Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain

The relationships between spinal amplitude of movement, pain and disability in low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The role of spinal movement alterations in low back pain (LBP) remains unclear. This systematic review and meta-analyses examined the relationships between spinal amplitude of movement, disability and pain intensity in patients with LBP.

DATABASES AND DATA TREATMENT

We searched PubMed, CINAHL, Embase, Pedro and Web of Science for relevant articles until 14th March 2023. Risk of bias was assessed with the Quality in Prognostic Studies Tool. We analysed the relationships between amplitude of movement, disability and pain intensity with standard correlational meta-analyses and meta-analytic structural equation modelling (MASEM) in cross-sectional and longitudinal data.

RESULTS

A total of 106 studies (9001 participants) were included. In cross-sectional data, larger amplitude of movement was associated with lower disability (pooled coefficient: -0.25, 95% confidence interval: [-0.29 to -0.21]; 69/5899 studies/participants) and pain intensity (-0.13, [-0.17 to -0.09]; 74/5806). An increase in amplitude of movement was associated with a decrease in disability (-0.23, [-0.31 to -0.15]; 33/2437) and pain intensity (-0.25, [-0.33 to -0.17]; 38/2172) in longitudinal data. MASEM revealed similar results and, in addition, showed that amplitude of movement had a very small influence on the pain intensity-disability relationship.

CONCLUSIONS

These results showed a significant but small association between amplitude of movement and disability or pain intensity. Moreover, they demonstrated a direct association between an increase in amplitude of movement and a decrease in pain intensity or disability, supporting interventions aiming to reduce protective spinal movements in patients with LBP.

SIGNIFICANCE

The large meta-analyses performed in this work revealed an association between reductions in spinal amplitude of movement and increased levels of disability and pain intensity in people with LBP. Moreover, it highlighted that LBP recovery is associated with a reduction in protective motor behaviour (increased amplitude of movement), supporting the inclusion of spinal movement in the biopsychosocial understanding and management of LBP.

Development of An Acceptance Based PrEP Intervention (ACTPrEP) to Engage Young Black MSM in the South Utilizing the Adaptome Model of Intervention Adaptation

Objectives

HIV disproportionately affects young Black men who have sex with men (YBMSM) in the Southern United States. Pre-exposure prophylaxis (PrEP) is an efficacious, biomedical approach to prevent HIV. While Mississippi (MS) has among the highest rates of new HIV infections, it also ranks among the top three states for unmet PrEP need. Thus, increasing engagement in PrEP care for YBMSM in MS is imperative. A potential method to improve psychological flexibility and promote PrEP uptake, explored by this study, is the incorporation of Acceptance and Commitment Therapy (ACT) into PrEP interventions. ACT is an evidence-based intervention used to treat a wide range of mental and physical illnesses.

Methods

Twenty PrEP-eligible YBMSM and ten clinic staff working with YBMSM in MS were surveyed and interviewed between October 2021 and April 2022. The brief survey covered PrEP structural barriers, PrEP stigma, and psychological flexibility. Interview topics included internal experiences related to PrEP, existing health behaviors, PrEP related personal values, and relevant constructs from the Adaptome Model of Intervention Adaptation (service setting, target audience, mode of delivery, and cultural adaptations). Qualitative data were coded based on ACT and the Adaptome model, organized using NVivo, then thematically analyzed.

Results

Patients identified side effects, costs, and taking a daily prescription as top barriers to taking PrEP. Staff reported the top barrier to PrEP for clients was concern others would believe they were living with HIV. Levels of psychological flexibility and inflexibility varied widely among participants. The resulting thematic categories derived from the interviews included 1) thoughts, emotions, associations, memories, and sensations (TEAMS) related to PrEP and HIV, 2) general health behaviors (existing coping techniques, views on medication, HIV/PrEP approach and avoidance), 3) values related to PrEP use (relationship values, health values, intimacy values, longevity values), and 4) Adaptome Model adaptations. These results informed the development of a new intervention, ACTPrEP.

Conclusions

Interview data organized by the Adaptome Model of Intervention Adaptation determined appropriate ACT-informed intervention components, content, intervention adaptations, and implementation strategies. Interventions informed by ACT that help YBMSM endure short-term discomfort related to PrEP by relating it to their values and long-term health goals are promising for increasing individuals' willingness to initiate and maintain PrEP care.

Pain acceptance and illness intrusiveness in low-back pain: A longitudinal study

BACKGROUND

In chronic pain syndromes, acceptance of pain may be a better approach than pain control. So far, little data have been available on how pain and its acceptance affect illness intrusiveness among patients with low-back pain (LBP).

