Doctor of Philosophy / School of Family Studies and Human Services / Jared A. Durtschi / Chronic pain is one of the most pervasive healthcare conditions being treated today. The onset of chronic pain can start at any age, and can follow a myriad of trajectories. Health conditions like chronic pain have been shown to be associated with increases in depression, anxiety, and other adverse mental health outcomes. The present study utilized a sample of 10,266 adult individuals with chronic conditions where chronic pain was typically present to identify different profiles of chronic pain sufferers and then examine the associations between general health, chronic pain profile membership, and mental health outcomes. Although previous studies have attempted to identify chronic pain profiles, no study has yet explored how pain frequency and intensity, fatigue, duration of chronic condition, and physical limitations caused by this condition may uniquely identify subgroups within the chronic pain population. Utilizing a latent profile analysis, four distinct profiles of chronic pain were identified, including a Constant Companion profile, an Adjustments Needed profile, an Annoying Companion profile, and a No Limitations profile. Through a path analysis, significant associations were found between both general health and changes in general health, chronic pain profile membership, and frequency of anxious, depressed, and hopeless feelings. Results generally were counterintuitive, with better health linked with higher odds of fitting the more extreme chronic pain profiles compared to the no limitations profile; and those in the more extreme chronic pain profiles had significantly less frequent feelings of depression, anxiety, and hopelessness. Ideas for clinical implications and suggestions for future research are provided.

La douleur chronique est souvent associée à la dépression et l’anxiété. Ces pathologies entretiennent des liens complexes qui ont été largement étudiés. Cependant en France, nous manquons d’informations permettant d’améliorer la prise en charge psychothérapeutique de ces patients. Le but de ce travail est d’améliorer la compréhension de l’influence des facteurs psychopathologiques et cognitifs dans la douleur chronique.Étude 1 : Une étude quantitative a été réalisée auprès d’un échantillon de 228 étudiants. L’analyse des croyances associées à la douleur a permis de mettre en lumière une perception positive du vécu de la sensation douloureuse. Ainsi, ils ne perçoivent pas la douleur comme étant un phénomène stable dans le temps ou mystérieux ; de plus, ils ne manifestent pas de sentiment de culpabilité lié à la douleur. Les résultats indiquent également que les participants ont des perceptions rationnelles des médicaments. Ils considèrent cependant qu’il y a une surconsommation des médicaments. Étude 2 : Une étude quantitative a été réalisée auprès d’un échantillon de 247 personnes atteintes de fibromyalgie. Dans cette étude, 93 % des participants présentaient des symptômes dépressifs, et 94 % présentaient des symptômes anxieux. En outre, des symptômes dépressifs sévères sont retrouvés dans 25 % des cas et 43 % des participants présentent une anxiété sévère. Les différentes analyses de régression réalisées ont montré que la relation entre la symptomatologie anxio-dépressive et la douleur est partiellement médiatisée par les croyances associées à la douleur.Étude 3 : Une étude quantitative a été menée auprès de 247 personnes atteintes de fibromyalgie. Les analyses de corrélation ont montré un lien entre la symptomatologie anxio-dépressive, les mesures relatives à la douleur, les croyances associées à la douleur, la dramatisation, la flexibilité psychologique et l’optimisme. L’analyse de régression multiple indique que les croyances associées à la douleur, l’optimisme et la flexibilité psychologique prédisent 58 % de la variance des scores de dramatisation. Une analyse en cluster a permis de mettre en évidence trois profils cognitifs : les catastrophistes, les modérés et les flexibles optimistes. Des analyses de variance ont montré que ces clusters se différenciaient au niveau des scores de dépression, d’anxiété, d’intensité et d’impact de la douleur. Le profil catastrophiste obtenait les scores les plus élevés à ces différentes mesures. / Chronic pain is often associated with depression and anxiety. These pathologies have complex links that have been widely studied. In France, however, there are few studies that provide information on psychotherapeutic treatment of these patients. The overall objective of this work is to improve understanding of psychopathological and cognitive factors linked to chronic pain. Study 1: A quantitative study was carried out on a sample of 228 students. An analysis of beliefs associated to pain provided insight into the concept of pain sensation. The participants perceived pain as an instable phenomenon over time, were not likely to associate pain with mysterious origins, and did not link pain to feelings of guilt. The results also showed that the participants had rational beliefs about medication, although they tended to believe that medication was overused. Study 2: A quantitative study was conducted on a sample of 247 fibromyalgia sufferers. In this study, 93 % of participants presented depressive symptoms, and 94 % presented anxiety symptoms. Severe depressive symptoms were found in 25 % of cases, and 43 % of participants reported severe anxiety. Regressions analyses showed that the relationship between depressive symptoms, anxiety and pain is partially mediated by beliefs associated with pain.Study 3: A quantitative study was conducted on a sample of 247 people suffering from fibromyalgia. Correlation analyses showed a link between anxio-depressive symptoms, measures related to pain, pain-related beliefs, dramatization, psychological flexibility, and optimism. A multiple regression analysis indicated that beliefs associated with pain, optimism and psychological flexibility predicted 58 % of the variance in scores of dramatization. A cluster analysis highlighted three cognitive profiles in these patients: ‘catastrophics’, ‘moderates’ and ‘flexible optimistics’. Analyses of variance showed that cluster groups differed in levels of depression, anxiety, intensity, and impact of pain. ‘Catastrophics’ had higher scores on these measures.

