Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in Cantonese-Speaking Chinese Patients

Acceptance of chronic pain has become an important concept in understanding and predicting that chronic pain sufferers can remain engaged with meaningful aspects of life. Assessment of acceptance has been facilitated by the development of Chronic Pain Acceptance Questionnaire (CPAQ). In this study, we aimed to test the reliability and validity of translated Chinese version of CPAQ to use this important tool in the future management of Hong Kong Chinese patients with chronic nonmalignant pain. Content validity was established by consensus formed among a panel of 5 experts in clinical psychology and pain specialty during the process of forward and backward translations. Test-retest reliability was examined by completing the Chinese CPAQ twice, 2 weeks apart, by 54 patients. A total of 224 Chinese patients with chronic nonmalignant pain attending our cluster multidisciplinary pain clinic were asked to complete a battery of psychometric instruments in Chinese, including an intake form for demographic data, Hospital Anxiety and Depression Score (HADS), Medical Outcome Study Short Form 36 (SF-36), Pain Catastrophizing Scale (PCS), and Pain Self-Efficacy Questionnaire (PSEQ). Analysis results showed that Chinese CPAQ had good test-retest reliability (intraclass correlation coefficient, 0.79) and internal consistency reliability (Cronbach α = 0.79). The Chinese CPAQ score was significantly correlated to anxiety, depression, pain catastrophizing, pain self-efficacy, and physical and psychosocial disability. Scree plot and Principal Components Factor analysis confirmed the same 2-factor construct as the original English CPAQ. Construct validity of the Chinese CPAQ can therefore be supported. In conclusion, the Chinese CPAQ is a reliable clinical assessment tool with valid construct for acceptance measurement in our heterogeneous Chinese patients sample with chronic nonmalignant pain.

Perspective

This article confirms the reliability and validity of a Chinese version of the CPAQ. The Chinese CPAQ can then be used by pain clinicians caring for Chinese chronic pain patients worldwide for acceptance-based psychometric assessment as well as therapies.     

Schmerzakzeptanz – Konzept und Überprüfung einer deutschen Fassung des Chronic Pain Acceptance Questionnaire

Background

Up to now, only an English version of the Chronic Pain Acceptance Questionnaire (CPAQ) has been available for measuring the acceptance of chronic pain. This paper presents and analyzes a German adaptation of this instrument.

Methods

The German scale was tested on 150 patients at the DRK Pain Center in Mainz. Validity was assessed by means of various indicators of pain and psychosocial impairment. In a subgroup (n=50) the association with the heat pain threshold was determined.

Results

The factor structure of the German CPAQ scale is largely concordant with the theoretical model. The internal consistency of the total and subscales is 0.84–0.87 (Cronbach’s alpha). The factors are closely related to indicators of psychosocial functioning. Associations with the affective dimension of pain are moderate and with the sensory dimension low. No association is found with heat pain thresholds (thermal sensory analyzer).

Conclusions

The German CPAQ scale is a useful German-language instrument for the measurement of acceptance and shows good psychometric properties. The study confirms that acceptance is not an expression of a physiologically based indolence.     

The Norwegian versions of the Chronic Pain Acceptance Questionnaire CPAQ-20 and CPAQ-8 – validation and reliability studies

Purpose: The aim of this study was to test the validity and reliability of the translated Norwegian version of the Chronic Pain Acceptance Questionnaire (CPAQ-20) and the shorter version CPAQ-8 based on the same data.

Method: The sample consisted of 120 women with chronic widespread musculoskeletal pain (CWP). The respondents completed CPAQ-20 and visual analogue scales (pain, fatigue, sleep problems and depression), General Health Questionnaire-12, The Pain Catastrophizing Scale, Fibromyalgia Impact Questionnaire and SF-8. Confirmatory factor analyses were performed on a one-factor baseline model, the previous validated CPAQ-20 and CPAQ-8 models, as well as an exploratory generated model based on the current sample.

