Inducing optimism to enhance exposure effects in chronic pain patients

Chronic pain is a major health problem, leading to various limitations in daily
life. According to the Fear-Avoidance model of pain, learned fear of painful
movements and avoidance behaviour instigate pain disability. Exposure
treatments aim to correct dysfunctional beliefs patients may have about
activities and movements to promote functional recovery. Although exposure
treatments have proven successful, we know from anxiety research that a subset
of patients may fail to achieve satisfactory results at the end of the exposure
treatment or may experience relapse following successful exposure. Inhibitory
learning, exposure treatment's key process in which a new safety-based
association about a feared movement (e.g. playing tennis - no harm) is learned
so that it can compete with the previously learned fear-based association (e.g.
playing tennis - injury) might be diminished and cause poor exposure effects.
Enhancing inhibitory learning in an exposure treatment might lead to enhanced
clinical effects in patients receiving exposure in vivo.

Positivity may support inhibitory learning. We know that several memory
processes and prerequisites for learning (e.g. motivation and attention) are
influenced by positivity. Support for this notion also arises from experimental
research in which inducing positive expectations has been linked to enhanced
fear extinction and diminished fear retrieval. Clinically relevant evidence for
the bolstering effect of optimism on inhibitory learning is however still
lacking.

This project aims to investigate the additive value of an optimism intervention
to an existing rehabilitation protocol for pain patients. It is expected that
including an optimism module in an exposure in vivo treatment or a graded
activity treatment with exposure elements leads to stronger increases in the
performance of personally relevant goals (versus disability) and stronger
decreases in fear of movement, pain catastrophizing, pain an distress (versus
well-being).

This study might provide a first clinical indication of the effect of inducing
positivity in the rehabilitation of chronic pain patients. The study may
contribute to optimizing rehabilitation treatment for chronic pain patients.

A series of replicated randomised two-phase (AB) single-case experiments will
be used. Specialized rehabilitation treatment (A-phase) will be compared to
optimism enriched specialised rehabilitation treatment (B-phase) within 8
participants. The start of the two-week optimism module will be randomized
between participants. The optimism module is based on earlier successful work
with the Best Possible Self exercise, a writing and visualisation exercise
focused on positive future expectations.

A positive psychology module aimed at inducing optimism will be used in this
study. This optimism module uses the Best Possible Self (= BPS) exercise, a
writing and visualisation exercise focused on one*s best possible self in the
future. The BPS has repeatedly and successfully been used as a single
exercise/module or as a module in a multi-modular positive psychology
intervention in chronic pain patients. The duration of the optimism module is 2
weeks. The module is designed as an online program that participants can work
on independently. Assistance is provided by means of telephone contact (1 fixed
appointment of 20-30 minutes) and e-mail correspondence with one of the
research team members. This module is introduced at a random moment during the
treatment that participants receive at the rehabilitation center of Adelante
Maastricht.

Burden is mainly related to the time invested that is asked of the participants.
The following time consuming activities are being asked of all participants:
- filling in a survey (15-20 minutes) at 5 times
- filling in a short daily diary (few minutes) 2 weeks prior, during and 2
weeks post exposure treatment.
In addition, the participants will spend +-3.5 hours on the online optimism
module and +-30 minutes on a scheduled telephone call with the research team.