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Conducting high-quality clinical research is dependent on merging scientific rigor with the clinical environment. This is often a complex endeavor that may include numerous barriers and competing interests. Overcoming these challenges and successfully integrating clinical research programs into clinical practice settings serving rehabilitation outpatients is beneficial from both a logistical perspective (eg, supports efficient and successful research procedures) and the establishment of a truly patient-centered research approach. Leveraging our experience with navigating this research-clinical care relationship, this article (1) proposes the Patient-Centered Framework for Rehabilitation Research, a model for integrating patient-centered research in an outpatient clinical setting that incorporates a collaborative, team-based model encompassing patient-centered values, as well as strategies for recruitment and retention, with a focus on populations living with disabilities or chronic diseases; (2) describes application of this framework in a comprehensive specialty multiple sclerosis center with both general strategies and specific examples to guide adaptation and implementation in other settings; and (3) discusses the effect of the framework as a model in 1 center, as well as the need for additional investigation and adaptation for other populations. The 5 interconnected principles incorporated in the Framework and which prioritize patient-centeredness include identifying shared values, partnering with the clinical setting, engaging with the population, building relationships with individuals, and designing accessible procedures. The Patient-Centered Framework for Rehabilitation Research is a model presented as an adaptable roadmap to guide researchers in hopes of not only improving individual patients' experiences but also the quality and relevance of rehabilitation research as a whole. Future investigation is needed to test the Framework in other settings.

OBJECTIVE: This study aimed to examine same-day associations of pain, fatigue, depressed mood, anxiety, and perceived cognitive function with social participation in the daily lives of adults with spinal cord injury (SCI). DESIGN: Observational study used a combination of baseline surveys and 7 end-of-day (EOD) diaries. SETTING: General community. PARTICIPANTS: Individuals with SCI (N=168; mean age, 49.8y; 63% male, 37% female). MAIN OUTCOME MEASURES: Patient-Reported Outcomes Measurement Information System short form measures (Ability to Participate in Social Roles and Activities, Pain Intensity, Depression, Anxiety, Cognitive Function Abilities) were adapted for daily administrations as EOD diaries. RESULT: Results of multivariable model showed that daily increases in fatigue (B=−0.10; P=.004) and depressive symptoms (B=−0.25; P=

To describe telehealth trends within a population-based workers' compensation system during the COVID-19 pandemic, and to assess telehealth utilization by sociodemographic characteristics.This cross-sectional study used Washington State workers' compensation claims and medical billing data from January 2019 to October 2020.Telehealth use averaged 1.2% of medical bills pre-pandemic, peaked in April 2020 at 8.8%, and leveled off to around 3.6% from July to October 2020. Telehealth utilization differed significantly by age, sex, number of dependents, injury, industry, and receipt of interpreter services. Workers residing in counties with higher population, lower poverty rates, and greater Internet access had higher telehealth usage.There were dramatic shifts in telehealth; usage differed by sociodemographic characteristics. Further studies evaluating disparities in tele-health access among injured workers are needed.

Purpose/objective To examine the association between physical and mental symptoms and cognition in people with spinal cord injury. Research Method/Design: One hundred seventy-four community-dwelling adults with spinal cord injury completed several self-reported measures of health-related quality of life (Patient-Reported Outcomes Measurement Information System [PROMIS] Cognitive Abilities, Anxiety, Depression, Fatigue, and Pain Intensity) as well as a traditional neuropsychological assessment (six tests that included assessments of processing speed, working memory, memory, executive function, and attention). A series of multivariable linear regressions were used to test for associations between physical and mental symptoms and the seven ratings of cognition (i.e., scores on PROMIS Cognitive Abilities, as well as the six scores from the neuropsychological tests) after controlling for age, gender, education, and injury classification. Results There was generally no association between symptom measures and neuropsychological test performance with one exception: Greater pain was associated with poorer performance on attention. However, anxiety and fatigue were associated with lower self-perceived cognitive function. Among those individuals with evidence of cognitive impairment in at least one cognitive domain, anxiety was also associated with lower working memory score, and fatigue was associated with lower delayed memory performance. Conclusions/implications While the associations between pain and cognitive performance are consistent with general literature, the absence of a relationship between other symptoms (i.e., depression and fatigue) and cognitive performance was somewhat more surprising. Similarly, the associations between anxiety and fatigue with perceived cognitive function are consistent with the general literature, yet the absence of a relationship with depression was somewhat more surprising. Future work is needed to replicate these findings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Purpose/objective Polypharmacy is common in people with spinal cord injury (SCI). Given the high rates of medication use, and the complicated side effect profile of many of the medications that are regularly prescribed in people with SCI, we were interested in the association between the use of different classes of medications and cognitive function in these individuals. Research Method/Design: One-hundred and 73 people with SCI participated in an observational study. Self-reported medications were provided by participants. Participants also completed several cognitive tests designed to capture multiple aspects of cognition (processing speed, attention, working memory, learning, free-recall memory, delayed free recall memory, executive function), as well as a self-report measure that captures participant perceptions of cognitive function. A series of multivariable linear regressions were used to test for associations between medications and the seven measures of cognition. Results In general, there was not a robust relationship between medication use and cognitive function; the sole exception was an association between opioid use and subjective cognitive function. There was some preliminary support for an association between medication use, especially benzodiazepine and opioid analgesic use, and poorer cognitive performance. Specifically: Opioid analgesic use was associated with slowed processing speed, worse attention, poorer working memory, poorer executive function and more subjective cognitive complaints; benzodiazepine use was associated with slower processing speed, poorer working memory, and worse executive function; anticonvulsant use was related to worse delayed free recall memory; and the number of medication categories a person with SCI was taking was related to slower processing speed, and worse subjective cognitive function. Antidepressant, cannabis, skeletal muscle relaxant, sedative and stimulant use were not significantly related to cognitive performance, nor to subjective reports of cognitive function. Conclusions/implications Findings did not support a strong relationship between medication use and cognitive function in people with SCI. There is some preliminary support for an association between benzodiazepine use and cognitive performance, but this needs to be confirmed in future research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Little is known about quality of life (QOL) at the time of multiple sclerosis (MS) or clinically isolated syndrome (CIS) diagnosis and how it evolves in the critical adjustment period immediately following a new diagnosis. To (1) describe QOL trajectory in the first year post-MS/CIS diagnosis and (2) examine associations of demographic and biopsychosocial factors with QOL at baseline and as it evolves over the first year post-MS/CIS diagnosis. Participants were N = 250 individuals newly diagnosed with MS or CIS. Participants completed self-report assessments of QOL, demographics, and biopsychosocial factors at 1, 2, 3, 6, 9, and 12 months post-diagnosis using validated measures. At 1-month post-diagnosis, QOL M = 75.2/100 with subsequent assessments revealing consistent ratings on average. Modelling revealed a small number of variables that were predictive of QOL at baseline and/or change in QOL over time. QOL in the first year post-MS/CIS diagnosis was, on average, high and stable. A subset of modifiable factors across the biopsychosocial spectrum was associated with baseline level of QOL and change in QOL over time. The stability in QOL suggests that patients can be assessed early after diagnosis for key variables that are predictive of both current and future QOL.

