I’ve always been interested in pain, even before completing the post-doc in Health Psych. Perhaps that’s because I’ve suffered an above-average number of injuries in my time: ulna fracture; concussion; compound bruise with threat of amputation mid-fibula/tibia; dislocated elbow; torn rotator cuff; knee hyperextension; metatarsal fracture; etc. Needless to say that these old injuries remind me they exist, dependent upon my level of exercise, sleep, stress, and diet, among other factors.
So my personal history combined with treating chronic pain patients leads me to be vigilant for updates in related research.
In 2016 there were over 42K pain-related articles published according to PubMed. Around 3,200 referenced “chronic pain.” Among these were 485 review articles, 89 clinical trials, and 28 meta-analyses. The following questions are based on some of the latter.
Just click on your answer to be shown the correct choice.
Question 1 Answer: The correct answer is “c. Equally accurate.” Pombo and his colleagues reviewed 62 studies, which included 13,338 patients. The researchers transformed pain intensity scores pre- and post-treatment from the original measure to a 0 – 100 scale, where 0 was the absence of pain and 100 was maximum. The aggregated mean technology ratings (48.67; SD 3.49) were equivalent to the more traditional methods (50.98; SD 3.35). What this mean is that for most common pen-and-paper measures of pain intensity, we should feel very comfortable that converting these to an on-line or “app” version should yield highly comparable ratings.
Question 2 Answer: The correct answer is “a. 3.3.” Enthovan et al., (2016) updated a 2008 Cochrane Review on the effectiveness of NSAIDs among people with chronic lower back pain. Searching the literature for both double- and single-blind Randomized Clinical Trials (RCTs), they located 13, which covered 1,354 patients. Overall, NSAIDS out-performed placebos by an average pain reduction of -3.3 points on a 0 – 100 visual analog scale (95% CI = -5.55 to -1.27) across an average treatment duration of 56 days. I included this study because readers might misinterpret a 3-point difference on a 100 point scale as meaning NSAIDS are only 3% more effective than placebo. However, while this is true in the aggregate, it might not be true for the individual. For example, consider a patient who has an average pain rating of 80 and NSAIDS get this down to a 40. Had they taken the placebo, chances are they’d report an average rating of 43.3. Relative to the starting point, in this case the NSAID is 10% more effective than placebo. In contrast, for a patient who only experiences a reduction in their pain rating to a 60, as compared to the placebo effect of 63.3, the NSAID would be 20% more effective.
Question 3 Answer: The correct answer is “a. Acceptance and Commitment Therapy (ACT).” Martine Veehof and her colleagues examined 25 RCTs covering 1,285 adults between 35 - 60 years old. Specific (e.g., headache, lumbago) and non-specific (e.g., fibromyalgia, rheumatoid arthritis) chronic pain sufferers were included.
Overall, the pooled standardized mean differences for all 3 therapies found a small effect for pain intensity (.24 (95% CI = .06, .42)) and depression ratings (.43 (95% CI = .18, .68)) and a moderate effect for anxiety (.51 (95% CI = .10, .92)) post-treatment.
However, in sub-group analyses, ACT’s effect sizes were significantly greater than the others. Veehof suggested that ACT’s focus on committed action towards life’s values may generate hope and motivate behavior change beyond MBSR and MBCT.
Question 4 Answer: The correct answer is “c. Equal.” Among the interns and residents I work with, most assume that ACT, MBSR, and MBCT – because they are modern – are superior to traditional CBT for treating the depression and anxiety associated with chronic pain. However, in sub-group analyses, Veehof and her colleagues found that CBT’s effect sizes were not significantly different from the other treatments.
My take-away is that when working with chronic pain patients, we should continue to focus on the core issues of catastrophizing cognitions, emotions such as kinesiophobia, mindfulness, psychological flexibility, and living towards one’s life values.
Question 5 Answer: The correct answer is “c. 82%.” Paladini and her colleagues assert that chronic pain is initiated and maintained, in part, by neuroinflammation of the immune system, the cells of which migrate throughout the central and peripheral nervous systems. Noting the high prevalence of chronic pain (over 1 in 3 Americans suffer) along with incomplete pain relief from most medications as well as their notable side-effects, they searched for possible complementary treatment options.
Palmitoylethanolamide (PEA) is one of several naturally occurring anti-inflammatory agents involved in immune response. It is widely distributed throughout the brain and body, but specifically at pain sites and in those regions of the brain involved in nociception. Searching among all clinical trials using PEA since 2010 (the year it was first micronized – made small enough to cross the blood brain barrier), they found 12 studies incorporating 1,484 patients with chronic pain.
Again, after 60 days, whereas 41% of the treatment-as-usual group wound up with a pain rating of less than 3, 82% of the PEA-group did. Including only those patients age 65 or older, the result was even more dramatic; 23% compared to 77%. In terms of the reduction on a 10-point pain scale, this amounted to 0.20 every 2 weeks for the treatment-as-usual group, as compared to 1.04 for the PEA-group.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
David J. Reynolds, Ph.D., is the Deployment Behavioral Health Psychologist at Malcolm Grow Medical Clinics and Surgery Center (MGMCSC) located on Joint Base Andrews, Maryland.
1. Pombo, N., Garcia, N., Bousson, K., Spinsante, S., & Chorbev, I. (2016). Pain Assessment--Can it be Done with a Computerised System? A Systematic Review and Meta-Analysis. International Journal of Environmental Research in Public Health. Apr 13;13(4):415. DOI: 10.3390/ijerph13040415
2. Enthoven, W.T., Roelofs, P.D., Deyo, R.A., van Tulder, M.W., & Koes, B.W. (2016). Non-Steroidal Anti-Inflammatory Drugs For Chronic Low Back Pain. Cochrane Database Systematic Review. 2016 Feb 10;2:CD012087. DOI: 10.1002/14651858.CD012087
3. Veehof, M.M., Trompetter, H.R., Bohlmeijer, E.T., & Schreurs, K.M. (2016). Acceptance- And Mindfulness-Based Interventions for the Treatment of Chronic Pain: A Meta-Analytic Review. Cognitive Behavioral Therapy. 45(1):5-31. DOI: 10.1080/16506073.2015.1098724
4. Paladini, A., Fusco, M., Cenacchi, T., Schievano, C., Piroli, A., & Varrassi, G. (2016). Palmitoylethanolamide, a Special Food for Medical Purposes, in the Treatment of Chronic Pain: A Pooled Data Meta-analysis. Pain Physician. Feb;19(2):11-24