Results: The two-factor model of CPAQ-20 and a two-factor model of CPAQ-8 obtained adequate model fit and outperformed the baseline model. The exploratory factor, analysis-generated two-factor model obtained only a marginally better fit, supporting the two-dimensional model of CPAQ-20. CPAQ-20 and CPAQ-8 had Cronbach’s alphas between 0.75 (Pain Willingness subscales both versions) and 0.85. Both scales correlated significantly in the hypothesised direction with all the other scales.

Conclusion: The Norwegian versions of CPAQ-20 and CPAQ-8 are reliable assessment tools with good construct validity for measurement of acceptance. Future studies should validate the scales in other Norwegian samples.

• Implication for Rehabilitation

• CPAQ-20 and CPAQ-8 are valid Norwegian instruments for measuring acceptance of pain.

• Acceptance of pain is an important process in the rehabilitation of persons with chronic widespread pain.

• Treatment models supporting acceptance can now be developed and measured further in Norway.

     

Chronic pain affects the whole person – a phenomenological study

Abstract

Purpose: The aim of this qualitative study was to explore participants’ perspectives on the effects of chronic pain on the psychophysical unity. Methods: Thirty-four chronic pain outpatients were interviewed, and the transcribed interviews were analysed with Giorgi’s four-phase phenomenological method. The mean age of the participants was 48 years, and 19 of them were women. For 21 of the participants, the pain duration was more than 5 years, and most had degenerative spinal pain. Results: The results of this whole research project indicated that the phenomenon chronic pain consisted of four essential themes: Pain affects the whole person, invisibility, negativity, and dominance of pain. This study concentrates only on one theme “Chronic pain affects the whole person”, in which were found eight subthemes in the interviews. The strongest argument made by the participants was not the physical pain itself but the psychosocial consequences, such as distress, loneliness, lost identity, and low quality of life which were their main problems. Conclusions: In multidisciplinary holistic rehabilitation, it is essential to take care of the patient’s psychological distress. A potential source of psychosocial symptoms may be the subjective responses to experience of chronic pain due to the subjective meanings of pain.

• Implications for Rehabilitation

• About chronic pain

• Pain is an experience, not only an aversive sensation. Intensity of pain describes only the sensation, not the experience of pain.

• In chronic pain, the main complaint may be not the physical pain, but the distress. In rehabilitation, the patient needs to be taken as a whole person.

• Multidisciplinary rehabilitation, including patient counselling should be the fundamental part of treatment.

• In rehabilitation, the individual meaning of chronic pain needs to be disclosed.

     

Healthcare professionals’ perceptions of psychological treatment for chronic pain in Singapore: challenges,barriers, and the way forward

Purpose: There are very few studies on healthcare providers’ experiences of delivering treatment for chronic pain in a Southeast Asian setting. The aims of this study are to understand the experiences of professionals delivering treatment for people with chronic pain in Singapore and identify possible barriers to psychological treatment for this condition within the broader experiences of these professionals. Method: Healthcare professionals with at least 1-year experience treating chronic pain were recruited and purposefully sampled. Fifteen inductive semi-structured interviews were conducted to explore healthcare professionals’ experiences of treating people with chronic pain. Interviews were transcribed verbatim and analysed using thematic analysis. Results: Four main themes were identified: ‘System Barriers’, ‘Core Beliefs and management of Chronic Pain’, ‘Engaging Patients in treatment’ and ‘Creating Awareness for Chronic Pain Management’. Professionals trained in a multidisciplinary approach to pain management were seen as rare. Professionals who could refer patients for psychological treatment do not refer due to costs, and their perception that patients may lack understanding of such a treatment. Conclusion: Reducing barriers in the access to psychological treatment in settings like Singapore will require a multifaceted approach.

• Implications for Rehabilitation

• A multifaceted approach is required to reduce barriers to psychological treatment for chronic pain in settings like Singapore.

• Educating healthcare professionals on the need for a multidisciplinary approach to chronic pain could help in reducing misconceptions and increase understanding of the benefits of psychological approaches.