Objective To describe pain intensity and interference in people with progressive multiple sclerosis (MS), compare these with people with relapsing-remitting multiple sclerosis (RRMS), and identify common and unique factors associated with pain intensity in people with progressive MS and RRMS. Design Observational, cross-sectional analysis using baseline data from a longitudinal survey on quality of life in participants with MS. Setting Community. Participants A total of 573 adults with MS (N=573; progressive MS, n=142; RRMS, n=431). Interventions Not applicable. Main Outcome Measures Average pain intensity was measured by an 11-point numeric rating scale, and pain interference was measured by the Patient-Reported Outcomes Measurement Information System Pain Interference Short Form. Results Participants with progressive MS reported moderate average pain intensity (3.22±2.50) and elevated pain interference (T score of 55.55±9.13). They did not differ significantly from those with RRMS in average pain intensity or pain interference. Common factors associated with higher average pain intensity were more severe disability, lower education level, unemployment, and current smoking. In those with progressive MS, older age was associated with lower average pain intensity. Conclusions Pain intensity and interference are similar across MS types. In addition to assessing and treating pain, it is important to screen for modifiable pain-related factors, such as smoking cessation, in this population.

Introduction People with chronic conditions, common among rehabilitation populations, may have risk factors that put them at higher risk for more severe illness due to coronavirus disease 2019 (COVID‐19). Objective To describe and compare adherence to public health guidelines, willingness to adhere to public health guidelines (including vaccination), information‐seeking, and perceived trustworthiness of information among people with and without chronic conditions during the early stages of the COVID‐19 pandemic. Design National cross‐sectional online survey of people with and without chronic health conditions conducted from April through May 2020. Participants Survey respondents were people with and without chronic conditions, ≥18 years old, able to read English, and in the United States since January 2020. In total, 3109 survey responses were received and 2572 complete unique responses were used in the analysis. Methods The survey assessed demographics, adherence to public health measures, information‐seeking, and perceived trustworthiness of information sources. Descriptive analyses characterized the sample, and t‐tests and nonparametric tests were used to compare those with and without a chronic condition on the public health measures. Results Participants with a chronic condition reported high adherence to public health recommendations and high willingness to adhere to anticipated recommendations across a wide range of chronic conditions and similar to those without a chronic condition despite advised caution for people with underlying health conditions. Of those with a chronic condition, 70.8% reported a willingness to be vaccinated. Participants reported accessing information from varied sources, with perceived trust highest for the health care providers and lowest for social media. Conclusion Participants reported high adherence to public health measures, regardless of chronic condition status, during the early phase of the COVID‐19 pandemic. Knowledge of adherence to public health measures, information‐seeking, and trust in information can assist rehabilitation providers and organizations seeking to mitigate disease transmission, particularly for those with chronic conditions.

This study reports a qualitative analysis of patient experiences following cognitive therapy (CT), mindfulness meditation (MM), or mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP). It aimed to investigate the procedural elements reported by participants as important across these approaches, as well as the role of treatment-related change processes and common factors. Research Method/Design: A qualitative analysis of posttreatment semistructured interviews was conducted with participants who enrolled in a randomized controlled trial comparing MM, CT, and MBCT (N = 57 adults with CLBP). A thematic analysis of transcribed interviews was undertaken by two independent coders; emerging themes, subthemes, and direct quotes were collated, and thematic maps were created. Procedural elements that were both unique (e.g., "cognitive restructuring" in CT) and shared among the three treatments (e.g., "knowledge gained" on pain-related topics) were reported as important. Each treatment was associated with a small number of unique therapeutic processes that were consistent with theoretical tenets underlying the interventions (e.g., "staying in the present moment" in MM). A large number of shared processes and common factors also emerged as important across all three treatments. These first-person accounts provide insight into those participant-identified therapeutic procedures and change processes that were most valued by individuals completing cognitive and mindfulness-based interventions for CLBP. Early identification of treatment barriers and strategies to overcome these barriers is necessary. Further, therapeutic rapport and training participants in coping skills they themselves can use were critical, as was engendering changes in cognitive, emotional, and behavioral mechanisms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective To (1) evaluate the effects of a group-based self-management treatment intervention (VETPALS) on physical and psychosocial functioning (primary outcomes) and quality of life (secondary outcome) in individuals with amputation and (2) examine the feasibility and acceptability of the intervention in a large national health care system. Design Randomized controlled trial with masked outcome assessment. Setting Five Veterans Affairs medical centers geographically dispersed across the United States. Participants 147 individuals with amputation during the past 2 years due to chronic limb threatening ischemia (N=147). Interventions Participants were randomized into VETPALS (N =71) or education control (N=76). VETPALS consisted of a 4-hour workshop and 4 additional 2-hour sessions addressing self-management skills, health and activity, managing emotions, communication and social support, and maintaining goals and gains. Education control consisted of the provision of amputation-related educational materials and provider follow-up if requested. Main Outcome Measures Primary outcomes were physical functioning (Short Musculoskeletal Functional Assessment) and psychosocial functioning (Patient Health Questionnaire-9). Secondary outcomes were quality of life (global) and quality of life (satisfaction with health) from the World Health Organization Quality of Life Scale (brief). Assessment was conducted at baseline, 6 weeks (treatment completion), and 6 months (follow-up). Results Participants randomized to VETPALS reported significantly improved psychosocial functioning and quality of life (satisfaction with health) relative to controls at 6 months (B=1.84; 95% confidence interval, 0.37,3.31 and B=−0.61; 95% confidence interval, −1.11,-0.12, respectively). There were no differences in physical functioning over time between VETPALS and education control at either time point. Follow-up multiple imputation sensitivity analyses produced an identical pattern of results. Among VETPALS participants, treatment initiation was low (56%), but treatment retention (93% attended 4 of 5 classes) and overall satisfaction (100% reported very helpful or better and would recommend to a friend) were high. Conclusions Group-based self-management improves psychosocial functioning for individuals with amputation due to chronic limb threatening ischemia. In-person participation is challenging for this population, but individuals who successfully initiate treatment typically persist and are highly satisfied.