OBJECTIVE

The present longitudinal study evaluates the impact of pain acceptance on illness intrusiveness in patients with LBP.

METHODS

Study participants were asked to complete the following questionnaires during their visit (T1) at one of four diverse rheumatologic outpatient clinics, and then 2-3 months later (T2) via phone or online: Chronic Pain Acceptance Questionnaire (CPAQ), Illness Intrusiveness Rating Scale (IIRS), Roland-Morris Disability Questionnaire (RMDQ), Patient Health Questionnaire Depression subscale (PHQ9), and socioeconomic data.

RESULTS

One hundred and twenty-seven individuals completed the questionnaires at baseline (31 having acute, 15 subacute and 81 chronic low back pain) and 97 at follow-up. Illness intrusiveness was negatively correlated with chronic pain acceptance both at T1 (r = -0.39) and T2 (r = -0.44). Illness intrusiveness scores have not changed significantly from T1 (M = 28.59 SD = 13.08) to T2 (M = 28.24, SD = 15.76). In a multiple regression model-including pain intensity, functional status, pain acceptance, depression severity, age, sex and educational level-the independent predictors of follow-up illness intrusiveness scores were lower pain acceptance and higher depression scores.

CONCLUSIONS

In our study, patients with acute, subacute and chronic low back pain reported similar levels of illness intrusiveness. In addition, illness intrusiveness scores have not changed significantly during the 2-month follow-up period and pain acceptance proved to be a significant independent predictor of illness intrusiveness among patients with chronic low-back pain.

Psychological Flexibility, Pain Characteristics and Risk of Opioid Misuse in Noncancerous Chronic Pain Patients

Chronic pain has an estimated annual prevalence rate between 10 and 35%. In the US, first-line treatment for chronic pain is often opioids.

OBJECTIVE

To our knowledge, this is the first study exploring psychological flexibility and its association with pain severity, pain interference and risk of opioid misuse in chronic pain patients.

METHODS

Data were collected at two outpatient pain clinics in the northeastern United States. Adults (N = 99) completed a cross-sectional survey with validated measures. Pain severity and pain interference were hypothesized to uniquely predict the risk of opioid misuse. Pain severity was hypothesized to predict pain interference. Finally, psychological flexibility was hypothesized as an indirect effect in these relationships.

RESULTS

Main findings suggest that pain severity predicts risk of opioid misuse, mediated by psychological flexibly. Pain interference also predicts risk of opioid misuse, mediated by psychological flexibility. Finally, results suggest pain severity predicts pain interference, mediated by psychological flexibility.

DISCUSSION

Implications of findings are discussed in terms of future psychological and medical assessments and interventions for chronic pain patients seeking prescription opioids.

Acceptance and commitment therapy for individuals having attention deficit hyperactivity disorder (ADHD): A scoping review

OBJECTIVES

Acceptance and commitment therapy (ACT) has accumulated increasing evidence-base for a broad range of mental health issues. Considering that ACT encourages broad and flexible patterns of behaviour and neutralizes the pervasive psychological processes proposed to be caused by most individuals' distress, such a modality may be effective for ADHD. This review aimed to give a synthesis of the studies, so far, focusing on the usefulness of ACT approaches among individuals having ADHD.

DESIGN/METHODS

This scoping review searched studies exploring the effectiveness of ACT approaches for individuals with ADHD across eight electronic databases (Medline, Embase, PsycInfo, ScienceDirect, PubMed, Emcare, Scopus, and Google Scholar). This review was based on a total of two quasi-experimental and four experimental studies.

RESULTS

A thematic analysis was suggested based on the PRISMA guidelines. Overall, the review presented preliminary evidence demonstrating the use of ACT among individuals with ADHD. It was found that the ACT was used to treat a variety of behavioural and psychosocial outcomes, which included reducing ADHD symptoms (e.g., impulsivity, inattention, inflexibility, etc.) and other sequelae related to the ADHD diagnosis such as poor quality of life, academic procrastination, depression and anxiety symptoms, and psychological maladjustment.

CONCLUSIONS

This review revealed that ACT was a flexible approach that could be adapted to deliver both targeted treatment of ADHD symptomatology and more general psychosocial issues. It could also be delivered in group or individual formats. Nevertheless, although the findings of the present scoping review indicate promising results, more research is needed.