• Utilizing both media and technological platforms as a means to facilitate psychological treatment uptake for chronic pain may be a way forward for a technological savvy generation.

     

Adapting principles of chronic pain self-management to the workplace

Purpose: To evaluate the extent to which the principles of chronic pain or illness self-management (SM) programs might be adapted to focus on the workplace concerns of adults with persistent or recurrent pain and lead to new workplace intervention opportunities. Method: Eight SM programs were selected as representative evidence-based programs and then compared to extract common instructional elements. Elements were analyzed for potential application to four workplace problem domains identified by workers with pain: activity interference, negative self-perceptions, interpersonal challenges, and the inflexibility of work. Results: Of 24 instructional elements, 17 were shared by at least half of the SM programs. Instructional elements judged to be best suited for dealing with workplace concerns included those focused on reducing pain and discomfort, making informed decisions, communicating effectively, and dealing with thoughts and feelings. However, aspects of the workplace that may alter the feasibility or effectiveness of SM strategies include the level of physical demands and limitations, job leeway, and the nature of workplace roles and relationships. Conclusions: Principles and methods of SM intervention programs are generally well suited to address pain-related problems in the workplace, but tailoring of messages may be necessary to incorporate the unique organizational, physical, and social aspects of work into psycho-educational programs.

Implications for Rehabilitation

• Chronic pain is a growing problem among working age adults that can contribute to workplace difficulties and disability.

• Pain self-management interventions applying psycho-educational techniques are generally well-suited for dealing with workplace problems.

• Pain self-management interventions may reduce pain and discomfort in the workplace, help with job-related problem-solving and decision-making, provide methods for communicating needs effectively, and deal with negative thoughts and feelings at work.

• Applying existing pain self-management techniques in the workplace requires that some changes be made to incorporate the unique organizational, physical, and social aspects of the workplace.

     

Comorbid insomnia in patients with chronic pain: a study based on the Swedish quality registry for pain rehabilitation (SQRP)

Abstract

Purpose: This study investigates the prevalence of insomnia and its relationship to other symptoms and health aspects in patients with chronic pain. Methods: Patients with chronic pain conditions (n?=?845) referred to a multidisciplinary pain centre completed surveys provided by the Swedish quality registry for pain rehabilitation (SQRP). The SQRP collects data on socio-demographics, health status, symptoms of pain, mood and insomnia and life satisfaction. Results: The majority of patients (65.3%) had clinical insomnia according to the insomnia severity index (ISI). Insomnia correlated significantly but weakly with pain, depression, anxiety and coping; the strongest multivariate correlations were found with depression and anxiety followed by pain interference and pain severity. Pain intensity, depression and anxiety correlated stronger than ISI with respect to the two investigated aspects of health. Conclusions: The prevalence of insomnia is high in patients with chronic pain conditions, but the level of importance in relation to other symptoms for health aspects is low, and the associations with other important symptoms are relatively weak. One way to increase the effects of multimodal rehabilitation programs may be to provide interventions directed specifically at insomnia rather than focusing only on interventions that address pain, depression and anxiety.

• Implications for Rehabilitation

• The prevalence of insomnia is high in patients with complex chronic pain conditions.

• Relatively low correlations existed between insomnia and pain intensity, depression, anxiety and other psychological aspects.

• Pain intensity, anxiety and depression were more important for perceived health aspects than insomnia.

• One way to increase the effects of multimodal rehabilitation programs may be to also include interventions directed directly to insomnia.

