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1.  Validating pain communication: Current state of the science 
Pain  2015;156(2):215-219.
PMCID: PMC4477266  PMID: 25599441
pain; communication; validation; invalidation
2.  Gender Differences in Acute and Chronic Pain in the Emergency Department: Results of the 2014 Academic Emergency Medicine Consensus Conference Pain Section 
Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas in May of 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine and the pain research field reviewed the current literature and identified eight candidate priority areas. At the conference, these eight areas were reviewed and all eight were ratified using a nominal group technique to build consensus. These priority areas were: 1) gender differences in the pharmacologic and non-pharmacologic interventions for pain, including differences in opioid tolerance, side effects, or misuse; 2) gender differences in pain severity perceptions, clinically meaningful differences in acute pain, and pain treatment preferences; 3) gender differences in pain outcomes of ED patients across the lifespan; 4) gender differences in the relationship between acute pain and acute psychological responses; 5) the influence of physician-patient gender differences and characteristics on the assessment and treatment of pain; 6) gender differences in the influence of acute stress and chronic stress on acute pain responses; 7) gender differences in biologic mechanisms and molecular pathways mediating acute pain in ED populations; and 8) gender differences in biologic mechanisms and molecular pathways mediating chronic pain development after trauma, stress, or acute illness exposure. These areas represent priority areas for future scientific inquiry, and gaining understanding in these will be essential to improving our understanding of sex and gender differences in the assessment and treatment of pain conditions in emergency care settings.
PMCID: PMC4390133  PMID: 25422152
3.  Restricted activity and persistent pain following motor vehicle collision among older adults: a multicenter prospective cohort study 
BMC Geriatrics  2016;16:86.
Restricted physical activity commonly occurs following acute musculoskeletal pain in older adults and may influence long-term outcomes. We sought to examine the relationship between restricted physical activity after motor vehicle collision (MVC) and the development of persistent pain.
We examined data from a prospective study of adults ≥65 years of age presenting to the emergency department (ED) after MVC without life-threatening injuries. Restricted physical activity 6 weeks after MVC was defined in three different ways: 1) by a ≥25 point decrease in Physical Activity Scale in the Elderly (PASE) score, 2) by the answer “yes” to the question, “during the past two weeks, have you stayed in bed for at least half a day?”, and 3) by the answer “yes” to the question, “during the past two weeks, have you cut down on your usual activities as compared to before the accident?” We examined relationships between each definition of restricted activity and pain severity, pain interference, and functional capacity at 6 months with adjustment for confounders.
Within the study sample (N = 164), adjusted average pain severity scores at 6 months did not differ between patients with and without restricted physical activity based on decreased PASE score (2.54 vs. 2.07, p = 0.32). In contrast, clinically and statistically important differences in adjusted average pain severity at 6 months were observed for patients who reported spending half a day in bed vs. those who did not (3.56 vs. 1.91, p < 0.01). In adjusted analyses, both decreased PASE score and cutting down on activity were associated with functional capacity at 6 months, but only decreased PASE score was associated with increased ADL difficulty at 6 months (0.70 vs. -0.01, p = 0.02).
Among older adults experiencing MVC, those reporting bed rest or reduced activity 6 weeks after the collision reported higher pain and pain interference scores at 6 months. More research is needed to determine if interventions to promote activity can improve outcomes after MVC in older adults.
PMCID: PMC4837524  PMID: 27094038
Aged; Motor Activity; Emergency medicine; Pain; Geriatrics; Traffic accidents
4.  Psychological and Behavioral Approaches to Cancer Pain Management 
Journal of Clinical Oncology  2014;32(16):1703-1711.
