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Item (506) The complex relationship between pain intensity and physical functioning in fibromyalgia: the mediating role of depression(The Journal of Pain, 2016) Steiner, Jennifer L.; Bigatti, Silvia M.; Slaven, James E.; Ang, Dennis C.Fibromyalgia (FM) is typically associated with the experience of diffuse pain and physical impairment. Depression also commonly co-exists in patients with FM, and it has been correlated with pain intensity and physical functioning. Previous research suggests an association between pain intensity and physical functioning; however, the direct causal relationship between improvements in pain intensity and in functioning is not observed in many FM patients. This may suggest that another factor such as depression is mediating this relationship. The present work examined the possibility of a mediating role of depression in the relationship between pain intensity and functioning over the course of time. 216 patients with FM completed self-report measures of pain intensity, depression, and physical impairment as part of a larger longitudinal study which investigated interventions to increase physical activity among FM patients. Assessments were completed at baseline, 12 weeks, 24 weeks, and 36 weeks. Longitudinal mediational analyses indicated that depression is a statistically significant partial mediator of the relationship between pain intensity and self-reported physical functioning at all four assessment points. To the authors’ knowledge, this is the first study to explicitly examine this relationship in a sample of FM patients, as well as the first to do so using a longitudinal design; this may significantly add to our understanding of the complexities behind creating improvements in physical functioning in this population. Clinical implication for these findings include focusing on depression and psychological correlates of depression as first line therapeutic targets in improving physical functioning of patients with FM, and treating co-morbid depression in patients with fibromyalgia earlier in the course of treatment to prevent engagement in and the perpetuation of the cycle of disability. This work was a secondary data analysis from a study funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.Item The Complex Relationship between Pain Intensity and Physical Functioning in Fibromyalgia: The Mediating Role of Depression(Journal of Applied Biobehavioral Research, 2017) Steiner, Jennifer L.; Bigatti, Silvia M.; Slaven, James E.; Ang, Dennis C.Fibromyalgia (FM) is typically associated with the experience of diffuse pain and physical impairment.Depression also commonly co-exists in patients with FM, and has been correlated with pain intensity and physical functioning.Previous research suggests an association between pain intensity and physical functioning; however, the direct causal relationship between improvements in pain intensity and in functioning is not observed in many FM patients.This may suggest that another factor such as depression is mediating this relationship. The present work examinedmediating role of depression. METHODS: 216 patients with FM completed measures of pain intensity, depression, and physical functionas part of a larger longitudinal study.Assessments were completed at baseline, 12, 24, and 36 weeks.RESULTS: Longitudinal mediational analyses indicated that depression is a partial mediator of the relationship between pain intensity and physical functioningat all four assessment points.Beta coefficients for the path from pain to physical functioning ranged from 0.18 –0.36, with attenuated path coefficients ranging from 0.03 –0.08, still showing significant but decreased associations when depression was added as a mediator. CONCLUSIONS: Clinical implication includes the importance of treating co-morbid depression in patients with fibromyalgia early in the course of treatment to prevent engagement in the cycle of disability.Item Disentangling trait versus state characteristics of the Pain Catastrophizing Scale and the PHQ-8 Depression Scale(Wiley, 2020-09) Dumenci, Levent; Kroenke, Kurt; Keefe, Francis J.; Ang, Dennis C.; Slover, James; Perera, Robert A.; Riddle, Daniel L.; Medicine, School of MedicineBackground: Research on the role of trait versus state characteristics of a variety of measures among persons experiencing pain has been a focus for the past few decades. Studying the trait versus state nature of the Pain Catastrophizing Scale (PCS) and the Patient Health Questionnaire (PHQ-8) depression scale would be highly informative given both are commonly measured in pain populations and neither scale has been studied for trait/state contributions. Methods: The PHQ-8 and PCS were obtained on persons undergoing knee