Showing papers by "Tamar Pincus published in 2017"
TL;DR: A systematic review of published literature in peer-reviewed journals identified several potential predictors of poor prognosis and worse outcome postinterventions in people with chronic headache.
Abstract: Objective: To identify predictors of prognosis and trial outcomes in prospective studies of people with chronic headache. Methods: This was a systematic review of published literature in peer-reviewed journals. We included (1) randomized controlled trials (RCTs) of interventions for chronic headache that reported subgroup analyses and (2) prospective cohort studies, published in English, since 1980. Participants included adults with chronic headache (including chronic headache, chronic migraine, and chronic tension-type headache with or without medication overuse headache). We searched key databases using free text and MeSH terms. Two reviewers independently extracted data and assessed the methodologic quality of studies and overall quality of evidence identified using appropriate published checklists. Results: We identified 16,556 titles, removed 663 duplicates, and reviewed 199 articles, of which 27 were included in the review—17 prospective cohorts and 10 RCTs with subgroup analyses reported. There was moderate-quality evidence indicating that depression, anxiety, poor sleep and stress, medication overuse, and poor self-efficacy for managing headaches are potential prognostic factors for poor prognosis and unfavorable outcomes from preventive treatment in chronic headache. There was inconclusive evidence about treatment expectations, age, age at onset, body mass index, employment, and several headache features. Conclusions: This review identified several potential predictors of poor prognosis and worse outcome postinterventions in people with chronic headache. The majority of these are modifiable. The findings also highlight the need for more longitudinal high-quality research of prognostic factors in chronic headache.
85 citations
TL;DR: Overall it is found that self-management interventions for migraine and tension-type headache are more effective than usual care in reducing pain intensity, mood and headache-related disability, but have no effect on headache frequency.
Abstract: Objectives To assess the effect of non-pharmacological self-management interventions against usual care, and to explore different components and delivery methods within those interventions Participants People living with migraine and/or tension-type headache Interventions Non-pharmacological educational or psychological self-management interventions; excluding biofeedback and physical therapy. We assessed the overall effectiveness against usual care on headache frequency, pain intensity, mood, headache-related disability, quality of life and medication consumption in meta-analysis. We also provide preliminary evidence on the effectiveness of intervention components and delivery methods. Results We found a small overall effect for the superiority of self-management interventions over usual care, with a standardised mean difference (SMD) of −0.36 (−0.45 to −0.26) for pain intensity; −0.32 (−0.42 to −0.22) for headache-related disability, 0.32 (0.20 to 0.45) for quality of life and a moderate effect on mood (SMD=0.53 (−0.66 to −0.40)). We did not find an effect on headache frequency (SMD=−0.07 (−0.22 to 0.08)). Assessment of components and characteristics suggests a larger effect on pain intensity in interventions that included explicit educational components (−0.51 (−0.68 to −0.34) vs −0.28 (−0.40 to −0.16)); mindfulness components (−0.50 (−0.82 to −0.18) vs 0.34 (−0.44 to −0.24)) and in interventions delivered in groups vs one-to-one delivery (0.56 (−0.72 to −0.40) vs −0.39 (−0.52 to −0.27)) and larger effects on mood in interventions including a cognitive–behavioural therapy (CBT) component with an SMD of −0.72 (−0.93 to −0.51) compared with those without CBT −0.41 (−0.58 to −0.24). Conclusion Overall we found that self-management interventions for migraine and tension-type headache are more effective than usual care in reducing pain intensity, mood and headache-related disability, but have no effect on headache frequency. Preliminary findings also suggest that including CBT, mindfulness and educational components in interventions, and delivery in groups may increase effectiveness. Trial registration number PROSPERO 2016:CRD42016041291
84 citations
TL;DR: Targeting obstacles to physical activity with an intervention that includes components to address self‐efficacy and fear avoidance appears to be more effective than usual physical therapy care in reducing long‐term disability.