M.Tech. / The aim of this study was to compare the effectiveness of cervical adjustment therapy, dry needling of the levator scapulae muscle and a combination of the two in the treatment of chronic mechanical neck pain. Forty-five patients were recruited via posters and advertisements from in and around the University of Johannesburg. The participants had to present with bilateral neck pain, decreased range of motion and an active levator scapulae muscles trigger point, which was diagnosed using range of motion and trigger point examination. The participants were randomly allocated into three groups of fifteen participants each. Prior to treatment a full case history, physical examination and cervical regional examination were performed to ensure that the patients were eligible to partake in the clinical trial. Group 1 was the adjusting group; group 2 was the combination group while group 3 was the needling group. Participants were treated five times over a period of three weeks. The objective measurements used in this clinical trial involved a cervical range of motion instrument (C.R.O.M., Performance Attainment Associates) and an algometer (Wagner Instruments). Subjective measurements were achieved using the Neck Pain and Disability Index (Appendix G) and the Numerical Pain Rating Scale (Appendix H). Each measurement was taken prior to treatment on the first and third visits and after treatment on the fifth visit with three measurements per participant overall. The statistical analysis was conducted using the Kruskal-Wallis, Friedman and Wilcoxon tests to compare data. The results indicated that the three groups responded favourably to their respective treatments. Overall, this study has indicated that dry needling of the Levator scapulae muscle provides no statistically significant contribution to the conservative treatment of mechanical neck pain caused by levator scapulae trigger points.

Introduction: Activity pacing is often advised as a coping strategy for managing chronic conditions (such as chronic low back pain, chronic widespread pain and chronic fatigue syndrome/myalgic encephalomyelitis). Despite anecdotal support for activity pacing, there is limited and conflicting research evidence regarding the efficacy of this strategy. Pacing has not been clearly operationalised, and existing descriptions are diverse and include strategies that encourage both increasing and decreasing activities. Moreover, there are few validated scales to measure activity pacing. Aim: To develop an activity pacing questionnaire (APQ) for adult patients with chronic pain and/or fatigue, and to determine its psychometric properties and acceptability. Methods: The study had a three stage mixed method design. Stage I, the Delphi technique involved a three-round consensus method to develop the initial items of the APQ using an expert panel of patients and clinicians. Stage II, the psychometric study, implemented a cross-sectional questionnaire design study, involving a large sample of patients with chronic conditions. This stage assessed the underlying pacing themes of the APQ using factor analysis, internal and test-retest reliability using Cronbach’s alpha and intraclass correlations (ICCs); and validity using correlations with validated measures of pain, fatigue, anxiety, depression, avoidance, and mental and physical function. Stage III, the acceptability study, explored patients’ opinions of the APQ, together with the concept of activity pacing via telephone interviews. The qualitative interview data were analysed using framework analysis. Results: Forty-two participants completed Stage I, the Delphi technique (4 patients, 3 nurses, 26 physiotherapists and 9 occupational therapists). The resulting APQ contained 38 questions involving a number of different facets, including breaking down tasks, gradually increasing activities and setting goals. Stage II, the psychometric study, was completed by 311 patients, of whom 69 were involved in a test-retest analysis. Following factor analysis, eight items were removed from the APQ. Five themes of pacing were identified in the 30-item APQ: Activity limitation, Activity planning, Activity progression, Activity consistency and Activity acceptance. These demonstrated satisfactory internal consistency, test-retest reliability, and construct validity against validated measures. Activity limitation, Activity planning, Activity progression and Activity acceptance correlated with worse symptoms, and Activity consistency correlated with improved symptoms. Sixteen patients participated in Stage III, the acceptability interviews. The APQ was found to be generally acceptable. Four activity behaviour typologies emerged through the interviews: Task avoidance, Task persistence, Task fluctuation (boom-bust) and Task modification (activity pacing).Conclusion: This is the first known study that has engaged both patients and clinicians in the development of an activity pacing questionnaire. Developed to be widely used across a heterogeneous group of patients with chronic pain and/or fatigue, the APQ is multifaceted, comprehensive and contains more themes of pacing than existing pacing subscales.

