Conducting rehabilitation groups for people suffering from chronic pain

Dysvik E, Stephens P. International Journal of Nursing Practice 2010; 16 : 233–240
Conducting rehabilitation groups for people suffering from chronic pain The aim of this study was to offer guidelines for counsellors who work with rehabilitation groups of patients with chronic pain. The sample involved nine counsellors engaged in a multidisciplinary pain management programme. Two focus group interviews were conducted. Data were analysed using qualitative content analysis. These indicate that main challenges facing counsellors were related to maintaining constructive group processes and being mentally prepared. The counsellors reported that knowledge concerning self‐awareness, theoretical frameworks and counselling techniques was important. Personal learning included: group leadership, teamwork, grasping the inside story and obtaining supervision. The results show how important it is to have trained counsellors that are well prepared to prevent and deal with challenging group processes. Counsellors need to understand the concept of pain and be acquainted with cognitive behavioural framework and group processes. The results indicate that counsellors perceive regular supervision as supportive and is likely to promote good team functioning.     

慢性疼痛患者疼痛恐惧心理研究进展

本文从疼痛恐惧的概念及来源、疼痛恐惧对慢性疼痛患者的影响、疼痛恐惧的测评工具、疼痛恐惧的干预方法4个方面进行综述,以期为今后采取有效措施降低慢性疼痛患者疼痛恐惧水平、提高疼痛管理效果提供参考。     

Attention management as a treatment for chronic pain

Attention management is often included in cognitive‐behavioural treatments (CBT). The aim of this study was to evaluate the effects of attention management strategies in the treatment for chronic pain. The present pilot study consisted of six weekly 90‐min treatment sessions and was based on a CBT attention management manual describing techniques such as attention diversion, imagery and mindfulness exercises. The intended outcomes were reduction in pain‐related anxiety and hypervigilance to pain and decrease in pain impact of everyday life, measured by self‐report. Information was collected at baseline, pre‐treatment, post‐treatment, and at 3 and 6 months follow‐up. The results at the end of treatment, and at 3‐month follow‐up, show significant reductions in pain‐related anxiety, hypervigilance and interference of pain (effect sizes 0.40–0.90). Reduction in pain‐related interference and anxiety remained at the 6‐month follow‐up. The results indicate that attention control skills can be a useful method to reduce anxiety in the short term. Clinical implications of the results are discussed.     

How chronic pain patients cope with pain: Relation to treatment outcome in a multidisciplinary pain clinic

One hundred male and 100 female chronic pain patients in a multidisciplinary pain clinic completed a 34-item Pain Coping Questionnaire (PCQ). Factor analysis identified four pain coping factors: self-management, helplessness, social support, and medical remedies. Multiple-regression analyses were conducted to determine the relation between PCQ factors and measures of adjustment at admission to the pain program as well as admission to discharge changes in adjustment measures. The following concepts relevant to coping with chronic pain were defined: cognitive strategies, self-efficacy, helplessness, catastrophizing, and cognitive distortion. Suggestions were made for integrating these concepts in the development of scales for assessing strategies for coping with chronic pain.     

Short wave diathermy in the symptomatic management of chronic pelvic inflammatory disease pain: A randomized controlled trial

Background and Purpose. Chronic pelvic inflammatory disease (PID) refers to both residue of acute and sub‐acute recurrence of a previous infection or/and as a result of late detection of and intervention for upper tract pelvic infection. Owing to the chronic nature of the disease, which may require large doses of analgesics and/or antibiotics both of which may have side effects on the body, there is a need for a non‐invasive therapeutic and symptomatic chronic pain management. The main purpose of this study was to determine the efficacy of short wave diathermy (SWD) in the symptomatic management of chronic PID pain. Method. An independent group; double blind random assignment design was used in data collection. A total of 32 subjects diagnosed as chronic PID patients referred for physiotherapy were randomly assigned to three (SWD, control and analgesic) groups. The SWD group received antibiotics, placebo (sham analgesic) tablets and SWD using the crossfire technique for an average of 15 exposures lasting for 20 minutes on alternate days of the week. Other groups; Analgesic group received antibiotics, Analgesics and sham SWD; while the control group received antibiotics, sham SWD and placebo tablets. The study lasted for a period of 30 days. Result. Findings of the study revealed significant effect of SWD over analgesic and control in pain responses and resolution of inflammation at p < 0.05. Conclusion. It was concluded that SWD may be an effective and non invasive therapy in the management of chronic PID pain. Copyright © 2010 John Wiley & Sons, Ltd.     