This review examines evidence for psychological factors that affect pain across the cancer continuum from diagnosis through treatment and long-term survivorship or end of life. Evidence is convincing that emotional distress, depression, anxiety, uncertainty, and hopelessness interact with pain. Unrelieved pain can increase a desire for hastened death. Patients with cancer use many strategies to manage pain, with catastrophizing associated with increased pain and self-efficacy associated with lower pain reports. A variety of psychological and cognitive behavioral treatments can reduce pain severity and interference with function, as indicated in multiple meta-analyses and high-quality randomized controlled trials. Effective methods include education (with coping skills training), hypnosis, cognitive behavioral approaches, and relaxation with imagery. Exercise has been tested extensively in patients with cancer and long-term survivors, but few exercise studies have evaluated pain outcomes. In survivors post-treatment, yoga and hypnosis as well as exercise show promise for controlling pain. Although some of these treatments effectively reduce pain for patients with advanced disease, few have been tested in patients at the end of life. Given the clear indicators that psychological factors affect cancer pain and that psychological and behavioral treatments are effective in reducing varying types of pain for patients with active disease, these methods need further testing in cancer survivors post-treatment and in patients with end-stage disease. Multidisciplinary teams are essential in oncology settings to integrate analgesic care and expertise in psychological and behavioral interventions in standard care for symptom management, including pain.
PMCID: PMC4031190  PMID: 24799497
5.  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.
PMCID: PMC4285744  PMID: 25532216
psychotherapeutic processes; cognitive behavioral therapy; Internet; eHealth; intervention; treatment efficacy; musculoskeletal pain; osteoarthritis
6.  A randomized pilot trial of a telephone-based couples intervention for physical intimacy and sexual concerns in colorectal cancer 
Psycho-oncology  2014;23(9):1005-1013.
We previously developed and piloted a telephone-based intimacy enhancement (IE) intervention addressing sexual concerns of colorectal cancer patients and their partners in an uncontrolled study. The current study tested the feasibility, acceptability, and preliminary efficacy of the IE intervention in a randomized, controlled trial.
Twenty-three couples were randomized to either the four-session IE condition or to a wait list control condition and completed sexual and relationship outcomes measures. The IE intervention teaches skills for coping with sexual concerns and improving intimacy. Feasibility and acceptability were assessed through enrollment and post-treatment program evaluations, respectively. Effect sizes were calculated by comparing differences in average pre/post change scores across completers in the two groups (n = 18 couples).
Recruitment and attrition data supported feasibility. Program evaluations for process (e.g., ease of participation) and content (e.g., relevance) demonstrated acceptability. Engaging in intimacy-building activities and communication were the skills rated as most commonly practiced and most helpful. For patients, positive effects of the IE intervention were found for female and male sexual function, medical impact on sexual function, and self-efficacy for enjoying intimacy (≥.58); no effects were found on sexual distress or intimacy and small negative effects for sexual communication, and two self-efficacy items. For partners, positive IE effects were found for all outcomes; the largest were for sexual distress (.69), male sexual function (1.76), communication (.97), and two self-efficacy items (≥.87).
The telephone-based IE intervention shows promise for couples facing colorectal cancer. Larger multi-site intervention studies are necessary to replicate findings.
PMCID: PMC4618456  PMID: 24615831
7.  Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial 
Pain  2014;155(9):1743-1754.
A multisite, randomized, controlled clinical effectiveness trial was conducted for osteoarthritis patients with chronic pain of the knee or hip. Adult health nurse practitioners provided a 10-session intervention, pain coping skills training (PCST), in patients’ doctors’ offices (N = 129 patients); the control group received usual care (N = 127 patients). Primary outcomes assessed at baseline, posttreatment, 6-month follow-up, and 12-month follow-up were: pain intensity, physical functioning, psychological distress, self-efficacy, catastrophizing, use of coping strategies, and quality of life. Secondary measures included fatigue, social functioning, health satisfaction, and use of pain medication. Methods favoring external validity, consistent with pragmatic, effectiveness research, were utilized. Primary ITT and secondary per-protocol analyses were conducted. Attrition was within the expected range: 11% at posttreatment and 29% at 12-month follow-up; rates did not differ between groups. Omnibus ITT analyses across all assessment points indicated significant improvement for the PCST group compared with the control group for pain intensity, physical functioning, psychological distress, use of pain coping strategies, and self-efficacy, as well as fatigue, satisfaction with health, and reduced use of pain medication. Treatment effects were robust to covariates (demographics and clinical sites). Trends in the outcomes across the assessments were examined. All outcomes, except for self-efficacy, were maintained through the 12-month follow-up; effects for self-efficacy degraded over time. Per-protocol analyses did not yield greater effect sizes. Comparisons of PCST patients who were more vs less treatment adherent suggested greater effectiveness for patients with high adherence. Results support the effectiveness of nurse practitioner delivery of PCST for chronic osteoarthritis pain.