Abstract: Study Design Prospective, pragmatic, nonrandomized controlled clinical trial. Background Clinical guidelines recommend physical activity for the treatment of chronic low back pain. But engaging patients in physical activity has proven difficult. Known obstacles to physical activity include low self-efficacy and fear avoidance. Objectives This study tested the effectiveness of an enhanced transtheoretical model intervention (ETMI) aimed at increasing recreational physical activity in patients with chronic low back pain, in comparison to usual physical therapy. Methods Patients (n = 220) referred to physical therapy for chronic low back pain were allocated to ETMI or to a control group. The ETMI was delivered by physical therapists and based on behavior-change principles, combined with increased reassurance, therapeutic alliance, and exposure to reduce fear avoidance. The primary outcome was back pain-related disability (Roland-Morris Disability Questionnaire). Secondary outcomes included pain intensity, me...
30 citations
TL;DR: Mediation analyses conducted on patients with chronic LBP showed that acceptance of pain reduced the impact of pain/disability on pain-related guilt in all mediation analyses.
Abstract: Pain-related guilt is a common yet unexplored psychological factor in low back pain (LBP). It has recently been linked to greater depression, anxiety and disability in LBP, hence an understanding of how it can be managed in the presence of pain and disability is necessary. Since acceptance of pain has been shown to be associated with improved outcomes in chronic pain, we examined whether it might also help reduce guilt in people with LBP. To this end, a series of mediation analyses were conducted on data from 287 patients with chronic LBP, in which acceptance of pain was tested as a mediator of the relationship between pain/disability and guilt. Results showed that acceptance of pain reduced the impact of pain/disability on pain-related guilt in all mediation analyses. Pain-related guilt might be a potential target for acceptance based interventions, thus this relationship should be further tested using longitudinal designs.
26 citations
TL;DR: Results indicate a potential mechanism through which beliefs about emotions and global impact might relate which might provide a theoretical basis for future research on treatments for fibromyalgia.
Abstract: Beliefs about the unacceptability of experiencing and expressing emotions have been found to be related to worse outcomes in people with persistent physical symptoms. The current study tested mediation models regarding emotional suppression, beliefs about emotions, support-seeking and global impact in fibromyalgia. One hundred eighty-two participants took part in an online questionnaire testing potential mechanisms of this relationship using mediation analysis. The model tested emotional suppression and affective distress as serial mediators of the relationship between beliefs about emotions and global impact. In parallel paths, two forms of support-seeking were tested (personal/emotional and symptom-related support-seeking) as mediators. Emotional suppression and affective distress significantly serially mediated the relationship between beliefs about emotions and global impact. Neither support-seeking variable significantly mediated this relationship. Results indicate a potential mechanism through which beliefs about emotions and global impact might relate which might provide a theoretical basis for future research on treatments for fibromyalgia.
14 citations
TL;DR: The findings suggest that participants with pain and depression exhibit a cognitive bias specific to negative aspects of health-related future thinking, which facilitates understanding of the relationship between depression and pain processing.
Abstract: Depression is a common feature of chronic pain, but the content of depressed cognitions in groups with chronic pain may be qualitatively different from other depressed groups. Future thinking has been extensively studied in depressed population; however, to our knowledge, this is the first study to investigate future thinking, using a verbal fluency task, in chronic pain. This study investigated the content of cognitions about the future, which are postulated to be a key mechanism in the development of clinical depression, but have not been studied in groups with chronic pain. This study used the future thinking task to investigate general future thinking and health-related future thinking in 4 groups of participants: those with pain and concurrent depression, those with pain without depression, those with depression without pain, and healthy control participants. One hundred seventy-two participants generated positive and negative future events, and rated the valence and likelihood of these events. Responses were coded for health-related content by 2 independent raters. Participants with depression (with and without pain) produced more negative and less positive future events than control participants. Participants with pain (depressed and nondepressed) produced more positive health-related future events than control participants. Participants with depression and pain produced more negative health-related future events than the nondepressed pain group. The findings suggest that participants with pain and depression exhibit a cognitive bias specific to negative aspects of health-related future thinking. This focus facilitates understanding of the relationship between depression and pain processing. The implications for therapeutic interventions are discussed.