Background Chronic pain in Veterans is a major problem compounded by comorbid posttraumatic stress disorder (PTSD) and depression. Adopting a transdiagnostic framework to understanding “shared territory” among these diagnoses has the potential to inform our understanding of the underlying cognitive processes and mechanisms that transverse diagnostic boundaries. Purpose To examine the associations between pain-related cognitive processes (diversion, distancing, absorption, and openness), pain intensity, PTSD and depressive symptoms, and the extent to which Veterans with chronic pain with and without comorbid PTSD and depression engage in different/similar pain-related cognitive processes. Methods Secondary analysis of pretreatment data with a subsample (n = 147) of Veterans with chronic pain from a larger clinical trial. Pretreatment PCL-5 and PROMIS Depression scales were used to categorize participants into three groups: (a) Pain-only; (b) Pain-PTSD; and (c) Pain-PTSD-DEP. Results Compared to the Pain-only group, the Pain-PTSD and Pain-PTSD-DEP groups reported significantly greater pain intensity, PTSD and depressive symptoms, and ruminative pain absorption. The Pain-PTSD-DEP group had significantly lower pain diversion and pain openness scores. When diversion and openness were used within the Pain-PTSD-DEP group, however, they were both associated with lower pain intensity and openness was additionally associated with lower PTSD scores. However, in the Pain-PTSD group, pain openness was associated with higher depression scores. Conclusions Across increasing complexity of comorbidity profiles (i.e., one vs. two comorbid conditions), ruminative absorption with pain emerged as a cognitive process that transverses diagnoses and contributes to worse outcomes. Nonjudgmental acceptance may not be universally beneficial, potentially depending upon the nature of comorbidity profiles.

Objective: We describe the process of working with stakeholders with multiple sclerosis (MS) to develop a web-based multisymptom self-management program to address chronic pain, fatigue, and/or depressive symptoms. The results of a pilot trial to test the feasibility and effects of the program are presented. Method: The first study phase involved the development of a web-based symptom self-management program. The second phase involved a single-arm pilot trial (N = 20) of unguided website use for 12 weeks in adults with MS and elevated levels of chronic pain, fatigue, and/or depressed mood. Results: A web-based symptom self-management program, My MS Toolkit, was developed and released for public use in 2019. The results from the pilot trial showed that on average, participants accessed the website 5.4 times, spending about 7 min on the site per visit. Eighty percent rated intervention-related changes in activity limitations, symptoms, emotions, and overall quality of life as either "somewhat" or "moderately" better. Although there were no significant improvements on outcome measures, of those who screened positive for the outcome of interest (i.e., showed a clinically elevated level of that symptom), clinically significant improvement was seen in 37.5% for fatigue, 45.5% for pain, and 40% for depressive symptoms. Conclusions: My MS Toolkit is an accessible, stakeholder-informed, web-based MS symptom self-management program that demonstrated a clinically significant positive impact on symptoms in a proportion of participants. More research is needed to further examine the effects of this program and elucidate who is most likely to benefit from this type of self-guided intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective Chronic pain is one of the most common and interfering symptoms experienced by people with MS. There is an opportunity to shift the paradigm from interventions delivered after pain has become chronic to early, proactive interventions to alter the impact of MS-related pain. The purpose of this study was to develop and test a remotely delivered single-session group intervention to modify the pain trajectory for individuals with early MS. Research Method/Design: This was a single-center 2-group pilot randomized (1:1) controlled trial comparing a novel videoconference-delivered single-session pain intervention to a waitlist control. Participants were N = 27 adults who were diagnosed with MS in the preceding 36 months and who had moderate or worse pain. The study team developed the intervention to introduce pain coping and commonly used cognitive, behavioral, and acceptance-based approaches for adaptive coping. Participants completed outcome assessments on pain intensity, interference, and coping at pretreatment, posttreatment, and 3-months posttreatment. Results Among participants in the treatment arm, the majority (54%) indicated satisfaction with treatment and all (100%) indicated continued use of strategies learned in the intervention. The 2 groups did not differ on any of the outcomes at any time point, and large standard deviations were found on most of the measures for both groups at all timepoints. Conclusions/implications This brief, highly accessible intervention targeting pain coping in individuals with early MS is feasible and acceptable. Further research is needed to better understand the effectiveness of the intervention both immediately and in positively impacting future coping in this population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

While there is evidence in other clinical groups to suggest that sleep problems can negatively impact cognitive performance, this relationship has not yet been examined in people with spinal cord injury (SCI). Thus, we sought to examine the association between sleep and cognitive function in people with SCI.Over the course of 7 days, 167 individuals with SCI completed daily subjective ratings of sleep (sleep quality, number of hours slept per night, and bedtime variability) and wore a wrist-worn device that continuously monitored autonomic nervous system (ANS) activity (i.e., blood volume pulse [BVP] signal and electrodermal activity [EDA] signal). At the end of this home monitoring period, participants completed a subjective rating of cognition and six objective cognitive tests. A series of multivariable linear regressions were used to examine associations between eight measures of sleep/ANS activity during sleep and eight cognitive variables.Subjective ratings of sleep were not related to either objective cognitive performance or self-reported cognitive function. However, there were some relationships between ANS activity during sleep and objective cognitive performance: lower BVP signal was associated with poorer performance on measures of processing speed, working memory, learning and long-term memory, and EDA signals were associated with poorer performance on a measure of executive function.Future work is needed to better understand the relationship of sleep, especially sleep physiology, and cognitive functioning for individuals with SCI, and how that may be similar or different to relationships in the general population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

This research examined whether brief sessions of mindfulness meditation (MM) or self-hypnosis (HYP) produce changes in cold pressor task (CPT) outcomes and whether outcome improvement, when it occurs, is mediated by attentional processes (i.e., pain focus, mindful observing) or pain appraisals (i.e., threat, challenge). Healthy adults (N = 201) were randomly assigned to 20-min sessions of MM, HYP, or an attention Control. Participants completed assessments of potential mediators before the first CPT and after experimental intervention, but before a second CPT. HYP and MM participants reported greater reductions in CPT pain intensity than Control participants, and CPT unpleasantness was reduced in HYP compared to Control. Neither MM nor HYP resulted in significant changes in pain focus or mindful observing, and these scales were not associated with CPT outcomes. However, threat appraisals were reduced in HYP versus Control, and threat appraisal reductions were associated with increased pain tolerance. Challenge appraisal increased in both HYP versus Control and HYP versus MM, and challenge increases were associated with reductions in CPT unpleasantness. Challenge changes were a significant mediator of unpleasantness changes when HYP was compared to MM (p = .042); this mediation effect was non-significant for HYP compared to Control (p = .059). The findings indicate single sessions of HYP and MM produce changes in CPT outcomes. HYP also influenced threat and challenge appraisals, which were associated with CPT outcome changes, and challenge appraisals emerged as a potential mechanism of HYP. Further research is needed to identify mediating mechanisms for these two pain management approaches.