The association between pain and depression is well documented across various populations, but not in puerperal women. This study examined the association of childbirth pain with postpartum depression (PPD) in a nationally representative sample of Canadian women. Data from the Canadian Maternity Experiences Survey (n=6421) was used. Multivariate logistic regressions and partial proportional odds models were fitted and included socio-demographic, obstetric, health, psychological, and psychosocial factors. Chronic pain sufferers at mean 7.3 months postpartum had adjusted odds of PPD of 2.4 (95% CI: 1.6, 3.6) compared to women without pain. Adjusted odds of PPD increased with the number of areas of chronic pain, reaching 4.2 (95% C.I.: 0.7, 25.0) for 3 or more areas. Immigration, obesity, cesarean section and social support increased the strength of the association while smoking and the use of pain relief were protective effect modifiers. Persistent postpartum pain is a major risk factor for PPD.

At least one in five Canadians lives with chronic pain, and the prevalence rate is rising. Chronic pain can be a result of injury, disease, surgery, and in some cases, the cause remains unknown. Due to the complexity and variability in the etiology and presentation of chronic pain, it can often be a challenge to implement an appropriate and effective treatment plan. Often, the effects of chronic pain are so debilitating that relief is only available temporarily with pain medication. However, there is the concern and possibility of addiction, health issues, and even increased risk of death with some medicinal interventions. Living with chronic pain can have widespread ramifications, affecting more than just the physical body. This includes psychological, emotional, interpersonal, and vocational challenges. In essence, all aspects of one’s quality of life can be affected by chronic pain. As chronic pain often persists over many years or even the lifetime, it is important to better understand how one might adapt to living with chronic pain. Mindfulness-Based Stress Reduction (MBSR) is a structured 8-week program that is commonly used as an intervention for people living with chronic pain, as several research studies have shown promising effects on pain outcomes and quality of life. Using hermeneutic phenomenology, the purpose of this study is to learn about the lived experiences of participating in an 8-week MBSR program from those living with chronic pain. Particularly, it explores how, if at all, an MBSR program may play a role in the participants’ adaptation to living with chronic pain. In depth semi-structured interviews were conducted with 3 participants at the end of the MBSR program. They were then analyzed, interpreted and checked by the researcher. The interpretative analysis involved the researcher explicitly detailing their own positioning in order to inform the interpretations and allow for a well-informed continued interpretation and understanding from readers. Overall, participants described several key aspects which may shed light into the benefits that MBSR can have in regards to adaptation to chronic pain as delineated by the following categories: physical pain and pain management, self-perception and identity, relationship dynamics, and emotional equilibrium. Lastly, broader themes included: being heard and understood, letting go and being here, the healing perspective, and moving from surviving to living. The results of this study speaks to the experience of living with chronic pain, and how an MBSR program offers the tools to help facilitate the adaptation process to living with chronic pain, thereby improving quality of life.

