Biometrics and Self-reported Health Changes in Adults Receiving Behavioral Treatments for Chronic Pain

Study Overview
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Brief Summary
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The study will provide important information regarding the biometric changes that occur in behavioral treatments for chronic pain and explore the additional impact of integrated movement and supervised exercise. The goal of this clinical trial is to determine if pain rehabilitation programs have impacts on physical function in patient reported outcomes and objective measures of physical activity or sedentary time with a wearable Fitbit. Additionally, we will examine the associations between movement, pain acceptance, and related health factors, such as pain severity, sleep, functional status, depression, and anxiety. The addition of biometric data will allow for further investigation of the association between objective measures and patient self-report measures.

Detailed Description
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Chronic pain has high impact on societal function as well as an individual person's mood, physical function, disability, and quality of life and their health. The purpose of the study is to collect objective outcome measures on movement, activity, biometrics and patient reported outcome measures for participants of behavioral treatment groups of 6-8 weeks duration at Stanford Pain Management Center. Group participants learn skills and develop a personalized plan to use the skills throughout the program. The study will follow participants with a removable wearable device on the wrist for 2 weeks pre group to establish movement activity baselines, during the group intervention (6-8 weeks) and 2 weeks post group to determine which groups have benefits across various aspects of health including: sleep, psychological processes of pain acceptance, physical mobility, quality of life and the impact of supervised movement and physical activity in the treatment groups.

Official Title
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What Objective Changes Occur With Behavioral Treatment: Evaluating Biometrics and Self -Reported Health Measures of Adult Patients Receiving Behavioral Treatments With Chronic Pain

Conditions
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Chronic Pain, Sedentary Time

Intervention / Treatment
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* Behavioral: Cognitive Behavioral Therapy
* Behavioral: Acceptance and Commitment Therapy (ACT)
* Behavioral: Moderate to high Intensity Group Exercise