Background Depression, fatigue, and pain commonly co-occur in multiple sclerosis (MS) and are positively associated with one another. However, it is unclear whether treatment-related improvement in one of these symptoms is associated with improvements in the other two symptoms. Purpose This study examined whether early improvements in depressive symptoms, fatigue impact, and pain interference during a multisymptom intervention in persons with MS were associated with overall improvements in the other two symptoms. Methods Secondary analysis of a randomized controlled trial in which both treatments improved depressive symptoms, fatigue, and pain interference. Adults with MS experiencing chronic pain, chronic fatigue, and/or moderate depressive symptoms (N = 154, 86% women) participated in an 8-week, telephone-delivered intervention: self-management (n = 69) or education (n = 85); intervention groups were combined for the current study. Outcome measures were depressive symptoms (PHQ-9), fatigue impact (Modified Fatigue Impact Scale), and pain interference (Brief Pain Inventory). Path analysis examined associations between pre-to-mid intervention improvement in one symptom (i.e., depression, fatigue, pain interference) and pre-to-post (overall) improvement in the other two symptoms. Results Early reduction in depressive symptoms was associated with an overall reduction in pain interference and fatigue impact (p’s < .01). Early reduction in fatigue impact was associated with an overall reduction in depressive symptom severity (p = .04) but not pain interference. Early reduction in pain interference was not associated with reductions in fatigue impact or depressive symptoms. Conclusions These findings suggest the potential importance of reducing depressive symptoms to overall improvement in fatigue and pain interference in persons with MS. Clinical Trial Registrations NCT00944190.

Chronic pain is a significant health problem worldwide with limited pharmacological treatment options. This study evaluated the relative efficacy of 4 treatment sessions each of 4 nonpharmacological treatments: (1) hypnotic cognitive therapy (using hypnosis to alter the meaning of pain); (2) standard cognitive therapy; (3) hypnosis focused on pain reduction, and (4) pain education. One hundred seventy-three individuals with chronic pain were randomly assigned to receive 4 sessions of 1 of the 4 treatments. Primary (pain intensity) and secondary outcome measures were administered by assessors unaware of treatment allocation at pretreatment, posttreatment, and 3-, 6-, and 12-month follow-up. Treatment effects were evaluated using analysis of variance, a generalized estimating equation approach, or a Fisher exact test, depending on the outcome domain examined. All 4 treatments were associated with medium to large effect size improvements in pain intensity that maintained up to 12 months posttreatment. Pretreatment to posttreatment improvements were observed across the 4 treatment conditions on the secondary outcomes of pain interference and depressive symptoms, with some return towards pretreatment levels at 12-month follow-up. No significant between-group differences emerged in omnibus analyses, and few statistically significant between-group differences emerged in the planned pairwise analyses, although the 2 significant effects that did emerge favored hypnotic cognitive therapy. Future research is needed to determine whether the significant differences that emerged are reliable.

Background: This study aimed to develop a Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) tablet application, “iCAMS,” and examine equivalency between the original paper-based and the tablet-based assessments. Methods: This study enrolled 100 participants with physician-confirmed multiple sclerosis (MS). Interrater reliability, parallel forms reliability, and concurrent validity were evaluated by incorporating two test administrators in each session: one scoring participant responses with the original paper assessments and the other with iCAMS. Although the participant was exposed to the material only once, responses were recorded on both administration methods. In addition to the standard test procedures, each research assistant used a stopwatch to measure the amount of time required to administer and score each version of BICAMS. Results: Pearson correlation coefficients (r) revealed strong and significant correlations for all three tests. Excellent agreement was observed between iCAMS and paper versions of the BICAMS tests, with all intraclass correlation coefficients exceeding 0.93. The scores from all the cognitive tests were not statistically significantly different, indicating no proportional bias. Including scoring, administration of the iCAMS application saved approximately 10 minutes over the paper version. Conclusions: Preliminary findings suggest that the tablet application iCAMS is a reliable and fast method for administering BICAMS.

Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) with an active education control (ED). Veterans (N = 328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity [API]) and secondary outcomes were assessed at pretreatment, posttreatment, and 3 and 6 months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pretreatment to posttreatment change in API; however, pretreatment to posttreatment improvements in API and several secondary variables were seen for participants in all 3 conditions. Participation in MM resulted in greater decreases in API and pain interference at 6 months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3 and 6 months posttreatment compared with ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all 3 interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.

The current study used data from a clinical trial to identify variables that are associated with and/or mediate the beneficial effects of 4 psychological chronic pain treatments: one teaching patients self-hypnosis to reduce pain intensity (HYP), one teaching self-hypnosis to change thoughts about pain (hypnotic cognitive therapy [HYP-CT]), one teaching cognitive restructuring skills to change thoughts about pain (cognitive therapy [CT]), and one providing education about pain (ED; included as an active control condition). Of 17 possible mechanism variables examined, and with alpha not corrected for multiple comparisons, significant between-group differences were observed for 3. Two of these (changes in beliefs about control over pain and number of days of skill practice) were supported as mediators of the beneficial effects of HYP, CT, or HYP-CT, relative to ED. Six mechanism variables evidenced significant pretreatment to post-treatment changes in the sample as a whole, without showing significant between-group differences. Pretreatment to post-treatment changes in all 6 were associated with improvements in pain interference, pain intensity, or both. In addition, participant ratings of therapeutic alliance at post-treatment were associated significantly with improvements in both pain intensity and pain interference in the sample as a whole. Thus, of the 17 possible mediators examined, there were relatively few that served as mediators for the beneficial effects of specific treatments; a larger number of variables predicted treatment outcome overall. The extent to which these variables are treatment mediators (ie, are responsible for, rather than merely associated with, treatment-related improvements) will require further research.