Background: Chronic pain is pain which has lasted for more than 3 months and is reported by 40 to 50% of adults in developed countries. The prevalence of chronic pain is consistently higher in women than in men. Chronic pain is more often reported by older adults than younger adults. As well as duration, pain can also be described in terms of its “widespreadness” by counting the number of body areas experiencing pain, or by the source of the pain e.g. musculoskeletal. Many social, psychological, physiological and behavioural factors have been found to be associated with pain. Altered sensitivity to stimuli may indicate aberrant pain processing mechanisms. Quantitative sensory testing (QST) evaluates responses to experimental, painful and non-painful stimuli. Although originally used in neurological conditions, QST data for people with musculoskeletal pain show differences from healthy controls. Aim: The aim of this study was to determine the relationship between sensitivity to stimuli (measured by QST), and both the number of body areas with pain and the prevalence of chronic widespread pain, and how these relationships vary with age and sex. Methods: A postal questionnaire which included questions about pain location and duration of pain, as well as known risk factors for pain, was returned by 2623 participants aged 34-101 years. A sub-group of 290 participants aged 34-97 years were selected on the basis of their responses to the pain questions and undertook a physical assessment which included QST. Regression models were used to quantify the relationships between QST factors and pain. Pain was classified as a continuum of “widespreadness” (0-29) and as “no pain”, “chronic widespread pain (CWP)” and “some pain” (i.e. pain other than CWP). Regression models with interaction terms were used to investigate whether these relationships varied between older (aged over 65 years) and younger (aged 65 years and younger) people, and between men and women. Results: There were very few differences in QST variables (except tender point count) across the two pain classifications, however, differences in several QST variables were found between the age and sex groups (Chapter 6). Three of the QST measures, tender point count, cool detection threshold at the foot and thermal sensory limen at the foot, were statistically significantly related to number of painful areas, and tender point count and cool detection threshold at the foot were also significantly different among participants with “no pain” and those with CWP (Chapter 7). None of these relationships were significantly moderated by age or sex (Chapter 8). Sleep quality and beliefs about pain duration were found to be statistically significantly related to number of pain areas and to the presence of CWP in all the analyses (Chapter 7). Conclusion: The findings from this study indicate that some QST variables are related to pain, but none of the relationships are moderated by age or sex. The importance of sleep quality and pain beliefs as risk factors for pain has been further confirmed. Further research may allow treatments for pain to be tailored to the individual in the light of these facts.

Data from daily diaries were used to examine the relationships between daily pain appraisals (Catastrophizing, Self-Efficacy, and perceived control over pain) and coping strategy use (Distraction, Ignoring Pain, Praying and Hoping, and Reinterpreting Pain Sensation) and nighttime negative mood and pain intensity for 88 women (mean age 46.83 years, SD 11.90) with chronic low back pain who were not attending a specialized pain treatment program. These relationships were examined at two levels using the Hierarchical Linear Modeling program (Bryk & Raudenbush, 1992). The first level of analyses examined whether pain appraisals and coping strategy use during the day predicted levels of nighttime depressed and anxious mood, and pain. This analysis was based on 30 days of monitoring for each participant. The second level of analyses examined whether these daily processes could be predicted by psychosocial and functional variables important to the experience of chronic pain. This analysis was based on the Mutidimensional Pain Inventory (Kerns, Turk, & Rudy, 1985) completed prior to participants beginning the daily monitoring. There were four major findings in this study. First, pain appraisals were more predictive of negative mood and pain intensity than coping strategy use, with Catastrophizing the strongest predictor of depressed and anxious mood, and control the strongest predictor of pain intensity. Second, general affective distress predicted higher levels of negative mood on a daily basis. Third, women who perceived their pain to be interfering a great deal in their lives were more anxious on a daily basis. Fourth, punishing spousal responses predicted nightly negative mood and pain more than solicitous or distracting spousal responses. These results are similar to findings based on patients attending pain treatment programs. This suggests that some of the same processes identified in clinical pain patients may apply to low back pain sufferers in the community who are comparable to study participants. The implications of these findings for pain research and treatment are discussed. / Education, Faculty of / Educational and Counselling Psychology, and Special Education (ECPS), Department of / Graduate

Injury-induced sensitization of nociceptors contributes to pain states and the development of chronic pain. Inhibiting activity-dependent mRNA translation through mechanistic target of rapamycin and mitogen-activated protein kinase (MAPK) pathways blocks the development of nociceptor sensitization. These pathways convergently signal to the eukaryotic translation initiation factor (eIF) 4F complex to regulate the sensitization of nociceptors, but the details of this process are ill defined. Here we investigated the hypothesis that phosphorylation of the 5' cap-binding protein eIF4E by its specific kinase MAPK interacting kinases (MNKs) 1/2 is a key factor in nociceptor sensitization and the development of chronic pain. Phosphorylation of ser209 on eIF4E regulates the translation of a subset of mRNAs. We show that pronociceptive and inflammatory factors, such as nerve growth factor (NGF), interleukin-6 (IL-6), and carrageenan, produce decreased mechanical and thermal hypersensitivity, decreased affective pain behaviors, and strongly reduced hyperalgesic priming in mice lacking eIF4E phosphorylation (eIF4E(S209A)). Tests were done in both sexes, and no sex differences were found. Moreover, in patch-clamp electrophysiology and Ca2+ imaging experiments on dorsal root ganglion neurons, NGF-and IL-6-induced increases in excitability were attenuated in neurons from eIF4ES209A mice. These effects were recapitulated in Mnk1/2(-/-) mice and with the MNK1/2 inhibitor cercosporamide. We also find that cold hypersensitivity induced by peripheral nerve injury is reduced in eIF4ES209A and Mnk1/2 (-/-) mice and following cercosporamide treatment. Our findings demonstrate that the MNK1/2-eIF4E signaling axis is an important contributing factor to mechanisms of nociceptor plasticity and the development of chronic pain.

