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      Pre-treatment pain predicts outcomes in multimodal treatment for tortured and traumatized refugees: a pilot investigation Translated title: El dolor previo al tratamiento predice el desenlace del tratamiento multimodal para refugiados torturados y traumatizados: una investigación piloto Translated title: 前期疼痛可预测多模式治疗对遭受酷刑和创伤的难民的结果:一项预研究

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          ABSTRACT

          Background: Chronic pain is a common comorbid complaint in traumatized refugees seeking treatment for posttraumatic stress disorder (PTSD) and depression. However, the effect of comorbid pain on treatment remains under investigated.

          Objective: To investigate whether pre-treatment pain (severity/interference) predicts outcomes in a multimodal treatment targeting PTSD, depression, anxiety, somatic complaints, and health-related disability in refugees exposed to torture and organized violence. Additional predictors were gender, age, and number of treatment sessions.

          Method: Participants were active cases at a specialist outpatient clinic for tortured refugees (n = 276; 170 men, 106 women) who were either on a treatment waitlist (mean length = 7.4 months, SD = 4.5), in treatment (mean length = 12.2 months, SD = 6.5), or who completed treatment and had (or were waiting for) a follow-up assessment. Participants completed symptom measures at referral, pre- and post-treatment, and 9-month follow-up. Multi-level mixed modelling was used to assess whether outcomes at post-treatment and 9-months were predicted by pain, gender, age, or the number of treatment sessions.

          Results: Treatment yielded significant pre-to-post-treatment reductions in PTSD, depression, anxiety, and number of pain locations, but no reductions in pain severity/interference, or health-related disability, except for societal participation. Gains for PTSD, depression, and societal participation were maintained at the 9-month follow-up. Higher levels of pain interference (but not severity) predicted poorer outcomes (PTSD, depression, and anxiety). Age, gender and number of treatment sessions did not predict outcomes, except for a small negative effect of (older) age on PTSD.

          Conclusions: A growing body of literature suggests that pain and PTSD symptoms interact in ways to increase the severity and impact of both disorders in refugee and non-refugee populations alike. The present study suggests interference from pain can lessen the effectiveness of standard multi-modal treatments for refugees.

           

          Antecedentes: el dolor crónico es una queja comórbida común en refugiados traumatizados que buscan tratamiento para el trastorno de estrés postraumático (TEPT) y depresión. Sin embargo, el efecto del dolor comórbido en el tratamiento sigue siendo investigado.

          Objetivo: investigar si el dolor previo al tratamiento (severidad/interferencia) predice los resultados en un tratamiento multimodal para el TEPT, depresión, ansiedad, quejas somáticas y discapacidad relacionada con la salud en refugiados expuestos a tortura y violencia organizada. Predictores adicionales fueron el sexo, edad y número de sesiones de tratamiento.

          Método: los participantes fueron casos activos en una clínica ambulatoria especializada para refugiados torturados (n = 276; 170 hombres, 106 mujeres) que estaban en una lista de espera de tratamiento (duración media = 7,4 meses, DE = 4,5), en tratamiento (duración media = 12.2 meses, DE = 6.5), o quienes completaron tratamiento y tuvieron (o estaban esperando) una evaluación de seguimiento. Los participantes completaron las mediciones de síntomas en la derivación, antes y después del tratamiento, y en un Seguimiento a los 9 meses. Se utilizó un modelo mixto multinivel para evaluar si los resultados en el postratamiento y a los 9 meses eran predichos por dolor, sexo, edad o el número de sesiones de tratamiento.

          Resultados: el tratamiento produjo reducciones significativas desde el pre al postratamiento en TEPT, depresión, ansiedad y número de localizaciones de dolor, pero no hubo reducciones en la severidad/interferencia del dolor o discapacidad relacionada con la salud, excepto por la participación social. Las ganancias para el TEPT, depresión y participación social se mantuvieron a los 9 meses de seguimiento. Los niveles más altos de interferencia del dolor (pero no la gravedad) predijeron resultados más pobres (TEPT, depresión y ansiedad). La edad, sexo y número de sesiones de tratamiento no predijeron los resultados, excepto por un pequeño efecto negativo de la edad (mayor) en TEPT.

          Conclusiones: un creciente cuerpo de literatura sugiere que el dolor y los síntomas de TEPT interactúan de manera que aumentan la gravedad y el impacto de ambos trastornos en las poblaciones de refugiados y no refugiados por igual. El estudio presente sugiere que la interferencia del dolor puede disminuir la efectividad de los tratamientos multimodales estándar para refugiados.

           

          背景:慢性疼痛是在寻求治疗创伤后应激障碍(PTSD)和抑郁症的受创伤难民中的常见合并症。但是,并发疼痛对治疗的影响仍在研究过程中。

          目的:在遭受酷刑和有组织暴力的难民中,研究针对PTSD, 抑郁, 焦虑, 躯体不适和健康相关残疾的多模式治疗,治疗前的疼痛(严重程度/干扰性)是否可预测结果。其他预测因素包括性别, 年龄和治疗次数。

          方法:参与者是在一家针对经历酷刑的难民的专科门诊诊所的常期病例(n = 276; 170名男性,106名女性)。这些难民或在治疗候补名单中(平均长度= 7.4个月,SD = 4.5),或在接受治疗(平均长度= 12.2个月,SD = 6.5),或完成治疗并已经(或正在等待)随访评估。参与者在转诊时, 治疗前和治疗后以及9个月的随访中完成了症状测量。使用多水平混合模型来评估是否通过疼痛, 性别, 年龄或治疗次数来预测治疗后和9个月的结果。