Background: Pain, fatigue, depression, and anxiety are common in multiple sclerosis, but little is known about the presence, co-occurrence, and trajectories of these symptoms in the year after multiple sclerosis (MS) diagnosis. Objectives: To determine, during the postdiagnosis year: (1) rates of pain, fatigue, depression, and anxiety; (2) rates of symptom co-occurrence; and (3) stability/change in symptom severity. Methods: Newly diagnosed adults with MS/clinically isolated syndrome ( N = 230) completed self-report measures of pain, fatigue, depression, and anxiety at 1, 2, 3, 6, 9, and 12 months after MS diagnosis. Clinical significance was defined based on standardized cutoffs. Descriptive statistics and Sankey diagrams characterized rates and trajectories. Results: Participants endorsed clinically significant symptoms at some point in the postdiagnosis year at rates of 50.9% for pain, 62.6% for fatigue, 47.4% for depression, and 38.7% for anxiety. A majority of patients exhibited co-occurring symptoms—21.3% with two, 19.1% with three, and 17.4% with four. The proportions of patients with clinically significant symptoms were generally stable over time; however, rates of symptom development/recovery revealed fluctuations at the individual level. Conclusions: Pain, fatigue, depression, and anxiety are prevalent in newly diagnosed MS. Prompt screening and evidence-based interventions are necessary if quality of life is to be optimized.

Background: The behavioural inhibition system and activation system (BIS-BAS) model of pain focusses on two clusters of responses to pain—escape/avoidance (BIS) and approach (BAS) behaviours. While the BIS-BAS model emphasizes active responses to pain, deactivation responses such as despondence and relaxation are also common. This study sought to develop self-report scales assessing cognitive, behavioural intentions and affective responses to pain consistent with this extended BIS-BAS framework. We also sought to develop short-forms of the emerging scales. Methods: Confirmatory factor analysis was performed to derive scales from a large item pool administered to a community sample with heterogeneous chronic pain (N = 476). Results: The items resulted in 16 scales assessing Thoughts, Affective responses, Behavioural Intentions and Valence-Associated Thoughts, which loaded on to the four theorized types of pain responses—Escape, Approach, Despondence and Relaxation—with the four emerging short-form scales assessing these overarching factors. The internal consistency reliabilities of the long-forms generally ranged from good to excellent (αs ≥ 0.83), with the exception of the Relaxation-Behavioural Intentions scale (α = 0.64). The four short-forms demonstrated at least adequate internal consistency reliability (αs ≥ 0.79). An initial test of the construct validity of the scales in relation to pain-related outcomes is also reported. Conclusions: We anticipate that the Pain Responses Scale (PRS) developed from this research will be useful for assessing mechanisms targeted by many psychosocial pain treatments and will provide a nuanced understanding of the shared versus specific nature of these mechanisms. Significance: The Pain Responses Scale emerging from this research assesses four theorized, overarching responses to pain: Escape, Approach, Giving Up and Relaxation. This measure will afford the capacity to test a reconceptualized BIS-BAS model of pain and inform treatments that are adapted based on this framework.

Highlights • As COVID-19 vaccines become available, it is important to understand rates of vaccine acceptability in adults with multiple sclerosis (MS). • Two-thirds of the participants reported a willingness to obtain a COVID-19 vaccine, with education level, perceived risk for COVID-19, and trust in COVID-19 information sources positively associated with vaccine acceptability. • These findings have important implications for guiding vaccine uptake among vaccine eligible people with MS during the COVID-19 pandemic., Background: As vaccines for the coronavirus become available, it will be important to know the rate of COVID-19 vaccine acceptability in adults with multiple sclerosis (MS), given that vaccination will be a key strategy for preventing SARS-CoV-2 infections. Using a national sample of adults with MS in the United States obtained early in the COVID-19 pandemic, the current study aimed to: (1) assess willingness to get a COVID-19 vaccine when available; (2) determine demographic, MS, and psychosocial correlates of vaccine willingness; and (3) measure where people with MS get their COVID-19 information and their perceived trustworthiness of such sources, which may influence COVID-19 vaccine willingness. Methods: Adults with MS (N = 486) living in the United States completed a cross-sectional online survey (between 10 April 2020 and 06 May 2020) about their willingness to receive a COVID-19 vaccination once available. Participants also completed measures to describe the sample and to assess factors potentially related to vaccine willingness, including demographics, MS-specific variables, psychological measures, COVID-19 information sources, and perceived trustworthiness of their information sources. Results: Approximately two-thirds of the participants (66.0%) reported a willingness to obtain a future COVID-19 vaccine, whereas 15.4%of the sample was unwilling. Greater willingness to receive the vaccine was associated with having a higher level of education and holding a higher perception of one's risk of catching COVID-19. Participants reported accessing COVID-19 information from many different sources. Approximately a third (31.6%) of the sample reported getting their information from healthcare providers. Healthcare providers and the National MS Society had the highest perceived trustworthiness for COVID-19 information. The perceived trustworthiness of information sources was highly associated with vaccine willingness. Conclusion: Early in the pandemic, willingness to get a COVID-19 vaccine was not universal in this large sample or people living with MS. Vaccine willingness was associated with a few variables including education level, perceived risk for COVID-19 infection, and trust in COVID-19 information sources. These results have important implications for guiding healthcare providers and the MS community as COVID-19 vaccines become widely available.

Little is known about quality of life (QOL) at the time of multiple sclerosis (MS) or clinically isolated syndrome (CIS) diagnosis and how it evolves in the critical adjustment period immediately following a new diagnosis.To (1) describe QOL trajectory in the first year post-MS/CIS diagnosis and (2) examine associations of demographic and biopsychosocial factors with QOL at baseline and as it evolves over the first year post-MS/CIS diagnosis.Participants were N = 250 individuals newly diagnosed with MS or CIS. Participants completed self-report assessments of QOL, demographics, and biopsychosocial factors at 1, 2, 3, 6, 9, and 12 months post-diagnosis using validated measures.At 1-month post-diagnosis, QOL M = 75.2/100 with subsequent assessments revealing consistent ratings on average. Modelling revealed a small number of variables that were predictive of QOL at baseline and/or change in QOL over time.QOL in the first year post-MS/CIS diagnosis was, on average, high and stable. A subset of modifiable factors across the biopsychosocial spectrum was associated with baseline level of QOL and change in QOL over time. The stability in QOL suggests that patients can be assessed early after diagnosis for key variables that are predictive of both current and future QOL.