Nursing leadership in a chronic pain management group approach

Dysvik E. & Furnes B. (2012) Journal of Nursing Management 20, 187–195
Nursing leadership in a chronic pain management group approach Aim To explore and debate nursing leadership and challenges on organizational and group levels when conducting rehabilitation groups for people suffering from chronic pain. Background Group approaches based on cognitive behavioural therapy are generally described as effective. Leadership in group approaches offered to people suffering from chronic pain is a great challenge for nurses on an organizational as well as a group level. Methods One overall leader and nine group leaders conducting 13 groups constituted the sample. Qualitative content analysis was used by identifying categories, subthemes and themes. Results The results from the content analysis revealed one main theme (‘Complexity in nursing leadership’) and three subthemes (‘Challenges in leadership on organizational level’, ‘Challenges in leadership on teamwork level’ and ‘Challenges in leadership on group level’. Conclusions The results show how important it is to have firm overall leadership and trained group leaders with a common purpose, interdependent roles and complementary skills, who are thus well prepared to prevent or deal with challenging group processes. Implications for nursing management The leaders of both levels, which are highly interrelated, should have a current theoretical understanding of pain theory, group leadership skills and a cognitive behavioural approach.     

A pain workshop: an approach to eliciting the views of young people with chronic pain

Chronic pain is complex and there is still much to discover about the burden that it places on children and their families. The aim of this study was to explore the way in which the experience of chronic pain impacts on the lives of young people. Through the use of a pain workshop that involved a series of guided activities and a focus group, young people were able to share their experiences with each other and the facilitators/researchers. Data were analysed using a theoretical coding technique supported by Atlas.ti. Five key interlinked themes emerged from the data and each theme is expressed in the words of the young people themselves: 'no one's pain's the same', 'getting on with it', 'it's hard 'cos...', 'keeping with the dream', and 'it depends ... some are OK'. The young people did experience significant disruption in their lives as a result of their pain. Pain was experienced as if it was both a separate entity as well as an intrinsic part of them and, to a degree, blighted their future. Based on the experiences shared by the young people, professionals need to develop insight and strategies into the challenges young people with chronic pain face on a daily basis.     

Primacy of existential pain and suffering in residents in chronic pain in nursing homes: a phenomenological study

The study's rationale:  Chronic pain is a major health problem among the elderly, both in the community and within nursing homes.
Aims and objectives:  The purpose of the study was to examine the essentials of the experience of residents in chronic pain in nursing homes.
Methodological design and methods:  The research approach was interpretive phenomenology. Data were collected in 23 dialogues with 12 residents, ages 74–97. Mean age was 86 years.
Results:  The main finding is the primacy of existential pain and suffering in residents in chronic pain in nursing homes. Indeed they recounted a culmination of existential pain and suffering, e.g. loss of loved ones, loss of former home, health and independence, as well as loss of connectedness. Many seemed to be in some kind of grief and their work towards reconciliation to their life and circumstances seemed an ongoing process with successful results while others seemed more haltering or even stuck. Living with chronic pain in a nursing home is indeed a challenge and many blocks to successful pain management were identified. The main sources of strength were loved ones who were seen as lifelines . Nurses seemed distant in their narratives of pain management.
Study limitations:  Frailty of residents is a limitation as a few were starting to forget from one interview to the other and some were actually in pain at the time of our dialogue.
Conclusions:  It is important to support a healthy process of grieving and reconciliation in elderly people who live with chronic pain in nursing homes. Those who suffer in silence with their pain and discomforts and do not seek help should be identified and cared for. The residents' own sources of strength should be identified and supported. Multi-professional collaboration with educational thrust is needed towards quality pain management of elderly people in nursing homes where existential pain and suffering is not excluded.     