arthroplasty at baseline, 2-, 6- and 12-month post-surgery (N = 402). The multi-trait generalization of the latent trait-state model was used to partition trait and state variability in PCS and PHQ-8 item responses simultaneously. A set of variables were used to predict trait catastrophizing and trait depression. Results: For total scores, the latent traits and latent states explain 63.2% (trait = 43.2%; state = 20.0%) and 50.2% (trait = 29.4%; state = 20.8%) of the variability in PCS and PHQ-8, respectively. Patients with a high number of bodily pain sites, high levels of anxiety, young patients and African-American patients had high levels of trait catastrophizing and trait depression. The PCS and the PHQ-8 consist of both enduring trait and dynamic state characteristics, with trait characteristics dominating for both measures. Conclusion: Clinicians and researchers using these scales should not assume the obtained measurements solely reflect either trait- or state-based characteristics. Significance: Clinicians and researchers using the PCS or PHQ-8 scales are measuring both state and trait characteristics and not just trait- or state-based characteristics.Item Does Vibration Training Improve Physical Function and Quality of Life in Fibromyalgia Syndrome?(Office of the Vice Chancellor for Research, 2010-04-09) Kaleth, Anthony S.; Ang, Dennis C.; Streepey, Jefferson W.; Mikesky, Alan E.; Bahamonde, Rafael E.; Dilts, SandiExercise and physical activity recommendations are an integral component of the overall management of fibromyalgia. Unfortunately, despite the known health, fitness, and symptom relief benefits, underlying pain and fatigue prevent most from initiating (or maintaining) physical activity and exercise programs, thereby contributing to sedentary lifestyles that lead to low levels of aerobic and muscular fitness. Therefore, it is important to identify alternative approaches to exercise programming in the overall management of fibromyalgia. Vibration training is a relatively new approach to exercise that has been shown to elicit numerous benefits; however little is known about the effects of this training method in fibromyalgia. Therefore, the primary aim of this study is to evaluate the effects of vibration training in improving musculoskeletal function, balance and postural control, and health-related quality of life in patients diagnosed with fibromyalgia.Item Obesity Moderates the Effects of Motivational Interviewing Treatment Outcomes in Fibromyalgia(Wolters Kluwer, 2017-03) Kaleth, Anthony S.; Slaven, James E.; Ang, Dennis C.; Kinesiology, School of Physical Education and Tourism ManagementObjective: Obesity is a common comorbid condition among patients with fibromyalgia (FM). Our objective was to assess if obesity moderates the treatment benefits of exercise-based motivational interviewing (MI) for FM. Methods: This is a secondary data analysis of a completed clinical trial of 198 FM patients who were randomized to receive either MI or attention control (AC). Using body mass index (BMI) to divide participants into obese (BMI >=30 kg/m2) and non-obese (BMI <30 kg m2) groups, mixed linear models were used to determine interaction between treatment arms and obesity status with regards to the primary outcome of global FM symptom severity (Fibromyalgia Impact Questionnaire, FIQ). Secondary measures included pain intensity (Brief Pain Inventory, BPI), 6-minute walk test, and self-reported physical activity (Community Health Activities Model Program for Seniors). Results: Of the 198 participants, 91 (46%) were non-obese and 107 (54%) were obese. On global FM symptom severity (FIQ), the interaction between treatment arms and obesity status was significant (P=0.02). In the non-obese group, MI was associated with a greater improvement in FIQ than AC. In the obese group, MI participants reported less improvement in FIQ compared to AC. The interaction analysis was also significant for BPI pain intensity (P=0.01), but not for the walk test and self-reported physical activity. Discussion: This is the first study to show that obesity negatively affects the treatment efficacy of MI in patients with FM. Our findings suggest that exercise-based MI may be more effective if initiated after weight loss is achieved.Item Opioid use prior to knee arthroplasty in patients who catastrophize about their pain: preoperative data from a multisite randomized clinical trial(Dovepress, 2018-08-21) Riddle, Daniel L.; Slover, James D.; Ang, Dennis C.; Bair, Matthew J.; Kroenke, Kurt; Perera, Robert A.; Dumenci, Levent; Medicine, School of MedicineBackground: Opioid use rates prior to knee arthroplasty (KA) among people who catastrophize about their pain are unknown. We determined prevalence of opioid use and compared patterns of preoperative