Effectiveness of acceptance and commitment therapy for mental illness in cancer patients: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Disease awareness is an important aspect of psychological adjustment in cancer patients; however, there is limited evidence that acceptance and commitment therapy (ACT) is recommended for the treatment of mental illness in cancer patients.

PURPOSE

To assess the effectiveness of ACT for cancer patients with mental illness.

METHODS

Ten databases were searched for publications up to July 25, 2020, using combinations of search terms related to mental health, cancer, and randomised controlled trials (RCTs). Two researchers independently screened the literature, extracted data, and assessed the quality of the study.

RESULTS

Seventeen RCTs (877 cancer patients) were mainly of low quality, compared with control group, ACT was associated with improved outcomes after treatment completion and at 1-3 months and at 3-6 months of follow-up for depression (Standardised mean difference [SMD] = -0.93, 95% CI, -1.36 to -0.51, P < .001), anxiety (SMD = -1.22, 95% CI, -2.16 to -0.29, P = .01), quality of life (SMD = 0.85, 95% CI, 0.17 to 1.11, P = .01), psychological distress (SMD = -0.80, 95% CI, -1.24 to 0.35, P < .001), and stress (SMD = -0.54, 95% CI, -1.02 to -0.07, P = .03). After 6 months of follow-up, depression, anxiety, quality of life, and stress were still significant. ACT was associated with psychological flexibility and was not associated with a reduction in fear at treatment completion. However, psychological flexibility (1-3 months) decreased and fear (1-6 months) decreased, and the longer-term effect was still significant.

CONCLUSION

ACT can be an important component of future cancer care, as it may alleviate depression, anxiety, stress, and fear, and improve quality of life. However, further research is required to determine long-term treatment effects. High-quality RCTs are needed to more reliably estimate treatment effects.

Relationship between psychological factors and spinal motor behaviour in low back pain: a systematic review and meta-analysis

ABSTRACT

This meta-analysis investigated whether more negative psychological factors are associated with less spinal amplitude of movement and higher trunk muscle activity in individuals with low back pain. Furthermore, it examined whether pain intensity was a confounding factor in this relationship. We included studies that provided at least 1 correlation coefficient between psychological (pain-related fear, catastrophizing, depression, anxiety, and self-efficacy) and spinal motor behaviour (spinal amplitude and trunk muscle activity) measures. In total, 52 studies (3949 participants) were included. The pooled correlation coefficients (95% confidence interval; number of participants) were -0.13 (-0.18 to -0.09; 2832) for pain-related fear, -0.16 (-0.23 to -0.09; 756) for catastrophizing, -0.08 (-0.13 to -0.03; 1570) for depression, -0.08 (-0.30 to 0.14; 336) for anxiety, and -0.06 (-0.46 to 0.36; 66) for self-efficacy. The results indicated that higher levels of pain-related fear, catastrophizing, and depression are significantly associated with reduced amplitudes of movement and larger muscle activity and were consistent across subgroup and moderation analyses. Pain intensity did not significantly affect the association between these psychological factors and spinal motor behaviour and had a very small independent association with spinal motor behaviour. In conclusion, the very small effect sizes found in the meta-analyses question the role of psychological factors as major causes of spinal movement avoidance in low back pain. Experimental studies with more specific and individualized measures of psychological factors, pain intensity, and spinal motor behaviour are recommended.

Effects of Acceptance and Commitment Therapy on health-related outcomes for patients with advanced cancer: A systematic review

BACKGROUND

Advanced cancer is an incurable and life-threatening disease that poses a major challenge to patients' psychological and physical well-being. Acceptance and Commitment Therapy is a mindfulness-based behavioural therapy for managing health outcomes and inducing health-related behaviour changes. However, the components and modality of Acceptance and Commitment Therapy and its effectiveness on health outcomes for patients with advanced cancer remain unclear.

OBJECTIVES

This review aimed to identify the main content, delivery mode, dosage and duration of Acceptance and Commitment Therapy, and to systematically summarise evidence regarding its application in patients with advanced cancer for improving physical and psychological outcomes and health-related quality of life.

DESIGN

Systematic review.

DATA SOURCES

PubMed, British Nursing Index, Medline, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure and WANFANG Data were searched to identify eligible clinical trials.

REVIEW METHODS

Two reviewers independently assessed the eligibility of each study and extracted data. The Joanna Briggs Institute critical appraisal checklist was used to evaluate the risk of bias in the included studies. Narrative synthesis was used to present the findings of this review.