A randomized trial to determine the duration of analgesia following a 15- and a 30-minute application of acupuncture-like TENS on patients with chronic low back pain

Background: Acupuncture-like TENS (AL-TENS) has been shown to produce prolonged pain relief, but no study has yet investigated its duration on a population suffering from chronic low back pain (CLPB). Objective: Our objective was to quantify the duration and magnitude of analgesia induced by a 15- or 30-minute application of AL-TENS. Methodology: We recruited a sample of 11 participants presenting with CLBP and conducted a randomized, crossover study, where participants were given AL-TENS for 15 and 30 minutes on two separate occasions. The pain intensity of their CLBP was assessed with a visual analogue scale before, during, and after AL-TENS applications. Magnitude and duration of analgesia were determined for each subject and for both AL-TENS application times. Results: The AL-TENS applications induced a clinically and statistically significant (p = 0.003) analgesia in all participants. Median duration of analgesia was 9 hours and 10 hours 30 minutes following the 15- and 30-minute AL-TENS applications, respectively; this 1.5-hour difference was not statistically significant (p = 0.55). Furthermore, we observed no significant difference in the magnitude of analgesia between both applications of AL-TENS (p > 0.56), suggesting that the duration of application of AL-TENS does not influence the magnitude of analgesia. Conclusion: Our results suggest that clinicians could use a 15-minute AL-TENS application to provide significant analgesia in patients presenting with low back pain since if provides a comparable analgesia versus a 30-minute application.     

Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash

Cognitive behavior therapy (CBT) has made important contributions to chronic pain management, but the process by which it is effective is not clear. Recently, strong arguments have been raised concerning the need for theory driven research to e.g. identify mechanisms of change in CBT and enhance the effectiveness of this type of treatment. However, the number of studies addressing these issues is still relatively scarce. Furthermore, the arrival of varieties of CBT with seemingly different process targets increases the need for such information. The present study explored the processes of change in a previously reported successful randomized controlled trial evaluating the effectiveness of an exposure‐based form of behavioral and cognitive therapy, Acceptance and Commitment Therapy (ACT), on improvement in pain‐related disability and life satisfaction for patients suffering from whiplash‐associated disorder (WAD). Several process variables relevant to theories underlying traditional CBT were included: pain, distress, kinesiophobia, self‐efficacy, and the process primarily targeted by ACT: psychological inflexibility. Mediation analyses were performed using a non‐parametric cross‐product of the coefficients approach. Results illustrated that pain intensity, anxiety, depression, kinesiophobia, and self‐efficacy did not have significant mediating effects on the dependent variables. In contrast, significant indirect effects were seen for psychological inflexibility on pain‐related disability (pre‐ to post‐change scores) and life satisfaction (pre‐ to post; pre‐ to 4‐month follow‐up change scores). Although tentative, these results support the mediating role of psychological inflexibility in ACT‐oriented interventions aimed at improving functioning and life satisfaction in people with chronic pain.     

Living a meaningful life with chronic pain from a nursing perspective. Narrative approach to a case story

This paper is a case story discussing the experience of chronic pain from the perspective of the sufferer and suggests ways of improving the use of this perspective in nursing care. A narrative approach is adopted and the analysis was based on content analysis. A condensation of meaning-units revealed a variation in subthemes: the body in pain, striving to preserve self and self-fulfilment. The extent to which living a meaningful life is possible seems to depend on several complex factors, including a person's belief system, life experiences, personal resources, the meaning of pain and the extent to which nurses understand the overall situation. This story might indicate that nociceptive pain can be less important than pain that reduces long-term life quality. A better understanding of living with chronic pain based on cognitive-behavioural techniques could be linked to the information drawn from the narrative and used to improve nursing practice.     