opioid use and oral morphine equivalent (OME), a measure of daily opioid dose, across varied geographic sites. We also determined which baseline variables were associated with opioid use and OME. Patients and methods: Preoperative opioid use data described type of opioid, dosage, and frequency among 397 patients scheduled for KA. Demographic, knee-related pain, and psychological distress dimensions were examined to identify variables associated with opioid use and opioid dose (OME). Opioid use prevalence and OME were compared across the four sites. A three-level censored regression determined variables associated with opioid use and OME. Results: The overall opioid use prevalence was 31.7% (95% confidence interval [CI] = 27.0, 36.3) and varied across sites from 15.9% (95% CI = 9.0, 22.8) to 51.2% (95% CI = 40.5, 61.9). After adjustment, patients using opioids were more likely to be younger, African American, and have higher self-efficacy and comorbidity scores (P < 0.05). The only variable independently associated with OME was lower depressive symptoms (P < 0.05). Conclusion: People who catastrophized prior to KA did not demonstrate increased preoperative opioid use based on current evidence, but variation in the prevalence of opioid use across study sites was substantial. Variables associated with opioid use were non-modifiable demographic and comorbidity variables.Item Pain Coping Skills Training for Patients Who Catastrophize About Pain Prior to Knee Arthroplasty: A Multisite Randomized Clinical Trial(Journal of Bone and Joint Surgery, Inc., 2019-02-06) Riddle, Daniel L.; Keefe, Francis J.; Ang, Dennis C.; Slover, James; Jensen, Mark P.; Bair, Matthew J.; Kroenke, Kurt; Perera, Robert A.; Reed, Shelby D.; McKee, Daphne; Dumenci, Levent; Medicine, School of MedicineBACKGROUND: Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty. Interventions to address pain catastrophizing, to our knowledge, have not been tested in patients undergoing knee arthroplasty. The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education. METHODS: A multicenter, 3-arm, single-blinded, randomized comparative effectiveness trial was performed involving 5 university-based medical centers in the United States. There were 402 randomized participants. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale, measured at baseline, 2 months, 6 months, and 12 months following the surgical procedure. RESULTS: Participants were recruited from January 2013 to June 2016. In 402 participants, 66% were women and the mean age of the participants (and standard deviation) was 63.2 ± 8.0 years. Three hundred and forty-six participants (90% of those who underwent a surgical procedure) completed a 12-month follow-up. All 3 treatment groups had large improvements in 12-month WOMAC pain scores with no significant differences (p > 0.05) among the 3 treatment arms. No differences were found between WOMAC pain scores at 12 months for the pain coping skills and arthritis education groups (adjusted mean difference, 0.3 [95% confidence interval (CI), -0.9 to 1.5]) or between the pain coping and usual-care groups (adjusted mean difference, 0.4 [95% CI, -0.7 to 1.5]). Secondary outcomes also showed no significant differences (p > 0.05) among the 3 groups. CONCLUSIONS: Among adults with pain catastrophizing undergoing knee arthroplasty, cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care. Future research should develop interventions for the approximately 20% of patients undergoing knee arthroplasty who experience persistent function-limiting pain. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.Item Predictors of Physical Activity in Patients with Fibromyalgia: A Path Analysis(Wolters Kluwer, 2022) Kaleth, Anthony S.; Bigatti, Silvia M.; Slaven, James E.; Kelly, Nicholas; Ang, Dennis C.; Kinesiology, School of Health and Human SciencesBackground/objective: The aim of this study was to identify psychological factors that influence moderate-vigorous physical activity (MVPA) participation in patients with fibromyalgia. Methods: In this secondary data analysis, 170 patients received personalized exercise plans and completed baseline and follow-up assessments of self-reported physical activity at weeks 12, 24, and 36. Structural equation modeling was used to examine the predictive strengths of psychological factors (exercise self-efficacy, perceived barriers, and intention) on MVPA participation. Results: Using a threshold increase in MVPA of 10 or greater metabolic equivalent hours per week (MET h/wk), 3 groups were defined based on subjects who achieved a minimum increase of 10 MET h/wk that was sustained for at least 12 weeks (SUS-PA), achieved an increase of 10 MET h/wk that was not sustained for at least 12 weeks (UNSUS-PA), and did not achieve an increase