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Key mechanisms of action of psychosocial treatments for chronic pain include decreased catastrophizing and increased self-efficacy [cognitive-behavioral therapy (CBT)] and increased mindfulness and possibly pain acceptance [mindfulness-based stress reduction (MBSR)]. Greater understanding of overlap among these variables is important in understanding treatment-specific and shared mechanisms of action. We examined, in an RCT comparing group CBT (n=112), MBSR (n=116), and usual care (UC; n=113) for chronic back pain: (1) baseline relationships among the Pain Catastrophizing Scale (PCS), Pain Self-Efficacy Questionnaire (PSEQ), Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), and Five Facet Mindfulness Questionnaire-short form (FFMQ-SF); and (2) pre- to post-treatment changes in these measures. We hypothesized that: (1) at baseline, the PCS would be associated negatively with the CPAQ-8, PSEQ, and FFMQ-SF Non-Reactivity, Non-Judging, and Acting with Awareness scales, and the CPAQ-8 would be associated positively with the PSEQ; and (2) adjusting for baseline variables, FFMQ-SF and CPAQ-8 scores would increase more pre- to post-treatment in MBSR than in CBT and UC, and PCS scores would decrease more and PSEQ scores would increase more in CBT than in MBSR and UC. The hypothesized baseline associations were confirmed between the PCS and the CPAQ-8 (Spearman’s rho = -0.40 to -0.55), PSEQ (-0.57), and FFMQ (-0.22 to -0.30) scales (all Ps < 0.01), and between the CPAQ-8 and the PSEQ (0.46-0.65; all Ps < 0.01). Among all participants who completed baseline and post-treatment assessments (n = 290), catastrophizing decreased significantly more pre- to post-treatment in MBSR than in UC and CBT. Among those who attended >6 of the 8 group sessions, mindfulness increased more in MBSR than in CBT, but the groups did not differ significantly in pre- to post-treatment change on the other measures. The results suggest overlap in mechanisms of action of CBT and MBSR. Supported by NCCAM grant 1R01AT006226.

Although yoga is an effective treatment for chronic low back pain, little is known about the mechanisms responsible for its benefits. In a trial comparing yoga to intensive stretching and self-care, we explored whether physical (hours of back exercise/week), cognitive (fear avoidance, body awareness, and self-efficacy), affective (psychological distress, perceived stress, positive states of mind, and sleep), and physiological factors (cortisol, DHEA) mediated the effects of yoga or stretching on back-related dysfunction (Roland-Morris Disability Scale (RDQ)). For yoga, 36% of the effect on 12-week RDQ was mediated by increased self-efficacy, 18% by sleep disturbance, 9% by hours of back exercise, and 61% by the best combination of all possible mediators (6 mediators). For stretching, 23% of the effect was mediated by increased self-efficacy, 14% by days of back exercise, and 50% by the best combination of all possible mediators (7 mediators). In open-ended questions, >/=20% of participants noted the following treatment benefits: learning new exercises (both groups), relaxation, increased awareness, and the benefits of breathing (yoga), benefits of regular practice (stretching). Although both self-efficacy and hours of back exercise were the strongest mediators for each intervention, compared to self-care, qualitative data suggest that they may exert their benefits through partially distinct mechanisms.

Mindfulness has been linked with decreased psychological distress, yet little is known about the possible intervening variables to explain this link. The aim of this study was to investigate the contribution of attachment styles and emotion regulation in explaining the relationship between mindfulness and psychological distress. It was hypothesised that mindfulness would be inversely associated with psychological distress, and that attachment style (attachment anxiety and attachment avoidance) and emotion regulation would mediate this relationship. Australian adults (N = 402) completed an online questionnaire assessing mindfulness, emotion regulation, attachment style, and current psychological distress. Bootstrap mediation analyses confirmed an inverse relationship between mindfulness and distress. Both attachment anxiety and emotion regulation deficits were found to mediate the association between mindfulness and distress; however, attachment avoidance was not found to have a mediating effect. The findings are the first to demonstrate that attachment anxiety and emotion regulation deficits, in part, explain the association between mindfulness and various indicators of psychological distress. These findings highlight factors that may be useful to focus on within psychosocial interventions addressing psychological distress.

CONTEXT: Studies suggest that yoga is effective for moderate to severe chronic low back pain (cLBP) in diverse predominantly lower socioeconomic status populations. However, little is known about factors associated with benefit from the yoga intervention. OBJECTIVE: Identify factors at baseline independently associated with greater efficacy among participants in a study of yoga for cLBP. DESIGN: From September-December 2011, a 12-week randomized dosing trial was conducted comparing weekly vs. twice-weekly 75-minute hatha yoga classes for 95 predominantly low-income minority adults with nonspecific cLBP. Participant characteristics collected at baseline were used to determine factors beyond treatment assignment (reported in the initial study) that predicted outcome. We used bivariate testing to identify baseline characteristics associated with improvement in function and pain, and included select factors in a multivariate linear regression. SETTING: Recruitment and classes occurred in an academic safety-net hospital and five affiliated community health centers in Boston, Massachusetts. PARTICIPANTS: Ninety-five adults with nonspecific cLBP, ages ranging from 20-64 (mean 48) years; 72 women and 23 men. OUTCOME MEASURES: Primary outcomes were changes in back-related function (modified Roland-Morris Disability Questionnaire, RMDQ; 0-23) and mean low back pain intensity (0-10) in the previous week, from baseline to week 12. RESULTS: Adjusting for group assignment, baseline RMDQ, age, and gender, foreign nationality and lower baseline SF36 physical component score (PCS) were independently associated with improvement in RMDQ. Greater than high school education level, cLBP less than 1 year, and lower baseline SF36 PCS were independently associated with improvement in pain intensity. Other demographics including race, income, gender, BMI, and use of pain medications were not associated with either outcome. CONCLUSIONS: Poor physical health at baseline is associated with greater improvement from yoga in back-related function and pain. Race, income, and body mass index do not affect the potential for a person with low back pain to experience benefit from yoga.