Background
Methods
EVP intervention
Week | EVP Core Components and Weekly Objectives | ||
---|---|---|---|
EVP ACT | EVP MM | EVP WH | |
1 | • Introductions • Reviewing group guidelines • Overview of ACT | • Introductions • Pain & the Brain Part 1 | • Introductions • Overview of WH |
2 | • Exploring personal values and life purpose | • Pain & the Brain Part 2 • Neutral Spine | • Introducing Mindful Awareness • Power of the Mind |
3 | • Metaphors exploring Psychological Flexibility | • Motion is Lotion Exercises (MILES) 1 • Hand motion | • Mindfulness practices • Food and Drink |
4 | • Noticing added suffering from current avoidance/ coping strategies | • MILES 1 & 2 • Head and eyes motion | • Mindfulness practices • Recharge/Sleep |
5 | • Defusion; Tricks of the mind | • MILES 1–3 • Feet and foot motion | • Observer Self practice • Choice of gratitude |
6 | • Cycle: Behaviors, Thoughts, and Emotions | • MILES 1–4 • Core motion • Computer workstation | • Self-Compassion practice • Choice of Kindness |
7 | • Committed Action | • MILES 1-5 • EVP Tai Chi (Part 1)1 | • Self-Compassion practice • Choice of active listening in relationship building |
8 | • Acceptance/Willingness | • MILES 1–5 • EVP Yoga1 | • Self-Compassion practice • Considering choice of forgiveness |
9 | • Maintaining progress | • MILES 1–5 • EVP Tai Chi (Part 2)1 | • Self-Compassion practice • Finding meaning in suffering |
10 | • Values declaration • Graduation | • EVP Tai Chi • Graduation | • Whole Body Scan • Graduation |
Design and sample
Data collection
Outcome measures
Scale | Construct | Description | Items | Scale |
---|---|---|---|---|
Pain
| ||||
Pain, Enjoyment, and General Activity (PEG) [33] | Pain Intensity | Pain intensity and interference with life enjoyment and general activity in the past week | 3 | 0 – no pain at all, 10 – worst possible pain |
PROMIS-29 – Pain Interference subscale [34] | Pain Interference | The impact of pain on daily functioning. | 4 | 1 – not at all, 5 – very much |
Pain Catastrophizing Scale (PCS) [35] | Pain Catastrophizing | Maladaptive and exaggerated beliefs “toward actual or anticipated” pain experiences” (p. 602). | 13 | 0 – not at all, 4 – all the time |
Physical
| ||||
PROMIS-29 – Fatigue subscale [34] | Fatigue | Physical fatigue. | 4 | 1 – not at all, 5 – very much |
PROMIS-29 – Physical Functioning subscale [34] | Physical Functioning | Perceived physical capability to engage in daily activities (e.g., self-care, endurance). | 4 | 1 – unable to do, 5 – without any difficulty |
Psychological
| ||||
PROMIS-29 – Anxiety subscale [34] | Anxiety | Anxiety symptom severity. | 4 | 1 – not at all, 5 – very much |
Patient Health Questionnaire-9 (PHQ-9) [36] | Depression | Depression symptom severity. | 9 | 0 – not at all, 3 – nearly every day |
PROMIS-29 – Sleep subscale [34] | Sleep Disturbance | Difficulty falling and staying asleep. | 4 | 1 – not at all, 5 – very much |
Social
| ||||
PROMIS-29 – Social subscale [34] | Social Health | Social roles (e.g., family, occupational) and activities (e.g., leisure) | 4 | 1 – always, 5 – never |
HRQoL
| ||||