12 citations
TL;DR: The hypothesis that different components of reassurance are associated with specific outcomes, and that psychological risk moderates this relationship for depression is supported, might have the potential to improve outcomes in people with LBP.
Abstract: Objectives: Reassurance is an essential part of treatment for low back pain (LBP), but evidence on effective methods to deliver reassurance remains scarce. The interaction between consultation-based reassurance and patients’ psychological risk is unknown. Our objective was to investigate the relationship between consultation-based reassurance and clinical outcomes at follow-up, in people with and without psychological risk. Methods: We tested the associations between specific reassurance components (data gathering, relationship building, generic reassurance, and cognitive reassurance), patients’ psychological risk (the presence of depression, anxiety, catastrophizing, or fear-avoidance), and postconsultation outcomes including, satisfaction and enablement, disability, pain, and mood at 3-month follow-up. Results: Adjusted linear regression models using data from patients who had recently consulted for LBP in primary care (n=142 in 43 practices) indicated that all reassurance components were strongly associated with increased satisfaction, whereas generic reassurance was significantly associated with postconsultation enablement. Generic reassurance was also associated with lower pain at 3 months, whereas cognitive reassurance was associated with increased pain. A significant interaction was observed between generic reassurance and psychological risk for depression at 3 months: high rates of generic reassurance were associated with lower depression in low-risk patients, but with higher rates of depression for high-risk groups. Discussion: The findings support the hypothesis that different components of reassurance are associated with specific outcomes, and that psychological risk moderates this relationship for depression. Clinicians reassuring behaviors might therefore have the potential to improve outcomes in people with LBP, especially for patients with higher psychological risk profiles.
10 citations
TL;DR: A role for emotional processing in medically unexplained symptoms is suggested and the need to address such beliefs about emotions in psychological therapies is implied.
Abstract: Suppression of undesirable emotions, as well as beliefs about the unacceptability of experiencing and expressing emotions, have both been shown to be related to poorer health-related outcomes in several clinical groups. Potential models through which these variables relate have yet to be tested in those with irritable bowel syndrome and are therefore examined in the current article. Online questionnaires were administered to people with Irritable Bowel Syndrome (n=84) to test a mediation model in which beliefs about the unacceptability of emotions are associated with greater emotional suppression, which in turn relates to increased affective distress and consequently poorer quality of life. An alternate model to test the direction of effect along with two further models using support-seeking as mediators of the same predictor and outcome were also tested. Emotional suppression and affective distress (in that particular order) mediate the relationship between beliefs about emotions and quality of life IBS. The models using support-seeking as mediators of the relationship between beliefs about emotions and the two outcomes were not supported. These findings suggest a role for emotional processing in medically unexplained symptoms and imply the need to address such beliefs about emotions in psychological therapies.
6 citations
TL;DR: Preliminary data suggest that associations between HIV stigma and HIV-related pain warrant further investigation, and future study should also include potential mechanisms, which may include mediation through depression.