RESULTS

Six studies involving 261 participants were included in this review, including five randomised control trials and one with a pretest-posttest design. Two out of the five studies reported Acceptance and Commitment Therapy significantly reduced depressive symptoms and psychological distress post-intervention with a large effect size compared with usual care. One study indicated significant improvements in anxiety, sleep characteristics and health-related quality of life with a large effect size post-intervention. Non-significant changes in fatigue and pain were found. Intervention programmes with no more than four sessions had high adherence rates.

CONCLUSION

Acceptance and Commitment Therapy may be a beneficial way to improve depressive symptoms, anxiety, psychological distress, sleep characteristics and health-related quality of life in patients with advanced cancer. However, limited studies, small sample size and methodological heterogeneity weaken the evidence. More rigorous research using brief Acceptance and Commitment Therapy programmes should be conducted within larger samples to further confirm the effectiveness and evaluate its long-term effect on this population.

Cognitive Behaviour Therapy Complemented with Emotion Regulation Training for Patients with Persistent Physical Symptoms: A Randomised Clinical Trial

INTRODUCTION

Persistent medically unexplained symptoms (MUS) are a major burden for health care. Cognitive behaviour therapy (CBT) is efficacious for patients with MUS, with small to medium effects. The current study investigates whether therapy outcomes of a CBT for MUS patients can be improved by complementing it with emotion regulation training.

METHODS

In a multicentre trial 255 patients with at least three persisting MUS were randomised to 20 sessions of either conventional CBT (n = 128) or CBT complemented with emotion regulation training (ENCERT; n = 127). Somatic symptom severity and secondary outcomes were assessed at pre-treatment, therapy session 8, end of therapy, and 6-month follow-up.

RESULTS

Linear mixed-effect models revealed medium to large effects in both study arms for almost all outcomes at the end of therapy and 6-month follow-up. ENCERT and CBT did not differ in their effect on the primary outcome (d = 0.20, 95% CI: -0.04 to 0.44). Significant time × group cross-level interactions suggested ENCERT to be of more benefit than conventional CBT for a few secondary outcomes. Moderator analyses revealed higher effects of ENCERT in patients with co-morbid mental disorders.

DISCUSSION/CONCLUSIONS

Current findings are based on a representative sample. Results demonstrate that both CBT and ENCERT can achieve strong effects on primary and secondary outcomes in MUS patients. Our results do not indicate that adding a training in emotion regulation skills generally improves the effect of CBT across all patients with MUS. Large effect sizes of both treatments and potential specific benefits of ENCERT for patients with co-morbid mental disorders are discussed.

Psychological Flexibility as a Resilience Factor in Individuals With Chronic Pain

Resilience factors have been suggested as key mechanisms in the relation between symptoms and disability among individuals with chronic pain. However, there is a need to better operationalize resilience and to empirically evaluate its role and function. The present study examined psychological flexibility as a resilience factor in relation to symptoms and functioning among 252 adults with chronic pain applying for participation in a digital ACT-based self-help treatment. Participants completed measures of symptoms (pain intensity, and anxiety), functioning (pain interference and depression), as well as the hypothesized resilience factor psychological flexibility (measured as avoidance, value obstruction, and value progress). As expected, symptoms, functioning and resilience factors were significantly associated. Hierarchical linear regression analyses showed that psychological flexibility significantly contributed to the prediction of pain interference and depression when adjusting for age, pain and anxiety. Also, participants with low levels of psychological flexibility were more likely to be on sick leave. Furthermore, a series of multiple mediation analyses showed that psychological flexibility had a significant indirect effect on the relationship between symptoms and functioning. Avoidance was consistently shown to contribute to the indirect effect. Results support previous findings and suggest the importance of psychological flexibility as a resilience factor among individuals with chronic pain and anxiety.

An Integrative Neuroscience Framework for the Treatment of Chronic Pain: From Cellular Alterations to Behavior