of 10 MET h/wk (LO-PA). Increases in exercise self-efficacy and intention and reductions in perceived barriers were associated with increased volume of PA, showing the greatest change in the SUS-PA, followed by UNSUS-PA. For the LO-PA group, there was no change in exercise self-efficacy, a decrease in intention, and an increase in barriers. Using path analysis, exercise self-efficacy and perceived barriers were associated with higher volumes of physical activity via greater intention to engage in MVPA. Conclusions: For patients with fibromyalgia, exercise self-efficacy, perceived barriers, and intention to exercise are important constructs for increasing physical activity. Our findings provide guidance for practitioners who seek to promote physical activity in fibromyalgia and suggestions for researchers aiming to improve prediction models.Item Research to Encourage Exercise for Fibromyalgia (REEF): Use of motivational interviewing design and method(Contemporary Clinical Trials, 2011) Ang, Dennis C.; Kaleth, Anthony S.; Bigatti, Silvia; Mazzuxa, Steve; Saha, Chandan; Hilligoss, Janna; Lengerich, Mimi; Bandy, RobertFibromyalgia (FM), defined as the presence of both chronic widespread pain and the finding of 11/18 tender points on examination, is an illness associated with major personal and societal burden. Supervised aerobic exercise is an important treatment modality to improve patient symptoms. Unfortunately, adherence to an exercise regimen after a structured supervised program is disappointingly low. Since FM is a chronic illness, studies are needed to test strategies that would enhance exercise adherence in these individuals. Individuals who are able to adhere to exercise almost always maintain the symptomatic benefits of exercise. The objective of this paper was to describe the protocol of the Research to Encourage Exercise for Fibromyalgia (REEF). REEF is a randomized attention-controlled trial that seeks to test the efficacy of 6 sessions of telephone delivered motivational interviewing (MI) that targets exercise adherence to improve FM-relevant clinical outcomes (i.e., physical function and pain severity). The trial has recently completed enrolling 216 subjects, and randomization has resulted in well-balanced groups. Details on the study design, MI program, and treatment fidelity are provided in the paper. Outcome assessments at week 12, week 24 and week 36 will test the immediate, intermediate and long-term effects of exercise-based MI on adherence (as measured by the Community Health Activities Model Program for Seniors/CHAMPS and accelerometer) and clinical outcomes. When completed, REEF will determine whether exercise-based MI could be utilized as a management strategy to sustain the clinical benefits of exercise for FM.Item Research to Encourage Exercise for Fibromyalgia (REEF): Use of Motivational Interviewing, Outcomes From a Randomized-controlled Trial(The Clinical Journal of Pain, 2013) Ang, Dennis C.; Kaleth, Anthony S.; Bigatti, Silvia; Mazzuca, Steven A.; Jensen, Mark P.; Hilligoss, Janna; Slaven, James; Saha, ChandanObjectives Regular exercise is associated with important benefits in patients with fibromyalgia (FM). Unfortunately, long-term maintenance of exercise after a structured program is rare. The present study tested the efficacy of Motivational Interviewing (MI) to promote exercise and improve symptoms in patients with FM. Methods 216 patients with FM were randomized to 6 MI sessions (n=107) or an equal number of FM self-management lessons (education control/EC, n=109). Co-primary endpoints were an increase of 30 minutes in moderate-vigorous physical activity and improvement in the Fibromyalgia Impact Questionnaire-Physical Impairment (FIQ-PI) score, assessed at pre-treatment, post-treatment, and 3- and 6-month follow-up. Secondary outcomes included clinically meaningful improvements in FIQ score, pain severity ratings, and a 6-minute walk test. Results There were no significant treatment group differences in either co-primary endpoint at 6-month follow-up. However, more MI participants than controls exhibited meaningful improvements in FIQ score at 6-month follow-up (62.9% vs. 49.5%, p=0.06). Compared to EC subjects, MI subjects also displayed a larger increment in their 6-minute walk test (43.9 vs. 24.8 meters, p=0.03). Additionally, MI was superior to EC in increasing the number of hours of physical activity immediately post-intervention and in reducing pain severity both immediately after the intervention and at 3-month follow-up. Conclusions Despite a lack of benefits on long term outcome, MI appears to have short-term benefits with respect to self-report physical activity and clinical outcomes. This is the first study in FM that explicitly addresses exercise maintenance as a primary aim.