Abstract: Objective HIV stigma remains common and has been associated with severity of HIV-related symptoms. Associations between HIV stigma and HIV-related pain, one of the most common symptoms in HIV, have not been investigated however. Data from low back pain populations suggest that stigma associates with worse pain intensity and so we hypothesised that the same would be the case in HIV. In a small pilot study we assessed the association between HIV stigma and pain intensity in PLWH with chronic pain while controlling for depression, a well-established correlate of pain. Methods Mediation analysis was used to assess the effect of depression on the relationship between stigma and pain intensity in a cross-sectional cohort of 50 PLWH and chronic pain (pain most days of the week for > 3 months) recruited in Johannesburg, South Africa. All participants were assessed using: HIV/AIDS stigma instrument – PLWA (HASI-P), 11-point numerical pain rating scale, and the Beck Depression Inventory II. Results 88% (44/50) of participants reported experiencing some form of HIV stigma (HIV stigma scale score ≥ 1). Worst pain intensity and depressive symptoms individually correlated with total stigma score (Spearman’s r = 0.33, p = 0.02 for both). The mediation analysis highlighted that mediation of the relationship by depression was equivocal (b = −0.002, bootstrapped CI −0.02 to 0.00). Conclusions Whilst these preliminary data are marginal, they do suggest that associations between HIV stigma and HIV-related pain warrant further investigation. Future study should also include potential mechanisms, which may include mediation through depression.
5 citations
TL;DR: Data demonstrate the acceptability and credibility of the iPOPP intervention, and the feasibility of proposed trial processes, in a pilot randomised controlled trial of Increasing Physical Activity in Older People with Pain.
Abstract: Background Chronic (≥3 months) pain is associated with physical inactivity in older (≥65 years) people. Walking is an acceptable form of physical activity with health benefits. We have developed Increasing Physical Activity in Older People with Pain (iPOPP), a brief intervention to increase walking. Objectives To assess the acceptability and credibility of iPOPP, and to test the feasibility of trial processes, in a pilot randomised controlled trial. Methods Eligible responders to a screening questionnaire (≥65 years; consulted their general practitioner for chronic pain; Chronic Pain Grade score ≥2) collected 7-day accelerometer data before randomisation and at the end of follow-up. Participants were randomised to one of Usual primary care; Pedometer, walking diary, pain toolkit (written pain management information); or iPOPP comprising week 1 face-to-face Health Care Assistant (HCA) consultation to develop a walking action plan, pedometer, walking diary, pain toolkit, discussion of walking behaviour and barriers, goal setting; week 2 follow up face-to-face or telephone (participant preferred) HCA consultation to review progress and goals, relapse prevention strategies; weeks 3–10 weekly motivational prompts (participant preferred postcard, email or text). A follow-up questionnaire was sent 12 weeks post-randomisation. Success criteria were: 7% of those screened would be eligible, return an accelerometer and be randomised; follow-up rates ≥75% of those randomised; ≥50% of those in iPOPP would complete week 1 and 2 intervention sessions; and a median score of ≥5/10 across a four-item intervention acceptability and credibility questionnaire. Results are number (%) or median (inter quartile range (IQR)). Results Of 2326 people mailed, 1256 (54%) responded and 695 (30%) were eligible. After mailing study information to 425 eligible participants, 161 (38%) agreed to participate, 159 (12% of those mailed) returned an accelerometer and were randomised, 7 withdrew, and 136 (86%) returned a follow-up questionnaire. Of those randomised to iPOPP 82% completed week 1 and 2 intervention sessions; 32% had a face-to-face week 2 follow-up; 48% preferred postcard motivational prompts, 10% email, 22% text, and 20% had no preference. Median (IQR) acceptability and credibility scores were: “how logical is treatment?” 8 (3, 9.8), “confidence in treatment success” 5.5 (3, 8), “would recommend treatment to friend” 7 (3.3, 9), and “treatment would be successful for another pain problem” 5 (3, 7.8). 152 participants were mailed a follow-up accelerometer and 144 (95%) were returned. 147 (91%) baseline and 117 (81%) follow-up accelerometers had useable data. Conclusions These data demonstrate the acceptability and credibility of the iPOPP intervention, and the feasibility of proposed trial processes. The effectiveness of iPOPP compared with usual care will be tested in a future main trial. Acknowledgements Funded by Arthritis Research UK (grant reference 20608). ELH, CJ, and CCG are part funded by the NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands. The views expressed in this paper are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health. Disclosure of Interest None declared
1 citations