The effectiveness of graded activity in patients with non-specific low-back pain: a systematic review

Background: Non-specific low-back pain (LBP) is considered a major health and economic problem in Western society. Nowadays a common used intervention on non-specific LBP is graded activity (GA). Graded Activity developed by Lindström et al., consisted of four parts: (i) measurements of functional capacity; (ii) a work-place visit; (iii) back school education and (iv) an individual, sub-maximal, gradually increased exercise program with an operant-conditioning behavioural approach as described by Fordyce et al. Objective: To evaluate the effectiveness of GA in adults with non-specific LBP on pain, disabilities and return to work. Data sources: An extensive literature search of PubMed, Embase, CINAHL and The Cochrane Library was conducted in July 2011. Review Methods: Randomized controlled trials (RCTs) evaluating the effect of GA in patients with non-specific LBP were eligible. Methodological quality of the studies was assessed according to the PEDro scale. A best-evidence synthesis was conducted according to van Peppen et al. to interpret the outcomes of the included studies. Results: Ten articles were included in this systematic review; these articles described five RCTs (680 patients). The best-evidence synthesis revealed that there was no or insufficient evidence for a positive effect of GA on pain, disabilities and return to work in patients with non-specific LBP. Conclusion: Currently there is no or insufficient evidence that GA results in better outcomes of patients with non-specific LBP.

Implications for Rehabilitation

Graded Activity in non-specific low-back pain

• Non-specific low-back pain is not only a physical problem but can be influenced by patient’s beliefs, psychological distress and illness behaviour.

• In clinical practise the use of Graded Activity (GA) can be recommend when a discrepancy between musculoskeletal functioning and disabilities are present in a patient, for instance the presence of kinesiophobia.

• There is no or insufficient evidence that GA results in better outcomes than usual care.

     

Relationships in pain: the experience of relationships to people living with chronic pain in rural areas

The aim of the study was to develop new understanding of the lived experience of relationships for rural people living with chronic pain. Rural residents have greater difficulty accessing health services and providers. This is especially important to those living with chronic pain who often find themselves isolated from professionals who could potentially offer support. A phenomenological study with seven participants who had experienced chronic non-malignant pain for 2-29 years (Mean = 13) was recruited via a number of approaches and data analyzed using van Manen's framework. The themes that emerged from the analysis were as follows: pain as silence; privacy as a way of protection; no place out here to get support; and dealing with health-care professionals who do not understand. Lack of specialist services and support in rural areas means people with chronic pain are placed in even more vulnerable situations. Nurses remain at the forefront of service delivery in rural areas; hence, their role in management of people with chronic pain is vital in supporting them to maintain meaningful contact with others, including health professionals.     

Self efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients

To clarify the relationships between physical, and psychosocial components of chronic pain, a path analytic model was tested conceptualizing self efficacy as a mediator of disability. In turn, disability was hypothesized to mediate depression. This model could help explain the circumstances under which disability develops and why so many chronic pain patients become depressed. Questionnaires from 126 chronic pain patients (without prior depression) were reviewed from three pain clinics. Hypothesized and alternate models were tested using separate regression equations to identified models which best fit these data. Regression analysis supported that self efficacy partially mediates the relationship between pain intensity and disability. This model accounted for 47% of the explained variance in disability (P<0.001). Six additional variables that were significantly related to disability in preliminary analysis, added to the explained variance in disability (R²=0.56), with gender and pain location paths remaining significant. In separate regression analyses, disability was found to partially mediate the relationship between pain intensity and depression (b=0.47–0.33). This model accounted for 26% of the explained variance in depression. The addition of self efficacy to this model supported it as a stronger mediator (R²=0.32), and suggested that support for disability as a mediator of depression was a spurious finding. Both pain intensity and self efficacy contribute to the development of disability and depression in patients with chronic pain. Therefore, the lack of belief in ones own ability to manage pain, cope and function despite persistent pain, is a significant predictor of the extent to which individuals with chronic pain become disabled and/or depressed. Nevertheless, these mediators did not eliminate the strong impact that high pain intensity has on disability and depression. Therefore, therapy should target multiple goals, including: pain reduction, functional improvement and the enhancement of self efficacy beliefs.