PMCID: PMC4171086  PMID: 24865795
Chronic pain; Clinical nursing research; Coping skills; Osteoarthritis; Treatment effectiveness
8.  The Effects of Written Emotional Disclosure and Coping Skills Training in Rheumatoid Arthritis: A Randomized Clinical Trial 
Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing.
We randomized 264 adults with RA in a 2 × 2 factorial design to one of two writing conditions (WED vs. control writing) followed by one of two training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups.
Completion of each intervention was high (> 90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and ANCOVAs at each assessment point, found no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared to control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on one of two measures at 4 and 12 months.
The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.
PMCID: PMC4115002  PMID: 24865870
Rheumatoid arthritis; emotional disclosure; expressive writing; cognitive behavioral therapy; coping skills training; pain
9.  Improving Patients’ Understanding of Terms and Phrases Commonly Used in Self-Reported Measures of Sexual Function 
The journal of sexual medicine  2014;11(8):1991-1998.
There is a significant gap in research regarding the readability and comprehension of existing sexual function measures. Patient-reported outcome measures may use terms not well understood by respondents with low literacy.
To test comprehension of words and phrases typically used in sexual function measures to improve validity for all individuals, including those with low literacy.
We recruited 20 men and 28 women for cognitive interviews on version 2.0 of the PROMIS Sexual Function and Satisfaction measures. We assessed participants’ reading level using the word reading subtest of the Wide Range Achievement Test (WRAT). Sixteen participants were classified as having low literacy.
Main Outcome Measures
In the first round of cognitive interviews, each survey item was reviewed by 5 or more people, at least 2 of whom had lower than a ninth-grade reading level (low literacy). Patient feedback was incorporated into a revised version of the items. In the second round of interviews, an additional 3 or more people (at least 1 with low literacy) reviewed each revised item.
Participants with low literacy had difficulty comprehending terms such as aroused, orgasm, erection, ejaculation, incontinence, and vaginal penetration. Women across a range of literacy levels had difficulty with clinical terms like labia and clitoris. We modified unclear terms to include parenthetical descriptors or slang equivalents, which generally improved comprehension.
Common words and phrases used across measures of self-reported sexual function are not universally understood. Researchers should appreciate these misunderstandings as a potential source of error in studies using self-reported measures of sexual function.
PMCID: PMC4248305  PMID: 24902984
10.  Short-term Improvement in Insomnia Symptoms Predicts Long-term Improvements in Sleep, Pain, and Fatigue in Older Adults with Co-Morbid Osteoarthritis and Insomnia 
Pain  2014;155(8):1547-1554.