World Health Organization Quality of Life Scale Brief Version (WHOQoL-BREF) [37] | Physical HRQoL | Mobility, daily activities, functional capacity, energy, pain, and sleep. | 26 | 1–5+ |
Psychological HRQoL | Self-image, negative thoughts, positive attitudes, self-esteem, mentality, learning ability, memory, concentration, religion, and mental status. | |||
Social HRQoL | Personal relationships, social support, and sex life. | |||
Environmental HRQoL | Financial resources, safety, health and social services, physical living environment, opportunities to acquire new knowledge and skills, recreation, general environment, and transportation. | |||
Acceptance
| ||||
Chronic Pain Acceptance Questionnaire (CPAQ) [38] | Activity Engagement | Engagement in life activities despite experiencing pain. | 20 | 0 – never true, 4 – always true |
Pain Willingness* | Willingness to experiences pain without attempts to control it. | |||
Mindfulness
| ||||
Five-Facet Mindfulness Questionnaire (FFMQ) [39] | Acting | Acting with awareness in the moment. | 39 | 0 – never or rarely true, 4 – very often or always true |
Describing* | Describing how we label experiences to ourselves and others. | |||
Non-Judgement* | Non-Judgement despite self-criticism. | |||
Non-Reactivity | Non-Reactivity of negative thoughts and emotions while accepting their presence. | |||
Observation | Observation of our sensory experiences to focus our attention on meaningful stimuli. | |||
Program Satisfaction
| ||||
Pain Outcomes Questionnaire – Veterans Affairs (POQ-VA) [40] | EVP Satisfaction | Satisfaction with the EVP administered at week 10 (post-EVP). | 5 | 0–10+ |
Covariates
| ||||
POQ-VA [40] | Demographics | Age | 5 | Continuous |
Gender | Male v. Female | |||
Race | White v. Non-White | |||
Service-Connected Disability | Yes, No | |||
Religion | Nominal |
Statistical analysis
Preliminary analyses
Primary analyses
Results
Sample characteristics
Characteristics | Graduates (n = 444) | Non-Graduates (n = 195) | Total (n = 639) | p-valuea |
---|---|---|---|---|
Age (years), | ||||
m ± sd | 57.26 ± 10.29 | 53.61 ± 11.37 | 56.15 ± 10.75 | < 0.001 |
Gender, n(%) | ||||
Female Male | 120 (27.03%) 324 (72.97%) | 66 (33.85%) 129 (66.15%) | 186 (29.11%) 453 (70.89%) | 0.081 |
Race, n(%) | ||||
Asian/Pacific Islander Black/African American Native American/Alaskan Native White/Caucasian Biracial/Multiracial Declined to Respond Missing | 3 (0.68%) 349 (78.60%) 0 (0.00%) 79 (17.79%) 1 (0.23%) 10 (2.25%) 2 (0.45%) | 2 (1.03%) 128 (65.64%) 1 (0.51%) 50 (25.64%) 1 (0.51%) 9 (4.62%) 4 (2.05%) | 5 (0.78%) 477 (75.65%) 1 (0.16%) 129 (20.19%) 2 (0.31%) 19 (2.97%) 6 (0.94%) | .018b |
Service Connection, n(%) | ||||
Service Connected Not Service Connected Missing | 360 (81.08%) 83 (18.69%) 1 (0.23%) | 83 (81.03%) 33 (16.92%) 4 (2.05%) | 518 (81.06%) 116 (18.15%) 5 (0.78%) | 0.906 |
Religion, n(%) | ||||
Theist Christian Theist Non-Christian Atheist/Agnostic/Unidentified Missing | 348 (78.38%) 14 (3.15%) 81 (18.24%) 1 (0.23%) | 141 (72.31%) 9 (4.62%) 41 (21.03%) 4 (2.05%) | 489 (76.53%) 23 (3.60%) 122 (19.09%) 5 (0.78%) | 0.884 |
Preliminary analyses
Primary analyses
Graduation status
EVP satisfaction