     

Quality of life of Finnish children with cerebral palsy

Purpose: The aim of this study was to examine the quality of life (QOL) of Finnish children with cerebral palsy (CP) in different parts of Finland from the children’s and caregivers’ perspectives. The acceptability of the Finnish version of the CP QOL-Child questionnaire for clinical use is also evaluated. Method: This study was conducted in 2010–2013 as a part of the national CP-project. It is based on validated CP QOL-Child questionnaires. Children between 9 and 12 years were asked to fill in the child-self-report version. Caregivers who had a 4- to 12-year-old child with CP filled in parent-proxy reports. Results: Responses were obtained from 63 children and 161 caregivers. The response rates were 63 and 60%, respectively. Overall QOL was reported to be fairly good with no significant regional differences within Finland. Children reported significantly higher QOL in all QOL-domains except “social wellbeing and acceptance” than their caregivers did. The results showed acceptable levels of internal consistency of the Finnish version of the CP QOL-Child. Conclusions: QOL of children with CP is quite good in Finland. However, barriers to participation and the impact of disability and pain impair QOL. The Finnish version of the CP QOL-Child questionnaire is an appropriate clinical tool to assess QOL.

• Implications for Rehabilitation

• The used questionnaire provides an effective tool to identify areas for targeting support actions and to set goals for rehabilitation plans.

• The study brings forward the voices of children.

• It was found that pain has a great role in QOL, which should be taken into account when making rehabilitation plans.

• The participation of children with CP should be strengthened in every possible ways.

     

Evaluating pain in cerebral palsy: comparing assessment tools using the International Classification of Functioning,Disability and Health

Abstract

Purpose: Pain is prevalent and affects functioning and quality of life of children with cerebral palsy (CP). However, pain in CP is under recognized. The International Classification of Functioning, Disabiity and Health (ICF) guides the selection of comprehensive chronic pain assessment tools. Our objectives were to identify measures addressing pain in children with CP, characterize the content of each measure using the ICF, and identify gaps and overlaps.

Materials and methods: Measures were identified from: (1) a systematic review of outcome measures (1998–2012) and (2) a scan of chronic pain measures (2013–2015). Included measures were those published in English, used in children and youth with CP, and contained an item/domain addressing pain. Constructs of the measures were linked to the ICF.

Results: Overall, 31 measures addressing chronic pain in CP were included. Considerable variability was found in the degree to which their content represented the ICF. Most of pain measures address pain intensity and pain location (body functions) as opposed to functional impact of pain (activities and participation).

Conclusions: Functional dimensions are poorly represented in pain measures. Our findings may guide the selection of measures for research and clinical needs for comprehensive chronic pain management in children with CP.

• Implications for Rehabilitation

• Chronic pain is prevalent among children with cerebral palsy and significantly interfere with functional activities.

• To effectively manage chronic pain in children with cerebral palsy, measures capturing functional-based information need to be part of routine chronic pain assessment.

     

Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain

Abstract

Purpose: The present study aimed to identify predictors of rehabilitation outcome for patients with chronic musculoskeletal pain (CMP) and psychological problems. Methods: A retrospective cohort study including 230 adult patients with CMP admitted for multidisciplinary pain rehabilitation. Potential predictors were patient characteristics, duration of complaints, baseline functioning, pain, personality, coping style, fear of movement, psychological distress and type of treatment. Outcome measures were physical functioning, mental health, pain and patient-reported effect. Multiple (logistic) regression models were used to identify predictors. Results: Patients who were more disabled and patients with more pain benefitted more from the rehabilitation treatment than less disabled patients or those with less pain. Age, work status, vitality, depression and coping style also predicted outcomes significantly. The models explained between 27 and 80% of the outcomes. There was an interaction between type of treatment, work status and the baseline pain score as regards the outcome in terms of pain. Conclusions: No strong predictors of treatment outcome were found other than the baseline scores of the respective outcome variables. More disabled patients and patients with more pain benefitted more from the rehabilitation program. Other predictors improved the prediction models slightly.

• Implications for Rehabilitation

• It remains challenging to correctly predict the outcome of treatment from patients’ baseline sociodemographic and psychological characteristics; predictors other than baseline scores of the outcome variables are only slightly associated with treatment outcome.

• Patients with chronic musculoskeletal pain and poor physical functioning or mental health benefit most from pain rehabilitation.

• Older patients benefit less from a pain rehabilitation program than younger patients in terms of physical functioning.

• Pain reduction during a pain rehabilitation program is greatest in patients with high pain intensity who are not at work at the start of the rehabilitation program.

