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      Identification of Indirect Effects in a Cognitive Patient Education (COPE) Intervention for Low Back Pain

      , , , ,
      Physical Therapy
      Oxford University Press (OUP)

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          Abstract

          <div class="section"> <a class="named-anchor" id="abs1"> <!-- named anchor --> </a> <h5 class="section-title" id="d4133042e170">Background</h5> <p id="d4133042e172">Many interventions for the treatment of low back pain exist, but the mechanisms through which such treatments work are not always clear. This situation is especially true for biopsychosocial interventions that incorporate several different components and methods of delivery. </p> </div><div class="section"> <a class="named-anchor" id="abs2"> <!-- named anchor --> </a> <h5 class="section-title" id="d4133042e175">Objective</h5> <p id="d4133042e177">The study objective was to examine the indirect effects of the Cognitive Patient Education (COPE) intervention via illness perceptions, back pain myths, and pain catastrophizing on disability outcome. </p> </div><div class="section"> <a class="named-anchor" id="abs3"> <!-- named anchor --> </a> <h5 class="section-title" id="d4133042e180">Design</h5> <p id="d4133042e182">This study was a secondary analysis of the COPE randomized controlled trial.</p> </div><div class="section"> <a class="named-anchor" id="abs4"> <!-- named anchor --> </a> <h5 class="section-title" id="d4133042e185">Methods</h5> <p id="d4133042e187">Mediation analysis techniques were employed to examine the indirect effects of the COPE intervention via residualized change (baseline – posttreatment) in the 3 variables hypothesized to be targeted by the COPE intervention on posttreatment disability outcome. Pain intensity at baseline, pain duration, clinician type, and a treatment-mediator interaction term were controlled for in the analysis. </p> </div><div class="section"> <a class="named-anchor" id="abs5"> <!-- named anchor --> </a> <h5 class="section-title" id="d4133042e190">Results</h5> <p id="d4133042e192">Preliminary analyses confirmed that changes in pain catastrophizing and illness perceptions (not back pain myths) were related to both allocation to the intervention arm and posttreatment disability score. The treatment exerted statistically significant indirect effects via changes in illness perceptions and pain catastrophizing on posttreatment disability score (illness perceptions standardized indirect effect = 0.09 [95% CI = 0.03 to 0.16]; pain catastrophizing standardized indirect effect = 0.05 [95% CI = 0.01 to 0.12]). However, the inclusion of an interaction term led to the indirect effects being significantly reduced, with the effects no longer being statistically significant. </p> </div><div class="section"> <a class="named-anchor" id="abs6"> <!-- named anchor --> </a> <h5 class="section-title" id="d4133042e195">Limitations</h5> <p id="d4133042e197">This study presents a secondary analysis of variables not identified a priori as being potentially important treatment targets; other, unmeasured factors could also be important in explaining treatment effects. </p> </div><div class="section"> <a class="named-anchor" id="abs7"> <!-- named anchor --> </a> <h5 class="section-title" id="d4133042e200">Conclusions</h5> <p id="d4133042e202">The finding that small indirect effects of the COPE intervention via changes in illness perceptions and pain catastrophizing on posttreatment disability could be estimated indicates that these variables may be viable treatment targets for biopsychosocial interventions; however, this finding must be viewed in light of the adjusted analyses, which showed that the indirect effects were significantly reduced through the inclusion of a treatment-mediator interaction term. </p> </div>

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          Fifteen Years of Explaining Pain: The Past, Present, and Future.

          The pain field has been advocating for some time for the importance of teaching people how to live well with pain. Perhaps some, and maybe even for many, we might again consider the possibility that we can help people live well without pain. Explaining Pain (EP) refers to a range of educational interventions that aim to change one's understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself. It draws on educational psychology, in particular conceptual change strategies, to help patients understand current thought in pain biology. The core objective of the EP approach to treatment is to shift one's conceptualization of pain from that of a marker of tissue damage or disease to that of a marker of the perceived need to protect body tissue. Here, we describe the historical context and beginnings of EP, suggesting that it is a pragmatic application of the biopsychosocial model of pain, but differentiating it from cognitive behavioral therapy and educational components of early multidisciplinary pain management programs. We attempt to address common misconceptions of EP that have emerged over the last 15 years, highlighting that EP is not behavioral or cognitive advice, nor does it deny the potential contribution of peripheral nociceptive signals to pain. We contend that EP is grounded in strong theoretical frameworks, that its targeted effects are biologically plausible, and that available behavioral evidence is supportive. We update available meta-analyses with results of a systematic review of recent contributions to the field and propose future directions by which we might enhance the effects of EP as part of multimodal pain rehabilitation. Perspective: EP is a range of educational interventions. EP is grounded in conceptual change and instructional design theory. It increases knowledge of pain-related biology, decreases catastrophizing, and imparts short-term reductions in pain and disability. It presents the biological information that justifies a biopsychosocial approach to rehabilitation.
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                Author and article information

                Journal
                Physical Therapy
                Oxford University Press (OUP)
                0031-9023
                1538-6724
                December 2017
                December 01 2017
                September 06 2017
                December 2017
                December 01 2017
                September 06 2017
                : 97
                : 12
                : 1138-1146
                Article
                10.1093/ptj/pzx091
                5803786
                29186635
                3ca9d688-419c-4e7d-b010-d7f67d006b3b
                © 2017
                History

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