Patient-reported outcomes
Outcome | Fixed Effects | p-value | 95%CI | Outcome | Fixed Effects | p-value | 95%CI | |||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
β ± SE |
LB
|
UB
| β ± SE |
LB
|
UB
| |||||||
PAIN
|
Social
| |||||||||||
Intensity
| Time | -0.234 ± 0.041 | < 0.001* | − 0.315 | -0.153 | |||||||
Timea | -0.305 ± 0.061 | < 0.001* | -0.426 | -0.184 | Graduation | -0.034 ± 0.078 | 0.664 | -0.186 | 0.119 | |||
Graduationb | 0.096 ± 0.128 | 0.754 | -0.155 | 0.347 | Racec | -0.189 ± 0.089 | 0.034 | -0.364 | -0.015 | |||
Interference
|
HRQoL
| |||||||||||
Time | -0.397 ± 0.044 | < 0.001* | -0.483 | -0.311 |
Physical
| |||||||
Graduation | 0.000 ± 0.075 | 0.998 | -0.147 | 0.147 | Time | 1.132 ± 0.116 | < 0.001* | 0.902 | 1.361 | |||
Catastrophizing
| Graduation | -0.238 ± 0.225 | 0.291 | -0.903 | 0.205 | |||||||
Time | -0.404 ± 0.045 | < 0.001* | -0.493 | -0.316 |
Psychological
| |||||||
Graduation | 0.052 ± 0.092 | 0.570 | -0.128 | 0.232 | Time | 0.887 ± 0.113 | < 0.001* | 0.663 | 1.110 | |||
Physical
| Graduation | -0.054 ± 0.291 | 0.851 | -0.626 | 0.516 | |||||||
Fatigue
| Race | 0.797 ± 0.331 | 0.016 | 0.147 | 1.448 | |||||||
Time | -0.296 ± 0.047 | < 0.001* | − 0.388 | -0.205 |
Social
| |||||||
Graduation | 0.021 ± 0.084 | 0.807 | -0.145 | 0.186 | Time | 6.128 ± 0.961 | < 0.001* | 4.326 | 8.019 | |||
Physical Function
| Graduation | 0.907 ± 2.101 | 0.666 | -3.221 | 5.034 | |||||||
Time | -0.149 ± 0.036 | <0.001* | -0.219 | -0.078 |
Environmental
| |||||||
Graduation | 0.080 ± 0.074 | 0.282 | -0.066 | 0.225 | Time | 0.569 ± 0.114 | < 0.001* | 0.344 | 0.793 | |||
Psychological
| Graduation | -0.518 ± 0.269 | 0.055 | -1.048 | 0.011 | |||||||
Anxiety
|
Mindfulness
| |||||||||||
Time | -0.250 ± 0.044 | < 0.001* | -0.336 | -0.164 |
Acting
| |||||||
Graduation | -0.041 ± 0.094 | 0.666 | -0.226 | 0.145 | Time | 0.089 ± 0.036 | 0.014 | 0.018 | 0.160 | |||
Race | -0.277 ± 0.108 | 0.011 | -0.489 | -0.065 | Graduation | 0.118 ± 0.078 | 0.132 | -0.036 | 0.271 | |||
Depression
| Race | 0.234 ± 0.089 | 0.009* | 0.059 | 0.409 | |||||||
Time | -0.315 ± 0.029 | < 0.001* | -0.372 | -0.257 |
Describing
| |||||||
Graduation | -0.010 ± 0.061 | 0.873 | -0.130 | 0.111 | Time | 0.044 ± 0.034 | 0.200 | -0.023 | 0.111 | |||
Sleep Disturbance
| Graduation | 0.102 ± 0.074 | 0.172 | -0.044 | 0.248 | |||||||
Time | -0.214 ± 0.047 | <0.001* | -0.306 | -0.122 |
Non-Judgement
| |||||||
Graduation | 0.020 ± 0.083 | 0.813 | -0.144 | 0.184 | Time | 0.069 ± 0.043 | 0.105 | -0.014 | 0.153 | |||
Acceptance
| Graduation | -0.006 ± 0.081 | 0.936 | -0.165 | 0.152 | |||||||
Activity Engagement
|
Non-Reactivity
| |||||||||||
Time | 0.825 ± 0.051 | <0.001* | 0.725 | 0.926 | Time | 0.127 ± 0.038 | < 0.001* | 0.052 | 0.202 | |||
Graduation | -0.037 ± 0.094 | 0.692 | -0.223 | 0.148 | Graduation | 0.079 ± 0.062 | 0.203 | -0.043 | 0.201 | |||
Race | 0.258 ± 0.107 | 0.017 | 0.047 | 0.469 |
Observation
| |||||||
Pain Willingness
| Time | 0.137 ± 0.036 | <0.001* | 0.066 | 0.208 | |||||||
Time | 0.304 ± 0.049 | < 0.001* | 0.208 | 0.400 | Graduation | 0.038 ± 0.070 | 0.587 | -0.100 | 0.176 | |||
Graduation | -0.044 ± 0.078 | 0.568 | -0.197 | 0.108 |