Research Objectives To identify longitudinal trajectories of depression in the first six months following amputation and to explore baseline predictors of these trajectories. A secondary aim was to utilize trajectories as predictors of PTSD as a 6-month distal outcome. Design Archival data from two inception cohort studies of persons with new onset limb loss. Participants completed assessments at initial, -3 and 6-month follow-ups. Setting hospitalized care, acute rehabilitation, ambulatory care, and community. Participants Individuals with new limb loss were recruited from consecutive cases within a large metropolitan hospital system over a four-year period (2002-2007). Final sample (n = 203) was predominantly male (78.8%) and white (83.3%) with an average age of 49.4 years (SD = 14.58) at the time of amputation. Interventions N/A. Main Outcome Measures Patient Health Questionnaire-9 (PHQ-9); PTSD checklist – Civilian Version (PCL-C). Results Using Latent Growth Mixture Modeling, four trajectories of depression were identified: resilience (73.2%), recovery (6.7%), emerging depression (8.9%), and chronic depression (11.2%). Pain intensity was a significant baseline predictor of trajectory membership, whereas demographic covariates were non-significant. In distal outcome analyses, trajectory membership significantly predicted PTSD at 6-months. Pairwise comparisons revealed significantly elevated PTSD in the chronic-depression trajectory versus all other classes; the resilient class had significantly fewer PTSD symptoms than the emerging depression class but did not differentiate from the recovery trajectory. Conclusions Findings support the conclusion that the course of depression post-amputation is heterogeneous, with varying profiles of symptom development and remission. Although the majority of individuals were classified as resilient, average depression was mildly elevated in the resilient class immediately post-amputation, underscoring the challenging nature of acute recovery. Further, a substantial minority of individuals (8.9%) developed clinically significant depression between 3 and 6-months, suggesting that early screening during acute care may be insufficient for the detection of emerging depression. The derivation of latent classes of depression in longitudinal data may prove useful as a clinical tool for the early identification of those at risk for PTSD, a diagnosis with unique time-course requirements. Author(s) Disclosuress None

Objective Psychological treatments for chronic low back pain (CLBP) are effective. However, limited research has investigated their neurophysiological mechanisms. This study examined electroencephalography- (EEG-) assessed brain oscillation changes as potential mechanisms of cognitive therapy (CT), mindfulness-meditation (MM), and mindfulness-based cognitive therapy (MBCT) for CLBP. The a priori bandwidths of interest were changes in theta, alpha and beta power, measured at pre- and post-treatment. Design A secondary analysis of a clinical trial. Setting University of Queensland Psychology Clinic. Subjects Adults (N = 57) with CLBP who completed pre- and post-treatment EEG and pain outcome assessments. Methods EEG data were examined for five regions of interest (ROIs); the primary outcome was pain intensity. Results A significant reduction in theta (P=.015) and alpha (P=.006) power in the left frontal ROI across all treatments was found, although change in theta and alpha power in this region was not differentially associated with outcome across treatments. There were significant reductions in beta power in all five ROIs across all treatments (P≤.013). Beta power reduction in the central ROI showed a significant association with reduced pain intensity in MBCT only (P=.028). Changes in other regions were not statistically significant. Conclusions These findings provide support for the capacity of psychological CLBP treatments to induce changes in brain activity. The reduced beta power in all five ROIs indicated that all three treatments engendered a state of lowered cortical arousal. The growing body of research in this area could potentially inform novel directions towards remedying central nervous system abnormalities associated with CLBP.

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p 0.001) and slower processing speed (r = 0.23, p 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p 0.001) and PTSD symptoms (r = 0.44, p 0.001), and slower processing speed (r = -0.22, p 0.001).The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Background Up-to-date information regarding the scope and impact of cannabinoid use among persons with MS (PwMS) is necessary to guide clinical practice and cannabinoid research. Objectives To assess utilization patterns and perceived impact of cannabinoid use among a national cohort of PwMS. Methods Data collected were part of a nationwide survey to characterize pain in PwMS. Items included questions about current/recent cannabinoid use, reasons for use, preferred THC/CBD formulations, and perceived benefits/side effects. PROMIS short-forms assessed symptom severity. Pain phenotype was assessed with the painDETECT questionnaire and FMSurvey Criteria Questionnaires. Results Among n = 1,027 respondents, 42% endorsed recent cannabinoid use, of which 18% endorsed healthcare provider guidance regarding use. PROMIS scores (except cognitive abilities), and pain centralization and neuropathic pain scores, were higher among recent/current users (each p Conclusion Cannabinoid use is common in PwMS, despite a paucity of provider guidance. The range of perceived benefits, and potential differential effects of THC and CBD, highlight the need for personalized, evidence-based guidelines regarding cannabinoid use.

Objectives To (1) describe depressive symptom severity and suicidal ideation (SI) in persons with progressive multiple sclerosis (MS); (2) compare depressive symptom severity and SI in persons with progressive MS and persons with relapsing-remitting multiple sclerosis (RRMS); and (3) identify common and unique risk factors for greater depressive symptom severity and SI in persons with progressive MS compared with individuals with RRMS. Design Observational, cross-sectional survey study. Setting Community. Participants Adults with MS (N=573). Interventions Not applicable. Main Outcome Measures The dependent variables were depression symptoms and any SI measured by the Patient Health Questionnaire-9. Comparisons between groups used t tests and chi-square analyses, and risk factors were tested by examining the interaction of MS subtype (progressive MS and RRMS) and each risk factor in multiple regression models with bootstrapping. Results Persons with progressive MS did not differ from persons with RRMS in levels of depressive symptoms or SI. Both groups reported mild depressive symptoms and approximately 10% endorsed SI. Common risk factors for greater depressive symptom severity were younger age, greater disability, greater speech and swallowing problems, and lower household income. Common risk factors for SI were shorter disease duration, greater disability, and greater speech and swallowing problems. Conclusions In this sample, there were no group differences between persons with progressive MS and persons with RRMS in depressive symptom severity and SI. Although both groups reported mild depressive symptoms on average, nearly 1 in 4 persons met criteria for probable major depression, which underscores the importance of screening for and treating depressive disorders in all persons with MS.