The research reported in the thesis investigated exergaming acceptance and expe-rience in older people with special reference to technology acceptance, flowstate, chronic pain and balance control. In recent years, there has been an increasing amount of literature on the beneficial effects of exergaming on older people’s health, well-being and balance, including the use of exergaming as a method of pain con-trol. Nevertheless, when taken separately, specific studies vary in methodology and in type(s) of exergaming topics studied. Health benefits from exergaming may only be gained if older people take part in it. There is evidence in the literature to indicate that usage of a technology is preceded by user acceptance. Few studies, to date, have investigated how older people perceive and experience exergaming in relation to their perceived abilities and future intention to use it, from a technology acceptance point of view. Therefore, the purpose of this thesis was to see if (1) the exergaming technology was acceptable to healthy older people and older people with chronic pain and (2) it had any effect in the self-reported health status, pain conditions and balance in older people with chronic pain. The current thesis consists of two separate studies. In Study 1, twenty-eight healthy older people participated in six 40-minute exergaming sessions within a three-week period. In Study 2, fifty-four older people with chronic musculoskeletal pain attended a twelve 40-minute exercise intervention within a six-week period, either randomised into an exergaming group (IREXTMsystem) or standard physical exercises. A modified version of the Unified Theory of Acceptance and Use of Technology (UTAUT) was analysed at baseline and upon completion of the intervention, including specific time points throughout the study. Self-perceived chronic pain and flow state were analysed at baseline and after exercise intervention. Rate of perceived expended physical and mental effort was recorded after every exercise session and compared between groups. Heart rate was recorded in the second study. Postural sway was assessed at the start and the end of the intervention with Centre of Pressure data being extracted via a Kistler force plate (AP SD, AP range ,ML SD, ML range and CoP velocity), where the conditions were quiet bipedal standing with eyes open and eyes closed. Evidence from both studies showed that exergaming technology was acceptable to healthy older people and older people with chronic musculoskeletal pain. Recorded high levels of flow indicated the occurrence of flow during the intervention. Perfor-mance expectancy emerged as the strongest predictor of older people’s behavioural intention to use exergaming. Previous behaviour was an important influence of future behaviour, within the context of exergaming. In Study 1, there were significant increases throughout the intervention in most of the flow state variables except challenge-skill-balance, paradox of control and transformation of time. Thematic analysis of olde rpeople’s responses relating to exergaming revealed that enjoyment was the most frequently cited theme. The significant increase of perceived physical exertion suggested that exergaming provided light-to-moderate intensity exercise for this cohort of healthy older people. In Study 2, an interesting pattern emerged over time where earlier on in the interven-tion, effort expectancy significantly predicted older people’s behavioural intention to use exergaming (instead of performance expectancy). This role was then taken over by performance expectancy midway through the intervention. This indicated that this sample of older people with chronic pain prioritised their personal ability to play the exergames, after which, they then considered the usability of the exergaming technology in choosing whether to use it in future, if it were readily made available. In addition, there was evidence of improvement in post-intervention pain intensity in the exergaming group, suggesting that exergaming may have alleviated older people’s experience of pain to some extent. Flow levels significantly increased from the start to the end of the intervention. Significant improvements over time in postural sway parameters in the control and exergaming groups suggested that short-term exercise contributed to improved balance in older people with chronic musculoskeletal pain. The indication of improved postural sway due to significant mediolateral reductions in the eyes-closed condition in the both groups suggested that older people with chronic pain could benefit from at least subtle improvements in balance after taking part in short-term exercise. Nevertheless, exergaming may have an effect on postural sway when visual sensory information is removed, as found in the experimental group that demonstrated a statistically significantly lower reduction of CoP excursion in the medio-lateral direction, than in the control group.