Chronic pain can result from many pain syndromes including complex regional pain syndrome (CRPS), phantom limb pain and chronic low back pain, among others. On a molecular level, chronic pain syndromes arise from hypersensitization within the dorsal horn of the spinal cord, a process known as central sensitization. Central sensitization involves an upregulation of ionotropic and metabotropic glutamate receptors (mGluRs) similar to that of long-term potentiation (LTP). Regions of the brain in which LTP occurs, such as the amygdala and hippocampus, are implicated in fear- and memory-related brain circuity. Chronic pain dramatically influences patient quality of life. Individuals with chronic pain may develop pain-related anxiety and pain-related fear. The syndrome also alters functional connectivity in the default-mode network (DMN) and salience network. On a cellular/molecular level, central sensitization may be reversed through degradative glutamate receptor pathways. This, however, rarely happens. Instead, cortical brain regions may serve in a top-down regulatory capacity for the maintenance or alleviation of pain. Specifically, the medial prefrontal cortex (mPFC), which plays a critical role in fear-related brain circuits, the DMN, and salience network may be the driving forces in this process. On a cellular level, the mPFC may form new neural circuits through LTP that may cause extinction of pre-existing pain pathways found within fear-related brain circuits, the DMN, and salience network. In order to promote new LTP connections between the mPFC and other key brain structures, such as the amygdala and insula, we propose a holistic rehabilitation program including cognitive behavioral therapy (CBT) and revolving around: (1) cognitive reappraisals; (2) mindfulness meditation; and (3) functional rehabilitation. Unlike current medical interventions focusing upon pain-relieving medications, we do not believe that chronic pain treatment should focus on reversing the effects of central sensitization. Instead, we propose here that it is critical to focus on non-invasive efforts to promote new neural circuits originating from the mPFC.

Acceptance and Commitment Therapy for Health Behavior Change: A Contextually-Driven Approach

Promoting health behavior change presents an important challenge to theory and research in the field of health psychology. In this paper, we introduce a context-driven approach, the Acceptance and Commitment Therapy (ACT) model which is built on Relational Frame Theory. The ACT-based intervention aims to promote individuals' new health behavior patterns through the improvement of the key construct of psychological flexibility, which is defined as the ability to contact the present moment more fully with acceptance and mindfulness as a conscious human being. Building on the psychological flexibility model, implemented through the six core ACT processes, individuals improve maintenance of long term health behavior change through committed acts in service of chosen values while acknowledging and accepting the existence of contrary thoughts, rules, and emotions as part of themselves but not determinant of their behaviors. Taking advantage of this context-driven approach of health behavior change, we recommend researchers and practitioners to design their health behavior change intervention programs based on ACT.

A Validation and Generality Study of the Committed Action Questionnaire in a Swedish Sample with Chronic Pain

PURPOSE

Psychological flexibility is the theoretical model that underpins Acceptance Commitment Therapy (ACT). There is a growing body of evidence indicating that ACT is an effective treatment for chronic pain but one component of the model, committed action, has not been sufficiently researched. The purpose of this study is to validate Swedish-language versions of the full length Committed Action Questionnaire (CAQ; CAQ-18) and the shortened CAQ (CAQ-8), to examine the generality of previous results related to committed action and to further demonstrate the relevance of this construct to the functioning of patients with chronic pain.

METHOD

The study includes preliminary analyses of the reliability and validity of the CAQ. Participants were 462 consecutive referrals to the Pain Rehabilitation Unit at Skåne University Hospital.

RESULTS

The Swedish-language versions of the CAQ (CAQ-18 and CAQ-8) demonstrated high levels of internal consistency and satisfactory relationships with various indices of patient functioning and theoretically related concepts. Confirmatory factor analyses showed that the Swedish versions of the CAQ yielded similar two-factor models as found in the original validation studies. Hierarchical regression analyses identified the measures as significant contributors to explained variance in patient functioning.

CONCLUSION

The development, translation and further validation of the CAQ is an important step forward in evaluating the utility of the psychological flexibility model to the treatment of chronic pain. The CAQ can both assist researchers interested in mediators of chronic pain treatment and further enable research on change processes within the psychological flexibility model.

Negative affect as mediator between emotion regulation and medically unexplained symptoms

BACKGROUND

Research on emotion regulation (ER) in medically unexplained physical symptoms (MUS) is rare.

PURPOSE

The goal of this study was to compare ER skills between MUS-patients without comorbid depression, MUS-patients with comorbid depression (MUS+MDD), patients with major depressive disorder (MDD), and healthy controls. Additionally, we examined the mediating effect of depression and anxiety on the relationship between ER and somatization.

METHODS

The Emotion-Regulation Skills Questionnaire (ERSQ) and other self-report measures were completed by 138 MUS-patients, 114 MUS+MDD-patients, 106 MDD-patients, and 100 healthy controls. Multiple mediation analyses were applied to investigate the role of depression and anxiety as potential mediators.