OBJECTIVES: This study evaluated theoretically derived mechanisms and common therapeutic factors to test their role in accounting for pain-related outcome change during group-delivered cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain. METHODS: A secondary analysis of a pilot randomized controlled trial was used to explore the primary mechanisms of pretreatment to posttreatment changes in pain control beliefs, mindful observing, and pain catastrophizing, and the secondary common factor mechanisms of therapeutic alliance, group cohesion, and amount of at-home skill practice during treatment. The primary outcome was pain interference; pain intensity was a secondary outcome. RESULTS: Large effect size changes in the 3 primary mechanisms and the outcome variables were found across the conditions. Across all 3 treatment conditions, change in pain control beliefs and pain catastrophizing were significantly associated with improved pain interference, but not pain intensity. Therapeutic alliance was significantly associated with pain intensity improvement and change in the therapy-specific mechanisms across the 3 conditions. Mindful observing, group cohesion, and amount of at-home practice were not significantly associated with changes in the outcomes. DISCUSSION: Cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain were all associated with significant changes in the primary mechanisms to a similar degree. Change in perceived pain control and pain catastrophizing emerged as potential "meta-mechanisms" that might be a shared pathway that contributes to improved pain-related outcomes across treatments. Further, strong working alliance may represent a critical therapeutic process that both promotes and interacts with therapeutic techniques to influence outcome.

Purpose The purpose of this study was to develop a publicly available, psychometrically sound item bank and short forms for measuring resilience in any population, but especially resilience in individuals with chronic medical conditions or long-term disability. Research methods A panel of 9 experts including disability researchers, clinical psychologists, and health outcomes researchers developed a definition of resilience that guided item development. The rigorous methodology used focus groups, cognitive interviews, and modern psychometric theory quantitative methods, including item response theory (IRT). Items were administered to a sample of people with chronic medical conditions commonly associated with disability (N = 1,457) and to a general population sample (N = 300) representative of the Unites States general population with respect to age, gender, race, and ethnicity. Results The final item bank includes 28 items calibrated to IRT with the scores on a T-metric. A mean of 50 represents the mean resilience in the general population sample. Four and eight item short forms are available, and their scores are highly correlated with the item bank score (r ≥ .94). Reliability is excellent across most of the resilience continuum. Initial analyses provide strong support for validity of the score. Conclusions The findings support reliability and validity of the University of Washington Resilience Scale (UWRS) for assessing resilience in any population, including individuals with chronic health conditions or disabilities. It can be administered using computerized adaptive testing or by short forms. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objective Although sleep difficulties are common after spinal cord injury (SCI), little is known about how day-to-day fluctuations in sleep quality affects health-related quality of life (HRQOL) among these individuals. We examined the effect of sleep quality on same-day HRQOL using ecological momentary assessment methods over a 7-day period. Design Repeated-measures study involving 7 days of home monitoring; participants completed HRQOL measures each night and ecological momentary assessment ratings 3 times throughout the day; multilevel models were used to analyze data. Setting Two academic medical centers. Participants A total of 170 individuals with SCI (N=170). Interventions Not applicable. Main Outcome Measures Daily sleep quality was rated on a scale of 0 (worst) to 10 (best) each morning. Participants completed end-of-day diaries each night that included several HRQOL measures (Sleep Disturbance, Sleep-related Impairment, Fatigue, Cognitive Abilities, Pain Intensity, Pain Interference, Ability to Participate in Social Roles and Activities, Depression, Anxiety) and ecological momentary assessment ratings of HRQOL (pain, fatigue, subjective thinking) 3 times throughout each day. Results Multilevel models indicated that fluctuations in sleep quality (as determined by end-of-day ratings) were significantly related to next-day ratings of HRQOL; sleep quality was related to other reports of sleep (Sleep Disturbance; Sleep-related Impairment; Fatigue) but not to other aspects of HRQOL. For ecological momentary assessment ratings, nights of poor sleep were related to worse pain, fatigue, and thinking. Generally, sleep quality showed consistent associations with fatigue and thinking across the day, but the association between sleep quality and these ecological momentary assessment ratings weakened over the course of the day. Conclusions Findings highlight the important association between sleep and HRQOL for people with SCI. Future work targeting sleep quality improvement may have positive downstream effects for improving HRQOL in people with SCI.

BackgroundChronic pain is one of the most prevalent and disabling symptoms associated with multiple sclerosis (MS). Individuals with MS are interested in nonpharmacologic pain management approaches. Cognitive-behavioral therapy (CBT) is efficacious in improving MS-related pain outcomes. Mindfulness-based cognitive therapy (MBCT) is a promising, alternative approach. Little is known about moderators of these treatments’ outcomes, however. This article describes the study protocol for the first randomized controlled trial comparing MBCT, CBT, and usual care and examining treatment effect moderators in individuals with chronic pain and MS.MethodsWe will conduct a single-center, randomized, single blind, parallel-group trial comparing MBCT, CBT, and usual care in adults with MS and chronic pain. Both interventions will be delivered via eight group sessions using videoconferencing technology. Primary (average pain intensity) and secondary outcomes (including pain interference, depressive symptoms, fatigue, and sleep) will be assessed pre-treatment, mid-treatment, post-treatment, and at 6-month follow up. Potential treatment moderators will be assessed pre-treatment. We hypothesize that participants randomly assigned to MBCT or CBT will report significantly greater reductions in average pain intensity than participants assigned to usual care at post-treatment (primary study endpoint) and 6-month follow up. We also hypothesize that mindfulness, pain catastrophizing, and behavioral activation pre-treatment will moderate response to both active treatments, but not response to usual care.DiscussionFindings will provide important new information about the efficacy and moderators of two nonpharmacologic pain management approaches delivered using technology to overcome common barriers to treatment access. The knowledge gained may lead to better patient-treatment matching and, ultimately, better pain treatment outcomes in MS.Trial registrationClinicalTrials.gov,NCT03782246. Registered on 20 December 2018.

Purpose/objective Starting in middle adulthood, individuals living with multiple sclerosis (MS) are confronted with the simultaneous challenge of coping with advancing MS alongside age-related changes. Psychological resilience is thought to play an important role in promoting healthy aging and thus may be important in the context of aging with MS. This study aimed to evaluate whether Everyday Matters, a novel positive psychology program, had a positive effect on resilience and other related outcomes in adults with MS relative to a wait-list control group. Research Method/Design: This was a single-center two-group pilot randomized (1:1) controlled trial comparing the Everyday Matters intervention to a waitlist control. Randomized participants were N = 31 adults with MS aged ≥ 45 years. The 6-week program, developed by the National MS Society, was delivered via group teleconference and supplemented with readings, videos, and online participation. Participants in both groups completed outcome assessments measuring resilience, satisfaction with social roles, mood, pain, fatigue, and sleep at baseline and posttreatment. Results Analyses on N = 27 participants who completed study assessments revealed a significant group effect for resilience and satisfaction with social roles, and trend differences for positive affect and well-being and depressive symptom severity. At posttreatment, participants in the intervention group reported the group to be very helpful, found the telephone-based delivery convenient, and felt the benefits of participating outweighed the effort. Conclusions/implications These results suggest that the Everyday Matters program shows promise for increasing resilience in adults with MS and that a full-scale randomized controlled trial is warranted. (PsycINFO Database Record

Objective To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS. Design Secondary analysis of a single-blind randomized controlled trial. Setting Community. Participants Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States. Interventions Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88). Main Outcome Measures Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation). Results Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes. Conclusions At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms.