• Coping style influences the outcome of rehabilitation of patients with chronic musculoskeletal pain.

     

Dutch version of the Fear of Pain Questionnaire for adolescents with chronic pain

Background: Fear of pain is important in the development and maintenance of chronic pain. The Fear of Pain Questionnaire-Child version has been developed to assess pain related fear in children and adolescents.

Objective: Translating the original questionnaire into Dutch, and investigating internal consistency and construct validity to enable use in the Dutch pain rehabilitation setting for treatment and research.

Methods: Cross-sectional validation study: After forward and back translation of the FOPQ-C, adolescents (11–22 years old) with chronic musculoskeletal pain completed an assessment containing the Dutch Fear of Pain Questionnaire, and questionnaires about demographics, pain catastrophizing, functional disability, and pain intensity. Internal consistency and construct validity were evaluated through exploratory factor analysis (principal axis factoring with oblique rotation) and hypotheses testing using pain catastrophizing, functional disability, and pain intensity as comparative constructs.

Results: Eighty-six adolescents completed the assessment. Exploratory factor analysis resulted in a two-factor structure, explaining 43% of the variance. Internal consistency was strong (Cronbach’s α?=?0.92 total scale, α?=?0.88 factor 1, and α?=?.86 factor 2). Five out of 6 hypotheses were confirmed.

Conclusions: The Dutch version demonstrated good internal consistency and good construct validity in a population of adolescents with chronic musculoskeletal pain.

• Implications for rehabilitation

• The Fear of Pain Questionnaire-Child version was developed to measure fear of pain and avoidance in children and adolescents with chronic pain.

• Identification of fear of pain and activities that are being avoided are important during screening and assessment of the adolescent for chronic pain rehabilitation treatment.

• The presence of fear of pain and/or avoidance behavior is important information to shape and target multidisciplinary rehabilitation treatment.

     

Health-related quality of life improvements among women with chronic pain: comparison of two multidisciplinary interventions

Purpose: To measure the effect of 4 weeks traditional multidisciplinary pain management program (TMP) versus neuroscience education and mindfulness-based cognitive therapy (NEM) on quality of life (HRQL) among women with chronic pain. Method: This observational longitudinal cohort study conducted in an Icelandic rehabilitation centre included 122 women who received TMP, 90 receiving NEM, and 57 waiting list controls. Pain intensity (visual analogue scale) and HRQL (Icelandic Quality of Life scale) were measured before and after interventions. ANOVA and linear regression were used for comparisons. Results: Compared with controls we observed statistically significant changes in pain intensity (p?p?p?=?0.008). Head to head comparison between study groups revealed that pain intensity improved more among TMP participants (21.8 versus 17.2?mm; p?=?0.013 adjusted). Women with low HRQL at baseline improved more than those with higher HRQL (mean TMP?=?13.4; NEM?=?12.9 if HRQL?≤?35 versus mean TMP?=?6.6 and NEM?=?7.8 if HQRL?>?35). Conclusions: Our non-randomized study suggests that both NEM and TMP programs improve pain and HRQL among women with chronic pain. Sleep quality showed more improvements in NEM while pain intensity in TMP. Longer-term follow-ups are needed to address whether improvements sustain.

• Implications for Rehabilitation

• Chronic pain is a debilitating condition affecting quality of life and restricting societal participation.

• Intensive multidisciplinary bio-psycho-social rehabilitation is essential for this patient group.

• This study shows improvement in health-related quality of life and pain intensity following such rehabilitation.

• Emphasizing mindfulness based cognitive therapy and neuroscience patient education improves sleep to more extend than more traditional approach.

     

Screening and assessment of chronic pain among children with cerebral palsy: a process evaluation of a pain toolbox

Abstract

Purpose: Though high numbers of children with cerebral palsy experience chronic pain, it remains under-recognized. This paper describes an evaluation of implementation supports and adoption of the Chronic Pain Assessment Toolbox for Children with Disabilities (the Toolbox) to enhance pain screening and assessment practices within a pediatric rehabilitation and complex continuing care hospital.