          结果:治疗的效果使治疗后的PTSD, 抑郁症, 焦虑症和疼痛部位数量相比治疗前明显减少。但疼痛严重程度/干扰性或与健康相关的残疾(除社会参与外)均未减少。在9个月的随访中,创伤后应激障碍, 抑郁症和社会参与的增加保持不变。较高水平的疼痛干扰(而非严重程度)预示较差的结果(PTSD,抑郁和焦虑)。年龄, 性别和疗程数均不能预测结果,除了(老年)年龄对PTSD的有较小的负性效应。

          结论:越来越多的文献表明,疼痛和PTSD症状相互作用增加了难民和非难民人群中两种疾病的严重程度和影响。本研究表明,疼痛带来的干扰会降低标准多模式治疗对难民的有效性。

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          Most cited references37

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          Missing data: our view of the state of the art.

          Statistical procedures for missing data have vastly improved, yet misconception and unsound practice still abound. The authors frame the missing-data problem, review methods, offer advice, and raise issues that remain unresolved. They clear up common misunderstandings regarding the missing at random (MAR) concept. They summarize the evidence against older procedures and, with few exceptions, discourage their use. They present, in both technical and practical language, 2 general approaches that come highly recommended: maximum likelihood (ML) and Bayesian multiple imputation (MI). Newer developments are discussed, including some for dealing with missing data that are not MAR. Although not yet in the mainstream, these procedures may eventually extend the ML and MI methods that currently represent the state of the art.
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            Chronic pain and posttraumatic stress disorder: mutual maintenance?

            Common sequelae following a traumatic event include chronic pain and posttraumatic stress disorder (PTSD). Over the last decade, the literature relating to PTSD has become progressively more sophisticated, resulting in well-supported theories and treatments for sufferers. Equivalent research relating to chronic pain has more recently gathered momentum. However, to date there has been minimal attention devoted to the concurrence of the two disorders, even though high comorbidity has been noted. This review begins by briefly summarizing the literature relating to the two disorders in terms of symptoms, prevalence and comorbidity. It explicates the major psychological theories of chronic pain and PTSD and reviews the evidence relating what factors maintain the disorders. A number of pathways by which chronic pain and PTSD may be mutually maintaining are highlighted. We conclude that chronic pain and PTSD are mutually maintaining conditions and that there are several pathways by which both disorders may be involved in the escalation of symptoms and distress following trauma. Treatment implications are considered, as are issues for future research.
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              Core outcome domains for chronic pain clinical trials: IMMPACT recommendations.

              To provide recommendations for the core outcome domains that should be considered by investigators conducting clinical trials of the efficacy and effectiveness of treatments for chronic pain. Development of a core set of outcome domains would facilitate comparison and pooling of data, encourage more complete reporting of outcomes, simplify the preparation and review of research proposals and manuscripts, and allow clinicians to make informed decisions regarding the risks and benefits of treatment. Under the auspices of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 27 specialists from academia, governmental agencies, and the pharmaceutical industry participated in a consensus meeting and identified core outcome domains that should be considered in clinical trials of treatments for chronic pain. There was a consensus that chronic pain clinical trials should assess outcomes representing six core domains: (1) pain, (2) physical functioning, (3) emotional functioning, (4) participant ratings of improvement and satisfaction with treatment, (5) symptoms and adverse events, (6) participant disposition (e.g. adherence to the treatment regimen and reasons for premature withdrawal from the trial). Although consideration should be given to the assessment of each of these domains, there may be exceptions to the general recommendation to include all of these domains in chronic pain trials. When this occurs, the rationale for not including domains should be provided. It is not the intention of these recommendations that assessment of the core domains should be considered a requirement for approval of product applications by regulatory agencies or that a treatment must demonstrate statistically significant effects for all of the relevant core domains to establish evidence of its efficacy.
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                Author and article information

                Journal
                Eur J Psychotraumatol
                Eur J Psychotraumatol
                ZEPT
                zept20
                European Journal of Psychotraumatology
                Taylor & Francis
                2000-8066
                2019
                11 November 2019
                : 10
                : 1
                : 1686807
                Affiliations
                [a ]Rehabilitation Department, DIGNITY - Danish Institute Against Torture , Copenhagen, Denmark
                [b ]Department of Psychology, Lund University , Lund, Sweden
                Author notes
                CONTACT Linda Nordin linda.nordin@ 123456psy.lu.se DIGNITY - Danish Institute Against Torture , Bryggervangen 55, Copenhagen 2100, Denmark
                Author information
                http://orcid.org/0000-0002-5468-4706
                Article
                1686807
                10.1080/20008198.2019.1686807
                6853218
                31762955
                7d213a96-3dca-4ce9-84fd-d91d9c20dd1e
                © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 12 July 2019
                : 19 September 2019
                : 20 October 2019
                Page count
                Tables: 3, References: 58, Pages: 11
                Funding
                Funded by: DIGNITY: Danish Institute Against Torture
                Funded by: Lund University 10.13039/501100003252
                This research was carried out at, and with the financial support of, DIGNITY: Danish Institute Against Torture, in partial fulfilment of a PhD in psychology at Lund University.
                Categories
                Clinical Research Article

                Clinical Psychology & Psychiatry
                refugees,torture,ptsd,pain,treatment outcome,predictors,tortura,tept,dolor,resultado del tratamiento,predictores,难民,酷刑,创伤后应激障碍,疼痛,治疗结果,预测变量

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