This pilot study evaluated the possibility that 2 interventions hypothesized to increase slower brain oscillations (e.g., theta) may enhance the efficacy of hypnosis treatment, given evidence that hypnotic responding is associated with slower brain oscillations. Thirty-two individuals with multiple sclerosis and chronic pain, fatigue, or both, were randomly assigned to 1 of 2 interventions thought to increase slow wave activity (mindfulness meditation or neurofeedback training) or no enhancing intervention, and then given 5 sessions of self-hypnosis training targeting their presenting symptoms. The findings supported the potential for both neurofeedback and mindfulness to enhance response to hypnosis treatment. Research using larger sample sizes to determine the generalizability of these findings is warranted.

Objective To examine the extent to which pain catastrophizing, fatigue catastrophizing, positive affect, and negative affect simultaneously mediated the associations between common symptoms of multiple sclerosis (MS; i.e., pain, fatigue) and impact on daily life, depressive symptoms, and resilience. Method Participants were community-dwelling adults with MS (N = 163) reporting chronic pain, fatigue, and/or moderate depressive symptoms. Multiple mediation path analysis was used to model potential mediators of pain and fatigue separately, using baseline data from a randomized controlled trial comparing two symptom self-management interventions. Results In the pain model, pain catastrophizing was a mediator of pain intensity with pain interference and depression. Negative affect was a mediator of pain intensity with depression and resilience. In the fatigue model, fatigue catastrophizing was a mediator of fatigue intensity with fatigue impact and depression. Positive affect was a mediator of fatigue intensity with depression and resilience. Conclusions These findings provide preliminary support for the presence of differential effects of cognitive-affective mediators and suggest potential targets for psychological interventions based on an individual's clinical presentation. The differential mediating effects also support the inclusion of both positive and negative aspects of psychological health in models of pain and fatigue, which would not be otherwise apparent if negative constructs were examined in isolation. To our knowledge, this is the first study to utilize a multivariate path analysis approach to examine cognitive-affective mediators of pain and fatigue in MS, while also examining positive and negative constructs concurrently. (PsycINFO Database Record

Background and objectives Evidence-based pharmacological and behavioral interventions are often underutilized or inaccessible to persons with multiple sclerosis (MS) who have chronic pain and/or depression. Collaborative care is an evidence-based patient-centered, integrated, system-level approach to improving the quality and outcomes of depression care. We describe the development of and randomized controlled trial testing a novel intervention, MS Care , which uses a collaborative care model to improve the care of depression and chronic pain in a MS specialty care setting. Methods We describe a 16-week randomized controlled trial comparing the MS Care collaborative care intervention to usual care in an outpatient MS specialty center. Eligible participants with chronic pain of at least moderate intensity (≥ 3/10) and/or major depressive disorder are randomly assigned to MS Care or usual care. MS Care utilizes a care manager to implement and coordinate guideline-based medical and behavioral treatments with the patient, clinic providers, and pain/depression treatment experts. We will compare outcomes at post-treatment and 6-month follow up. Projected patient outcomes We hypothesize that participants randomly assigned to MS Care will demonstrate significantly greater control of both pain and depression at post-treatment (primary endpoint) relative to those assigned to usual care. Secondary analyses will examine quality of care, patient satisfaction, adherence to MS care, and quality of life. Study findings will aid patients, clinicians, healthcare system leaders, and policy makers in making decisions about effective care for pain and depression in MS healthcare systems. (PCORI- IH-1304-6379; clinicaltrials.gov : NCT02137044 ). This trial is registered at ClinicalTrials.gov , protocol NCT02137044 .

Fatigue is one of the most prevalent and impactful symptoms for people with multiple sclerosis (MS). Yet, fatigue is less understood in progressive forms of MS, and few studies have explored the extent to which MS disease course is associated with fatigue. The current study aimed to (1) describe fatigue severity and fatigue interference (the extent to which fatigue interferes with individuals' physical, mental, and social activities) in people with progressive MS (primary progressive MS and secondary progressive MS); (2) compare fatigue severity and fatigue interference in people with progressive forms of MS to people with relapsing-remitting MS (RRMS); and (3) identify factors associated with fatigue severity and fatigue interference in people with progressive forms of MS and RRMS.Secondary analysis of baseline data from participants with MS (N = 573; progressive forms of MS n = 142; RRMS n = 431) in a survey-based longitudinal study on healthy aging in people with a physical disability. Primary outcomes were average fatigue severity (0-10 Numerical Rating Scale), and fatigue interference (PROMIS Fatigue Short Form). Correlates were variables across the demographic and biopsychosocial domains, collected with validated self-reported measures. Statistical methods included t-test and chi-square analyses to compare fatigue severity and fatigue interference in people with progressive MS to those with RRMS, and multiple regression analyses to examine the association of variables with fatigue severity and fatigue interference.Participants with progressive forms of MS reported moderate to severe levels of average fatigue severity (5.9 ± 2.8) and elevated levels of fatigue interference (T-Score of 58.2 ± 7.9). There were no group differences between people with progressive MS and RRMS in average fatigue severity or fatigue interference. Common factors associated with greater fatigue severity were lower income, being unemployed, shorter disease duration, greater disability, and greater sleep disturbance. Common factors associated with fatigue interference were younger age, lower income, being unemployed, greater disability, lower alcohol consumption, being a smoker, and greater sleep disturbance. For those with progressive forms of MS, longer MS disease duration was associated with lower average fatigue severity (b = -0.08, t(532) = -3.69, p.001) and having a college degree or higher was associated with higher fatigue interference (b = 2.84, t(520) = 2.23, p = .026).In this sample, fatigue severity and fatigue interference were similar for progressive forms of MS and RRMS. Future research should consider if interventions that work for fatigue management in people with relapsing forms of MS work similarly for people with progressive forms of MS.