In a primary care population of 367 older adults (age 60+) with osteoarthritis (OA) pain and insomnia, we examined the relationship between short-term improvement in sleep and long-term sleep, pain and fatigue outcomes through secondary analyses of randomized controlled trial data. Study participants, regardless of experimental treatment received, were classified as either Improvers (≥30% baseline to 2-month reduction on the Insomnia Severity Index [ISI]) or Non-Improvers. After controlling for treatment arm and potential confounders, Improvers showed significant, sustained improvements across 18 months compared to Non-Improvers in Pain Severity (p<.001, Adjusted Mean Difference = −0.51 [95% Confidence Interval: −0.80, −0.21]), Arthritis Symptoms (p<.001, 0.63 [0.26, 1.00]), and Fear Avoidance (p=.009, −2.27 [−3.95, −0.58]) but not in Catastrophizing or Depression. Improvers also showed significant, sustained improvements in ISI (p<.001, −3.03 [−3.74, −2.32]), Pittsburgh Sleep Quality Index Total (p<.001, −1.45 [−1.97, −0.93]) and General Sleep Quality (p<.001, −.28 [−.39, −.16]) scores, Flinders Fatigue Scale (p<.001, −1.99 [−3.01, −0.98]), and Dysfunctional Beliefs about Sleep (p=.037, −2.44 [−4.74, −0.15]), but no improvements on the Functional Outcomes of Sleep Questionnaire or the Epworth Sleepiness Scale. We conclude that short-term (2-month) improvements in sleep predicted long-term (9- and 18-month) improvements for multiple measures of sleep, chronic pain, and fatigue. These improvements were not attributable to non-specific benefits for psychological well-being such as reduced depression. These findings are consistent with benefits of improved sleep for chronic pain and fatigue among older persons with osteoarthritis pain and co-morbid insomnia if robust improvements in sleep are achieved and sustained.
PMCID: PMC4104256  PMID: 24793909
Aging; Cognitive-Behavioral Therapy; Fatigue; Insomnia; Pain; Osteoarthritis; Sleep
11.  Temporal associations between spouse criticism/hostility and pain among patients with chronic pain: A within-couple daily diary study 
Pain  2013;154(12):2715-2721.
Chronic musculoskeletal pain can strain marriages, perhaps even to the point of engendering spouse criticism and hostility directed toward patients. Such negative spouse responses may have detrimental effects on patient well-being. While results of cross-sectional studies support this notion, we extended these efforts by introducing expressed emotion (EE) and interpersonal theoretical perspectives, and by using electronic diary methods to capture both patient and spouse reports in a prospective design. Chronic low back pain (CLBP) patients and their spouses (N = 105 couples) reported on perceived spouse behavior and patient pain 5 times/day for 14 days using Personal Data Assistants (PDAs). Concurrent and lagged within-couple associations between patient's perceptions of spouse criticism/hostility and patient self-reported pain and spouses’ observations of patient pain behaviors revealed that 1) patient perceived spouse criticism and hostility were correlated significantly with pain intensity, and spouse observed patient pain behavior was related significantly with patient perceived hostility at the same time point; 2) patient perceived spouse hostility significantly predicted patient pain intensity three hours later, and spouse observed pain behaviors significantly predicted patient perceived spouse hostility three hours later. Results support both EE and interpersonal models, and imply that a comprehensive model would combine these conceptualizations to fully illustrate how spouse criticism/hostility and patient pain interact to produce a negative spiral. Given that marital interactions are amenable to clinical intervention, improved insight into how spouse behavior and patient pain are tightly linked will encourage productive translational efforts to target this neglected area.
PMCID: PMC4513644  PMID: 23932908
Chronic low back pain; spouse criticism/hostility; patient pain behavior; electronic diary methods; lagged effects
12.  Anger Arousal and Behavioral Anger Regulation in Everyday Life among Patients with Chronic Low Back Pain: Relationships to Patient Pain and Function 
To determine the degree to which patient anger arousal and behavioral anger regulation (expression, inhibition) occurring in the course of daily life was related to patient pain and function as rated by patients and their spouses.
Married couples (N = 105) (one spouse with chronic low back pain) completed electronic daily diaries, with assessments 5 times/day for 14 days. Patients completed items on their own state anger, behavioral anger expression and inhibition, and pain-related factors. Spouses completed items on their observations of patient pain-related factors. Hierarchical linear modeling was used to test concurrent and lagged relationships.
Patient-reported increases in state anger were related to their reports of concurrent increases in pain and pain interference and to spouse reports of patient pain and pain behavior. Patient-reported increases in behavioral anger expression were related to lagged increases in pain intensity and interference and decreases in function. Most of these relationships remained significant with state anger controlled. Patient-reported increases in behavioral anger inhibition were related to concurrent increases in pain interference and decreases in function, which also remained significant with state anger controlled. Patient-reported increases in state anger were related to lagged increases in spouse reports of patient pain intensity and pain behaviors.