Methods: A multicomponent knowledge translation strategy facilitated Toolbox adoption, inclusive of a clinical practice guideline, cerebral palsy practice points and assessment tools. Across the hospital, seven ambulatory care clinics with cerebral palsy caseloads participated in a staggered roll-out (Group 1: exclusive CP caseloads, March–December; Group 2: mixed diagnostic caseloads, August–December). Evaluation measures included client electronic medical record audit, document review and healthcare provider survey and interviews.

Results: A significant change in documentation of pain screening and assessment practice from pre-Toolbox (<2%) to post-Toolbox adoption (53%) was found. Uptake in Group 2 clinics lagged behind Group 1. Opportunities to use the Toolbox consistently (based on diagnostic caseload) and frequently (based on client appointments) were noted among contextual factors identified. Overall, the Toolbox was positively received and clinically useful.

Conclusion: Findings affirm that the Toolbox, in conjunction with the application of integrated knowledge translation principles and an established knowledge translation framework, has potential to be a useful resource to enrich and standardize chronic pain screening and assessment practices among children with cerebral palsy.

• Implications for Rehabilitation

• It is important to engage healthcare providers in the conceptualization, development, implementation and evaluation of a knowledge-to-action best practice product.

• The Chronic Pain Toolbox for Children with Disabilities provides rehabilitation staff with guidance on pain screening and assessment best practice and offers a range of validated tools that can be incorporated in ambulatory clinic settings to meet varied client needs.

• Considering unique clinical contexts (i.e., opportunities for use, provider engagement, staffing absences/turnover) is required to optimize and sustain chronic pain screening and assessment practices in rehabilitation outpatient settings.

     

Short- and long-term effects of a six-week clinical Pilates program in addition to physical therapy on postmenopausal women with chronic low back pain: a randomized controlled trial

Purpose: To determine the short- and long-term effectiveness of the application of Clinical Pilates in addition to physical therapy versus a physical therapy treatment alone in a population of postmenopausal women with chronic low back pain (CLBP). Methods: A single-blind randomized controlled trial with repeated measures and a follow-up period. One hundred and one patients were randomly allocated to a Pilates?+?physical therapy (PPT) group or to a physical therapy (PT) only group for six weeks. Pain and disability were measured by visual analog scale (VAS) and the Oswestry disability index respectively preintervention, after 6 weeks of treatment and after 1-year follow-up. Results: There were significant differences between groups in pain and disability after 6 weeks of treatment, with better results in the PPT group with an effect size of d?=?3.14 and d?=?2.33 for pain and disability. After 1-year follow-up, only PPT group showed better results compared with baseline with an effect size of d?=?2.49 and d?=?4.98 for pain and disability. Conclusion: The results suggest that using Clinical Pilates in addition to physical therapy provides improved results on pain management and functional status for postmenopausal woman with CLBP and that its benefits still linger after one year.

• Implications for Rehabilitation

• Chronic Low Back Pain could benefit from the Pilates practice in postmenopausal women.

• Improvement in pain and disability derived from CLBP seem to be maintained over time due to Pilates practice.

• Pilates constitutes a safe tool to be applied in older population with CLBP due to its ability to be adapted to every performance and physical level.

     

Meanings of “acceptance” for patients with long-term pain when starting rehabilitation

Purpose: The study aimed to elucidate the meaning of acceptance in relation to the lived body and sense of self when entering a pain rehabilitation programme. Methods: Six women and three men with long-term pain were interviewed. The interviews were analysed according to interpretative phenomenological analysis. Results: The analysis revealed three different meaning structures, first: acceptance as a process of personal empowerment, “the only way forward”. Here, the individuals expressed that the body felt integrated: a trusting cooperation between self and body gave rise to hope. Second: acceptance as an equivocal project, a possible but challenging way forward. The hopeful insight was there, acknowledging that acceptance was the way to move forward, but there was also uncertainty and doubt about one’s ability with a body ambiguous and confusing, difficult but important to understand. Third, in acceptance as a threat and a personal failure, “no way forward” the integration of the aching body in sense of self was impossible and pain was incomprehensible, unacceptable and unfair. Pain was the cause of feeling stuck in the body, affecting the sense of self and the person’s entire life. Conclusions: The meaning of acceptance was related to acceptance of the persistency of pain, to how the individual related to the lived body and the need for changes in core aspects of self, and to the issue of whether to include others in the struggle of learning to move on with a meaningful life.

