Mindful Action for Pain: An Integrated Approach to Improve Chronic Pain Function

慢性疼痛，定义为持续性或阵发性疼痛，不能通过治疗缓解，影响多达 50%的退伍军人，每年花费国家5600到6350亿美元，与高 伤残率和生活质量低下。根据2009年退伍军人健康管理局(VHA)指令， 疼痛治疗的目标是改善身体和心理社会功能，强调非 药理学方法，如心理社会干预，以针对维持 残疾。不幸的是，慢性疼痛的黄金标准心理社会干预，认知行为 治疗(CBT)，并不可靠地产生有意义的功能增加。退伍军人将受益匪浅 来自创新的和有理论基础的慢性疼痛的替代心理社会干预。 一种应用于慢性疼痛的新兴科学模型是心理弹性(PF)。 模特。PF指的是即使面对不想要的想法时，也能按照自己的价值观行事的能力。 感觉，以及身体上的感觉，如疼痛。接受和承诺疗法(ACT)是最著名的 治疗源于PF模型，与黄金标准CBT一样有效，但仍达不到 在功能改进方面实现有意义的变化。尽管ACT旨在影响PF，但方法 来自不同治疗方法的模型也是一致的。一种经验式策略 增强PF的承诺是正式的正念冥想，一种用于训练非判断性意识的练习 以及对当下体验的关注，这在PF模型中从未被测试过。的确有 令人信服的理论和经验基础，即正式正念冥想背后的机制 将支持PF过程，从而可以应用于促进功能改进。为了测试这一点，Dr。 首席调查员(PI)赫伯特开发了一种新的为期8周的小组干预方法--正念行动 对于疼痛(MAP)，它将正式的正念冥想与来自不同国家的经验方法相结合 循证治疗方法符合PF模式。地图的设计使得每天 正念冥想练习被用来发展更全面地利用策略解决问题的能力 达到最佳功能的关键心理社会障碍(例如，疼痛灾难)。 拟议的CDA-2包括两个阶段。第一阶段(1-2年级)包括使用定性和 迭代开发和提炼MAP的定量方法(n=20)。第二阶段(3-5年)由一个试点项目组成 MAP与CBT治疗慢性疼痛(CBT-CP)的随机试验(n=86)以确定未来的可行性 大规模试验和评估MAP的初步影响。功能改善将通过以下方式衡量 减少疼痛干预(主要临床结果)。此外，冥想的坚持性将被评估为 探索与功能改善和客观体力活动测量的剂量-反应关系 (动作图)将被捕获，以探索MAP的心理物理影响。 PF模型是一种进步的科学模型，与VHA治疗慢性疼痛的目标一致 管理，但到目前为止，基于这一模式制定的干预措施(即ACT)还没有完成 VHA制定的目标。因此，我们寻求充分开发和评估一部小说的初步影响， 符合PF模式的综合干预。在地图中，正式的正念冥想和 以循证经验为基础的方法作为帮助参与者保持在场的实用工具而被教授 专注于接受和创造距离，按顺序接受和创造持续的不愉快的想法、情绪和痛苦 积极追求有意义的人生方向。这项拟议的研究结果有可能 大大提高了患有慢性疼痛的退伍军人的身体和心理社会功能，并 减轻慢性疼痛的社会和经济负担的潜力。

Chronic pain, defined as persistent or episodic pain that does not resolve with treatment, affects up to 50% of Veterans, costs the nation between $560 and $635 billion dollars annually, and is associated with high rates of disability and low quality of life. According to the 2009 Veterans Health Administration (VHA) Directive, the goal of pain treatment is to improve physical and psychosocial functioning, emphasizing non- pharmacological approaches, such as psychosocial interventions, to target psychosocial factors that maintain disability. Unfortunately, the gold standard psychosocial intervention for chronic pain, Cognitive Behavioral Therapy (CBT), does not reliably produce meaningful increases in function. Veterans would greatly benefit from innovative and theoretically-grounded alternative psychosocial interventions for chronic pain. An emerging scientific model that has been applied to chronic pain is the psychological flexibility (PF) model. PF refers to the ability to behave consistently with one's values even in the face of unwanted thoughts, feelings, and bodily sensations such as pain. Acceptance and Commitment Therapy (ACT) is the best known treatment derived from the PF model and is as effective as the gold standard CBT, but still falls short on achieving meaningful changes in functional improvement. Although ACT was designed to impact PF, methods from different treatment approaches are also consistent with the model. An experiential strategy that holds promise for enhancing PF is formal mindfulness meditation, a practice used to train non-judgmental awareness and attention to present-moment experiences, which has never been tested within the PF model. There is compelling theoretical and empirical rationale that the mechanisms underlying formal mindfulness meditation will bolster PF processes and thereby can be applied to facilitate functional improvement. To test this, Dr. Herbert, the principal investigator (PI), has developed a novel 8-week group-based intervention, Mindful Action for Pain (MAP), which integrates formal mindfulness meditation with experiential methods from different evidence-based treatment approaches in accordance with the PF model. MAP is designed such that daily mindfulness meditation practice is used to develop the capacity to more completely utilize strategies to address the key psychosocial barriers (e.g., pain catastrophizing) to optimal functioning. The proposed CDA-2 consists of two phases. Phase 1 (years 1 – 2) consists of using qualitative and quantitative methods to iteratively develop and refine MAP (n = 20). Phase 2 (years 3 – 5) consists of a pilot randomized trial (n = 86) of MAP vs. CBT for chronic pain (CBT-CP) in order to establish feasibility of a future large-scale trial and estimate the preliminary impact of MAP. Functional improvement will be measured by reductions in pain interference (primary clinical outcome). Further, meditation adherence will be assessed to explore dose-response relationships with functional improvement, and objective measures of physical activity (actigraphy) will be captured to explore the psychophysical impact of MAP. The PF model is a progressive scientific model that is consistent with VHA goals for chronic pain management, but so far interventions developed based on this model (i.e., ACT) are not accomplishing the goals set forth by the VHA. Therefore, we seek to fully develop and estimate the preliminary impact of a novel, integrated intervention that is consistent with the PF model. In MAP, formal mindfulness meditation and evidence-based experiential methods are taught as practical tools to help participants remain present moment focused while accepting and creating distance with ongoing unpleasant thoughts, emotions, and pain in order to actively pursue meaningful life directions. Findings from the proposed study have the potential of substantially increasing the physical and psychosocial functioning of Veterans with chronic pain, and also have the potential of reducing the social and economic burden of chronic pain.