Results indicate that in patients with chronic pain, anger arousal and both behavioral anger expression and inhibition in everyday life are related to elevated pain intensity and decreased function as reported by patients. Spouse ratings show some degree of concordance with patient reports.
PMCID: PMC4513650  PMID: 25110843
Anger arousal; behavioral anger expression and inhibition; pain and function; patient and spouse ratings; electronic daily diary; lagged associations
13.  Couple-Oriented Education and Support Intervention for Osteoarthritis: Effects on Spouses’ Support and Responses to Patient Pain 
The purpose of this study was to determine whether a couple-oriented education and support intervention for osteoarthritis was more efficacious than a similar patient-oriented intervention in terms of enhancing spouses’ support of patients and their positive and negative responses to patient pain. Repeated-measures analyses of covariance with the completers sample (N = 103 dyads) showed that at the postintervention assessment, patients in the couple-oriented intervention reported a greater decrease in their spouses’ punishing responses (e.g., anger, irritation) than did patients in the patient-oriented intervention. In addition, a trend effect was observed in regard to the advantage of couple-oriented intervention for increasing spouses’ attempts to distract patients from their pain. At the 6-month follow-up, patients in the couple-oriented intervention reported greater increased spouse support than those in the patient-oriented intervention. Findings illustrate the value of examining change in specific types of marital interactions targeted in a couples intervention, and the need to strengthen the impact of future couple-oriented interventions.
PMCID: PMC2783596  PMID: 19946460
osteoarthritis; spouses; couple-oriented; randomized controlled trial
14.  Energy Recovery in Individuals with Knee Osteoarthritis 
Pathological gaits have been shown to limit transfer between potential (PE) and kinetic (KE) energy during walking, which can increase locomotor costs. The purpose of this study was to examine whether energy exchange would be limited in people with knee osteoarthritis (OA).
Ground reaction forces during walking were collected from 93 subjects with symptomatic knee OA (self-selected and fast speeds) and 13 healthy controls (self-selected speed) and used to calculate their center of mass (COM) movements, PE and KE relationships, and energy recovery during a stride. Correlations and linear regressions examined the impact of energy fluctuation phase and amplitude, walking velocity, body mass, self-reported pain, and radiographic severity on recovery. Paired t-tests were run to compare energy recovery between cohorts.
Symptomatic knee OA subjects displayed lower energetic recovery during self-selected walking speeds than healthy controls (p=0.0018). PE and KE phase relationships explained the majority (66%) of variance in recovery. Recovery had a complex relationship with velocity and its change across speeds was significantly influenced by the self-selected walking speed of each subject. Neither radiographic OA scores nor subject self-reported measures demonstrated any relationship with energy recovery.
Knee OA reduces effective exchange of PE and KE, potentially increasing the muscular work required to control movements of the COM. Gait retraining may return subjects to more normal patterns of energy exchange and allow them to reduce fatigue.
PMCID: PMC4435530  PMID: 24752039
Knee osteoarthritis; Energy recovery; Mechanical work; Locomotor costs
15.  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.
PMCID: PMC3358356  PMID: 22503223
osteoarthritis; pain; coping; physical disability; overweight; obese
16.  Pain Intensity and Pain Interference in patients with lung cancer: A pilot study of Biopsychosocial Predictors 
American journal of clinical oncology  2013;10.1097/COC.0b013e3182a79009.
To explore biopsychosocial factors (beliefs, depression, catastrophizing cytokines) in individuals newly diagnosed with lung cancer and no pain in order to determine their relationship at diagnosis and across time and to determine whether these factors contribute to pain intensity or pain interference with function at pain onset.
A longitudinal, exploratory, pilot study was implemented in a private medical center and a VA medical center in the southeast. Twelve subjects not experiencing pain related to cancer of the lung or its treatment were recruited. A Karnofsky status of 40% and Hemoglobin of 8 grams were required. Five questionnaires were completed and 10 cc of blood was drawn at Baseline; 4 questionnaires and blood draws were repeated monthly for 5 months. One Baseline questionnaire and a pain assessment were added at Final. Demographic, clinical and questionnaire data were summarized; standardized scale scores were calculated.