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18+ Non-cancer chronic pain (pain that occurs on at least half of the days of 6 months or more) English fluency Ability to attend >70% treatment sessions to ensure active treatment is delivered Exclusion Criteria: Cognitive impairment, non-English speaking, or psychological factors that would preclude comprehension of material and/or full participation in the study. Participants with acute cauda equina syndrome Inability to complete a 6 minute walk test without LOB 3) Chronic pain as explained by inflammatory disease For the movement-based portions of group: Exclusion: For our CBT + Movement (low intensity/ restorative) movement group: Patient must be able to sit upright for 20 minutes without loss of balance or upper extremity (UE) assistance. Inability to sit without use of UE support would be excluded. This ensures safety that the participant can completed the adapted movement program without risk of falls. HR will not be elevated > 50% HRmax in these restorative movement classes. Exclusion criteria for the Back in ACTion (higher intensity) movement group is inability to complete a 6-minute walk test safely or without loss of balance, as this poses a fall risk that requires individual assistance throughout the class, or medical exclusion from cardiovascular exercise over 50% HRmax, as HR will be elevated to 50-70% HR max in these classes.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Behavioral Group Treatment (Cognitive Behavioral Therapy CBT + Movement)<br>Cognitive Behavioral Therapy Group led by a psychologist to learn pain coping skills, with gentle movement component of duration from 45 minutes to 60 minutes under a licensed Healthcare provider (PT or OT). | Behavioral: Cognitive Behavioral Therapy<br>* The participants will attend one of the behavioral group treatments programs offered by the Stanford Pain Management Center. This class may be held online via Zoom, or in person based at the Stanford Pain Management Center. The class may be recorded for training purposes. No names or images/faces will be recorded for privacy reasons. The behavioral groups are 3 types, with or without exercise/movement. Current Evidence Based treatments that are provided as standard practice include: Cognitive Behavioral Therapy Group, with movement, Acceptance and Commitment Therapy Group, with or without movement. Group participants will learn different skills in each group and develop a personalized plan to use the skills after group ends. At the end of group participants will be given an anonymous survey about the class to evaluate satisfaction of the treatment. Movement in this portion of class is designed to low impact and restorative/gentle, with no significant increases in HR > 50% HRmax.<br>* Other names: Group Movement;|
| Behavioral Group Treatment (ACT) only<br>Acceptance and Commitment Therapy Group led by a psychologist to learn skills to change their relationship with pain to decrease pain's impact on their life. | Behavioral: Acceptance and Commitment Therapy (ACT)<br>* ACT is a 6 week behavioral group program led by a psychologist to improve psychological flexibility and reduce pain interference in patients with chronic pain.<br>|
| Behavioral Group Treatment (ACT + Movement)- Back in ACTion<br>Acceptance and Commitment Therapy Group led by a psychologist to learn skills to change their relationship with pain to decrease pain's impact on their life and improve willingness to engage in valued activities. Movement component to last from with intense and gentle movement sessions with a total movement time of 90 minutes - 2 hours led by licensed health care provider a PT or OT. | Behavioral: Acceptance and Commitment Therapy (ACT)<br>* ACT is a 6 week behavioral group program led by a psychologist to improve psychological flexibility and reduce pain interference in patients with chronic pain.<br>Behavioral: Moderate to high Intensity Group Exercise<br>* Group exercise led by supervised clinician with Cardiovascular focus to increase HR into zones to see adaptations to improve cardiovascular fitness.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in sedentary behavior time | Sedentary behavior is defined as any waking behavior such as sitting or leaning with an energy expenditure of 1.5 metabolic equivalent task (MET) or less | Pre intervention (baseline), and post intervention (at 10 weeks) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| HF-Heart rate variability | Heart rate variability (per participant) is where the amount of time between your heartbeats fluctuates slightly. Even though these fluctuations are undetectable except with specialized devices, they can still indicate current or future health problems, including heart conditions and mental health issues like anxiety and depression. Heart rate variability (in milliseconds) has no standard reference range. HF is the high frequency band of HRV. | Pre intervention (baseline), end of treatment session (week 6), and post intervention (at 10 weeks) | 
| Sleep Duration | Amount of time asleep per night cycle | Pre intervention (baseline), end of treatment session (week 6), and post intervention (at 10 weeks) | 
| Daily Step Count | Amount of steps occurring in a 24 hour day | Pre intervention (baseline), end of treatment session (week 6), and post intervention (at 10 weeks) | 
| Pain Catastrophizing | 13-item self-report measure designed to assess catastrophic thinking related to pain among adults. The score ranges from 0-52, where higher scores indicate greater pain catastrophizing. | Pre intervention (baseline), and post intervention (at 10 weeks) and 6 months follow up (post group) | 
| PROMIS Depression Score | Self reported Questionnaires to assess depression. Patient-Reported Outcomes Measurement Information System (PROMIS) - Depression use a T-score metric, and the scores range from 10T to 85T, with the population mean score of 50T (SD of 10). Higher T scores would indicate worse symptom in each domain. | Pre intervention (baseline), and post intervention (at 10 weeks),and 6 months follow up (post group) | 
| PROMIS Anxiety Score | Self reported Questionnaires to assess anxiety. Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety measures use a T-score metric, and the scores range from 10T to 85T, with the population mean score of 50T (SD of 10). Higher T scores would indicate worse symptom in each domain. | Pre intervention (baseline), and post intervention (at 10 weeks),and 6 months follow up (post group) | 
| PROMIS Sleep Disturbance Score | Self reported Questionnaires to assess sleep quality. Patient-Reported Outcomes Measurement Information System (PROMIS) , Sleep Disturbance use a T-score metric, and the scores range from 10T to 85T, with the population mean score of 50T (SD of 10). Higher T scores would indicate worse symptom in each domain. | Pre intervention (baseline), and post intervention (at 10 weeks),and 6 months follow up (post group) | 
| PROMIS Physical Function Score | Self reported Questionnaires to assess physical function/mobility. Patient-Reported Outcomes Measurement Information System (PROMIS) physical function measures use a T-score metric, and the scores range from 10T to 85T, with the population mean score of 50T (SD of 10). Higher T scores would indicate worse symptom in each domain. | Pre intervention (baseline), and post intervention (at 10 weeks),and 6 months follow up (post group) | 
| PROMIS Pain Interference Score | Self-reported Questionnaires to assess pain interference. Patient-Reported Outcomes Measurement Information System (PROMIS), pain interference, and physical function measures use a T-score metric, and the scores range from 10T to 85T, with the population mean score of 50T (SD of 10). Higher T scores would indicate worse symptom in each domain. | Pre intervention (baseline), and post intervention (at 10 weeks),and 6 months follow up (post group) | 
| Duration of Heart Rate in Exercise Zones (50-70% HRMax) (during exercise) | The time in a 24 hour period that the participant has an elevated heartrate for sustained duration indicating exercise. We would want to increase our amount of time (minutes) in HRzones to indicate more time spend in active exercise during the movement portions of the interventions. | Pre intervention (baseline), and post intervention (at 10 weeks) | 
| Average Resting Heartrate | A 2013 study in the journal Heart tracked the cardiovascular health of about 3,000 men for 16 years and found that a high resting heart rate was linked with lower physical fitness and higher blood pressure, body weight, and levels of circulating blood fats. The researchers also discovered that the higher a person's resting heart rate, the greater the risk of premature death. Specifically, an RHR between 81 and 90 doubled the chance of death, while an RHR higher than 90 tripled it. A low resting heart rate often suggests greater physical fitness. A reduction in average resting heart rate would indicate improvement in CV fitness for our treatment interventions. | Pre intervention (baseline), end of treatment session (week 6), and post intervention (at 10 weeks) | 
| Physical Activity Vital Sign | the subjective measure of minutes a person is physically active in a week (in minutes) | Pre intervention (baseline), end of treatment session (week 6), and post intervention (at 10 weeks) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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movement, behavioral treatments, biometrics, chronic pain