• Implications for Rehabilitation

• Healthcare professionals should be aware that individuals with long-term pain conceptualize and hold different meanings of acceptance when starting rehabilitation; this should be considered and addressed in rehabilitation programmes.

• The meaning given to acceptance is related to the experience of the lived body and the sense of self, as well as to getting legitimization/acceptance by others; therefore these aspects need to be considered during rehabilitation.

• The process of achieving acceptance seems to embrace different processes which can be understood as, and facilitated by, an embodied learning process.

• The bodily existential challenges presented in the present study, for example to develop an integrated and cooperative relationship with the painful body, can inspire health professionals to develop interventions and communication strategies focusing on the lived body. A wide range of competencies in rehabilitation clinics seems to be needed.

     

Basic body awareness therapy or exercise therapy for the treatment of chronic whiplash associated disorders: a randomized comparative clinical trial

Purpose: Chronic whiplash-associated disorders (WAD) incur both costs and suffering. Treatments that can relieve chronic WAD are therefore needed. Exercise therapy (ET) has been shown to provide pain relief. Another often used treatment for chronic pain in Scandinavia is basic body awareness therapy (BAT). We compared the effectiveness of 10 weeks of twice-weekly, 90-min sessions of either ET or BAT in a randomized comparative trial. Method: We recruited 113 patients suffering from chronic WAD grades I–III and several years’ duration of symptoms in a primary health care setting. 57 were allocated to ET and 56 to BAT. Primary outcome measures were Neck Disability Index and SF-36 v.2. Results: From baseline to post-treatment, the BAT group increased their physical functioning (median 5, IQR?=?15) more than the ET group (median?=?0, IQR?=?15), p?=?0.032, effect size ?0.54. Three months after the end of treatment, the BAT group had less bodily pain (m?=?17.5, 95% CI 6.9–17.6) than the ET group (m =?4.9, 95% CI ?0.1 to 9.8), p?=?0.044, effect size ?0.4. The BAT group had also increased their social functioning (m?=?13.3, 95% CI 6.6–19.9) more than the ET group (m?=?3.5, 95% CI ?3 to 9.9), p?=?0.037, effect size ?0.41. No statistically significant differences between groups were found for the change of other outcomes. No serious adverse effects were found in either groups. Conclusions: The present trial indicates that BAT led to greater improvements than ET for the patients with chronic WAD.

• Implications for Rehabilation

• Chronic whiplash-associated disorders are disabling and incur great costs to society often through inability to work.

• Exercise therapy (ET) may alleviate symptoms of chronic WAD.

• Basic body awareness therapy (BAT) is often a component of multimodal pain rehabilitation programs.

• In this randomized comparative trial, BAT increased physical functioning and led to greater pain reduction and social functioning 3 months after the end of treatment.

     

Early maladaptive schema factors,pain intensity,depressiveness and pain disability: an analysis of biopsychosocial models of pain

Purpose: To test different biopsychosocial models of pain within two different samples. Method: Early maladaptive schemas, pain intensity, depressiveness and pain disability were assessed using questionnaire data from 271 first visit pain patients and 276 municipal employees as controls. Exploratory factor analysis was used as the early maladaptive schema factor extraction method and path analysis as the model specification and estimation method. Results: Cross-sectionally, early maladaptive schema factors were predictors of depressiveness in both groups. The effect size of depressiveness on pain disability was 11 times that of the pain intensity in the pain patient group. The situation was opposite in the control group, where effect size of pain intensity was 5.6 times that of depressiveness. In subgroups of pain duration, the effect size of pain intensity on pain disability became insignificant when pain duration was more than 2 years in pain patients. Conclusions: The study supported the importance of early emotional adversities in predicting depressiveness especially among pain patients. Depressiveness was the main predictor of pain disability in the pain patient group and as the pain duration increased, the significance of pain intensity on disability vanished. Pain intensity was the main predictor of pain disability in the control group.

