and cost of chronic pain conditions, present a unique opportunity to shift the care paradigm for patients with chronic pain.
doi:10.1007/s13142-012-0163-2
PMCID: PMC3578318  PMID: 23440672
Chronic pain; Interdisciplinary/multidisciplinary teams; Primary care; Implementation; Research; Pragmatic clinical trials
19.  Cognitive-Behavioral Treatment for Comorbid Insomnia and Osteoarthritis Pain in Primary Care: The Lifestyles Randomized Controlled Trial 
OBJECTIVES
To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive–behavioral therapy for pain and insomnia (CBT-PI), a cognitive–behavioral pain coping skills intervention (CBT-P), and an education-only control (EOC) differed in sleep and pain outcomes.
DESIGN
Double-blind, cluster-randomized controlled trial with 9-month follow-up.
SETTING
Group Health and University of Washington, 2009 to 2011.
PARTICIPANTS
Three hundred sixty-seven older adults with OA pain and insomnia.
INTERVENTIONS
Six weekly group sessions of CBT-PI, CBT-P, or EOC delivered in participants’ primary care clinics.
MEASUREMENTS
Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms.
RESULTS
CBT-PI reduced insomnia severity (score range 0–28) more than EOC (adjusted mean difference = −1.89, 95% confidence interval = −2.83 to −0.96; P < .001) and CBT-P (adjusted mean difference = −2.03, 95% CI = −3.01 to −1.04; P < .001) and improved sleep efficiency (score range 0−100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44−4.84; P = .02). CBT-P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85−4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results.
CONCLUSION
Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes. J Am Geriatr Soc 2013.
doi:10.1111/jgs.12275
PMCID: PMC3772673  PMID: 23711168
aging; cognitive–behavioral therapy; insomnia; osteoarthritis; pain
22.  Pain Catastrophizing in Patients with Non-Cardiac Chest Pain: Relationships with Pain, Anxiety, and Disability 
Psychosomatic medicine  2009;71(8):861-868.
Objective
This study examined the contributions of chest pain, anxiety, and pain catastrophizing to disability in 97 patients with non-cardiac chest pain (NCCP). We also tested whether chest pain and anxiety were indirectly related to greater disability via pain catastrophizing.
Methods
Participants completed daily diaries measuring chest pain for seven days prior to completing measures of pain catastrophizing, trait anxiety, and disability. Linear path model analyses examined the contributions of chest pain, trait anxiety, and catastrophizing to physical disability, psychosocial disability, and disability in work, home, and recreational activities.
Results
Path models accounted for a significant amount of the variability in disability scales (R2=.35 to .52). Chest pain and anxiety accounted for 46% of the variance in pain catastrophizing. Both chest pain (β=.18, Sobel test Z=2.58, p<.01) and trait anxiety (β=.14, Sobel test Z=2.11, p<.05) demonstrated significant indirect relationships with physical disability via pain catastrophizing. Chest pain demonstrated a significant indirect relationship with psychosocial disability via pain catastrophizing (β=.12, Sobel test Z=1.96, p=.05). After controlling for the effects of chest pain and anxiety, pain catastrophizing was no longer related to disability in work, home, and recreational activities.
Conclusions
Chest pain and anxiety were directly related to greater disability and indirectly related to physical and psychosocial disability via pain catastrophizing. Efforts to improve functioning in NCCP patients should consider addressing pain catastrophizing.
doi:10.1097/PSY.0b013e3181b49584
PMCID: PMC2762482  PMID: 19737857
non-cardiac chest pain; catastrophizing; anxiety; disability
23.  Pilot Feasibility Study of a Telephone-Based Couples Intervention for Physical Intimacy and Sexual Concerns in Colorectal Cancer 
Journal of sex & marital therapy  2012;38(5):402-417.