Biopsychosocial scores that were low at Baseline increased from T1-T4 but decreased slightly T5-T6. Individuals with higher pain intensity and higher pain interference at Final had higher psychosocial scores at Baseline than individuals with lower pain intensity and lower pain interference at Final.
Unrelated to disease stage, metastasis or treatment, unique, levels of biopsychosocial factors are observed in patients newly diagnosed with lung cancer who report higher levels of Pain Intensity and higher levels of Pain Interference at the time pain occurs. Replication studies are needed to validate this response pattern and determine the value of repeated individual assessments.
PMCID: PMC3962526  PMID: 24064756
17.  Toward a Next Generation of Widely Accessible Spatial Interfaces: Mobile VR Environments for Patients with Persistent Pain 
We present a series of multi-modal spatial interfaces and virtual environments that can be implemented with widely accessible virtual reality (VR) technologies. The results demonstrate and evaluate the new degree to which rich virtual experiences involving motion sensing, physiological inputs, stereoscopic imagery, sound, and haptic feedback can now be created using low-cost (e.g., mobile phone based) VR environments. Adapting spatial interfaces to these new platforms can open up exciting new application areas for VR. This is demonstrated through a series of prototype systems aimed at delivering in-home VR therapies to patients suffering from persistent pain conditions (e.g. arthritis pain, cancer pain). A rich spatial interface and visual aesthetic is particularly important for the success of these applications; thus an interdisciplinary team with expertise in technology, design, meditation, and the psychology of pain worked together to iteratively develop and evaluate the current prototypes.
PMCID: PMC4362961  PMID: 24807994
18.  Spouse Confidence in Self-Efficacy for Arthritis Management Predicts Improved Patient Health 
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.
The current study examined the influence of patient and spouse efficacy beliefs for arthritis management on patient health.
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.
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.
Our findings add to a growing literature that highlights the important role of spouse perceptions in patients’ long-term health.
PMCID: PMC4331068  PMID: 24604529
Arthritis; Chronic illness; Couples; Longitudinal; Self-efficacy
19.  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.
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.
PMCID: PMC3874446  PMID: 24135432
dorsolateral prefrontal cortex; neuroimaging; Voxel-Based Morphometry; pain catastrophizing; CBT
20.  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.
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.
To investigate the relationship between pain and food intake using ecological momentary assessments in a sample of 71 over-weight and obese OA patients.
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.
Pain significantly predicted calorie (Z=2.57; P=0.01) and fat intake (Z=1.99; P=0.05).
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
21.  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.
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.
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.
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).
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 Identifier NCT00736268
PMCID: PMC4197099  PMID: 25251888
COPD; stress; depression; coping skills; disease-management
22.  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.
PMCID: PMC3778108  PMID: 23791895
Pain expression; spouse responses; osteoarthritis; daily
23.  Hope in the Context of Lung Cancer: Relationships of Hope to Symptoms and Psychological Distress 
Hope may be important in explaining the variability in how patients adjust to lung cancer.
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).
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.
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).
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.
PMCID: PMC2921459  PMID: 20579840
Hope; lung cancer; pain
24.  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.
Examining the degree to which disease severity and domains of self-efficacy (pain, function, other symptoms) explain pain and functioning in rheumatoid arthritis patients.
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.
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.
Disease severity and self-efficacy both impact RA functioning and intervening in these areas may lead to better outcomes.
PMCID: PMC2885011  PMID: 20535796
25.  Validity of an Observation Method for Assessing Pain Behavior in Individuals With Multiple Sclerosis 
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.
To evaluate the reliability and validity of a pain behavioral observation protocol in individuals who have MS.
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.
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.
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.
PMCID: PMC3593957  PMID: 23159684
Multiple sclerosis; pain behaviors; observation protocol; validity

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