Implications for Rehabilitation

• To decrease disability among chronic pain patients is mainly to treat their depressiveness.

• To decrease disability among people with mild pain is mainly to treat their pain intensity.

• The focus of psychotherapy among depressive chronic pain patients should be a pattern of inadequacy, shame, submission, failure, social isolation and dependence.

     

Effects of long-term home-based exercise on health-related quality of life in patients with chronic neck pain: A randomized study with a 1-year follow-up

Purpose: To evaluate whether long-term neck and upper body exercises conducted in economical community-based outpatient clinic and home-based settings could improve health-related quality of life (HRQoL)for individuals affected by chronic neck pain. The effect of baseline HRQoL and neck pain values on training adherence was also studied. Methods: Subjects (n?=?101, 91 women/10 men, mean age 41.0?±?9.5 years) with chronic non-specific neck pain were randomized to a combined strength-training and stretching-exercise group (CSSG, n?=?49) or to a stretching exercise group (SG, n?=?52). HRQoL was assessed at baseline and after 12 months using the RAND-36 questionnaire. Comparisons between groups were performed using bootstrap-type analysis of covariance. The impact of HRQoL and neck pain values on training adherence, determined using participants’ exercise logs, was studied using generalized estimating equations. Results: CSSG showed significant improvements in five and SG in four of eight of the HRQoL dimensions. There were no significant differences between the groups. Adherence to long-term training was only slightly affected by baseline-assessed HRQoL and neck pain values. Conclusions: The two training protocols were feasible and equally effective in improving HRQoL. Baseline HRQoL and pain values had only a minor effect on training adherence.

Implications for Rehabilitation

• Long-term strength training and stretching are effective in improving HRQoL in people with chronic neck pain.

• Baseline HRQoL and neck pain values have little effect on training adherence.

     

What does coping mean to the worker with pain-related disability? A qualitative study

Purpose: Pain coping is important in health outcomes. In the current literature, pain coping usually means those goal-directed strategies to manage pain. The study goal was to explore what personal meaning “coping” has for work-disabled individuals in pain. Method: Qualitative, in depth interviews with follow-up verification interviews were conducted with 13 volunteers who were off work and in rehabilitation for chronic pain from a musculoskeletal injury. The two main questions were: (1) How did participants understand the term “coping with pain”; and (2) how did they come to this understanding of coping. The theoretical approach was social phenomenology and data were analyzed using thematic analysis. Results: The dominant theme was that pain coping is an intrinsic and life-defining attitude and belief. This understanding primarily arose through early modeling by parents and significant others. Secondary theme was that coping is practical strategies to manage or eliminate pain. This arose through more current interactions with health care providers and others in the social network. Conclusions: Researchers’ and clinicians’ view of coping may not always match the views held by individuals with chronic pain. This might impact on the effectiveness of interventions designed to modify coping behaviors, and alternative ways of intervening may be needed.

Implications for Rehabilitation

• Coping has an important impact on health recovery after musculoskeletal injuries but interventions to modify pain coping strategies in those with chronic pain have met with modest success.

• The dominant model for coping in the research literature defines coping as a behavioral and/or cognitive response to a stressful situation.

• A qualitative study to examine what personal meaning “coping” holds for work-disabled persons with chronic pain suggests that coping is primarily conceptualized as an intrinsic and life-defining attitude/belief learned early in life.

• The above incongruence between the dominant research model of coping and the views of workers with chronic pain might impact on the effectiveness of interventions designed to modify coping behaviors for this population, and alternative ways of intervening may be needed.