No studies have tested interventions addressing the sexual concerns of colorectal cancer patients and their partners. We report findings from a pilot feasibility study of a novel telephone-based Intimacy Enhancement protocol that addresses the intimacy and sexual concerns of couples facing colorectal cancer. Based on a flexible coping model (Reese, Keefe, Somers, & Abernethy, 2010), the intervention was designed to help couples make cognitive and behavioral shifts in their intimate relationships. Eighteen individuals (9 dyads) completed the intervention and completed measures of feasibility (frequency, ease of use, and helpfulness of skills, ratings of rapport), program evaluations, and measures of sexual and relationship functioning. Most participants reported that the intervention was “quite a bit” or “extremely helpful” and that they had used the skills taught within the past week. The skills most commonly practiced and perceived as most helpful tended to be behavioral (e.g., trying a new sexual activity). The largest effect sizes (≥ .60) were found for sexual distress, sexual function (female), and sexual communication. Findings from this pilot study suggest that the Intimacy Enhancement protocol is feasible and holds promise for improving sexual and intimacy outcomes in colorectal cancer patients and their partners. Research and clinical implications are discussed.
doi:10.1080/0092623X.2011.606886
PMCID: PMC3428742  PMID: 22900623
Colorectal cancer; Sexuality; Sexual Dysfunctions; Couple Therapy; Feasibility Studies
24.  Attachment styles in patients with lung cancer and their spouses: associations with patient and spouse adjustment 
Purpose
This study examined attachment styles in patients with lung cancer and their spouses and associations between attachment styles and patient and spouse adjustment.
Methods
One hundred twenty-seven patients with early stage lung cancer completed measures of attachment style, marital quality, self-efficacy, pain, depression, anxiety, and quality of life. Their spouses completed measures of attachment style, marital quality, self-efficacy, caregiver strain, and mood.
Results
Analyses indicated that, among patients, those high in either attachment anxiety or avoidance had significantly higher levels of anxiety and poorer social well-being. Attachment avoidance was also significantly associated with higher levels of depression and poorer marital quality and functional well-being. Spouse avoidant attachment was significantly associated with patient reports of increased pain and poorer functional well-being, and spouse anxious attachment was associated with poorer patient marital quality. Among spouses, those high in attachment avoidance reported significantly higher levels of caregiver strain, anger, depressed mood, and poorer marital quality; those high in attachment anxiety reported higher anxious mood. Dyads in which both partners were insecurely attached had significantly poorer adjustment compared to dyads in which both partners reported secure attachment.
Conclusions
These preliminary findings raise the possibility that attachment styles of cancer patients and their spouses as individuals and as a dyad may be important factors affecting adjustment in multiple domains.
doi:10.1007/s00520-011-1367-6
PMCID: PMC3753069  PMID: 22246596
Attachment; Lung cancer; Adjustment; Quality of life; Couples; Caregiving
25.  Pain Catastrophizing and Pain-Related Fear in Osteoarthritis Patients: Relationships to Pain and Disability 
This study examined the degree to which pain catastrophizing and pain-related fear explain pain, psychological disability, physical disability, and walking speed in patients with osteoarthritis (OA) of the knee. Participants in this study were 106 individuals diagnosed as having OA of at least one knee, who reported knee pain persisting six months or longer. Results suggest that pain catastrophizing explained a significant proportion (all P's ≤ 0.05) of variance in measures of pain (partial r2 [pr2] = 0.10), psychological disability (pr2 = 0.20), physical disability (pr2 = 0.11), and gait velocity at normal (pr2 = 0.04), fast (pr2 = 0.04), and intermediate speeds (pr2 = 0.04). Pain-related fear explained a significant proportion of the variance in measures of psychological disability (pr2 = 0.07) and walking at a fast speed (pr2 = 0.05). Pain cognitions, particularly pain catastrophizing, appear to be important variables in understanding pain, disability, and walking at normal, fast, and intermediate speeds in knee OA patients. Clinicians interested in understanding variations in pain and disability in this population may benefit by expanding the focus of their inquiries beyond traditional medical and demographic variables to include an assessment of pain catastrophizing and pain-related fear.
doi:10.1016/j.jpainsymman.2008.05.009
PMCID: PMC2702756  PMID: 19041218
Pain catastrophizing; pain-related fear; osteoarthritis

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