RESULTS

A MANCOVA and post-hoc test with age, sex and education as covariates indicated that ER skills of the MUS-group were lower than the controls (p<0.001-p=0.047), but higher than the MDD- and MUS+MDD-group (p<0.001-p=0.042). ER skills of the MDD-group and MUS+MDD-group did not differ (p=0.78-p=0.99), but were lower than controls (p<0.001-p=0.011). In the MUS-groups depression and anxiety had a mediating effect on the relationship between ER and somatization (b=-0.23, 95% bias-corrected CI: -0.30, -0.17). The direct effect of ER on somatization was no longer significant when controlling for the mediating variables (b=0.07, p=0.083).

CONCLUSIONS

Our study reveals that patients with MUS+MDD have higher deficits in ER skills than MUS patients without MDD. Additionally, deficits in ER in MUS-patients are influenced by depression and anxiety. This indicates that MUS-patients with comorbid mental disorders might benefit from an emotion regulation training.

The Use of Acceptance and Commitment Therapy in Oncology Settings: A Narrative Review

Various psychotherapeutic approaches have been developed to address the psychosocial stressors and distress associated with cancer diagnosis and treatment. One such approach, Acceptance and Commitment Therapy (ACT), may be particularly well suited to people with cancer as it offers a model of healthy adaptation to difficult circumstances. This paper provides a description and theoretical rationale for using ACT in psychosocial oncology care that emphasizes emotional distress and cancer-related pain and provides a narrative review of the current state of evidence for this setting. Six studies met eligibility criteria for inclusion in the review. The research designs included one case study, three pre-post cohort studies, and two randomized controlled trials. Cancer diagnoses of patients included breast cancer, ovarian cancer, colorectal cancer, and mixed cancer populations at various stages of disease progression or recovery. ACT interventions demonstrated significant improvements in symptoms including quality of life and psychological flexibility as well as reductions in symptoms including distress, emotional disturbances, physical pain, and traumatic responses. Overall, although there is limited published research currently available, there is some evidence to support ACT as an effective psychotherapeutic approach for cancer patients. Further research is needed for different cancer populations across the illness trajectory. Barriers to implementation are discussed.

Acceptance and Commitment Therapy: A Transdiagnostic Behavioral Intervention for Mental Health and Medical Conditions

Psychological interventions have a long history of successful treatment of patients suffering from mental health and certain medical conditions. At the same time, psychotherapy research has revealed key areas of growth for optimizing patient care. These include identifying novel treatment delivery methods that increase treatment adherence, developing new strategies to more effectively address the ever-growing population of patients with comorbid conditions, and elucidating the mechanisms by which effective treatments work in order to further refine their design. Acceptance and commitment therapy (ACT) is an empirically supported psychotherapy that offers promise for patients suffering from a wide range of mental and physical conditions, while addressing these gaps and challenges in the field. ACT rests on the fundamental premise that pain, grief, disappointment, illness, and anxiety are inevitable features of human life, with the therapeutic goal of helping individuals productively adapt to these types of challenges by developing greater psychological flexibility rather than engaging in counterproductive attempts to eliminate or suppress undesirable experiences. This is achieved through committed pursuit of valued life areas and directions, even in the face of the natural desire to escape or avoid painful and troubling experiences, emotions, and thoughts. ACT is transdiagnostic (applies to more than one condition), process-focused, and flexibly delivered. In a relatively short period of time, ACT has been effectively implemented across a broad range of therapeutic settings, including mental health, primary care, and specialty medical clinics. ACT has also been delivered in a variety of formats, including 1-day group workshops, online and smartphone applications, and telehealth. Focus on how best to package and deliver treatment to meet the unique needs of different patient populations helps to ensure treatment adherence and has fostered successful application of ACT for patients in everyday clinical settings.

Acceptance and Commitment Therapy for Pediatric Chronic Pain: Theory and Application

Acceptance and Commitment Therapy (ACT) is a third wave behavior therapy approach which aims to increase engagement in activities that bring meaning, vitality, and value to the lives of individuals experiencing persistent pain, discomfort, or distress. This goal is particularly relevant when these aversive experiences cannot be effectively avoided or when avoidance efforts risk their exacerbation, all of which may be common experiences in children and adolescents with chronic pain conditions. The primary aim of the present paper is to review and summarize the extant literature on the application, utility, and evidence for using ACT with pediatric chronic pain populations by: (1) defining the theoretical assumptions of the ACT model; (2) summarizing research study findings and relevant measures from the published literature; and (3) critically discussing the strengths, limitations and areas in need of further development.

Chronic pain experience on depression and physical disability: The importance of acceptance and mindfulness-based processes in a sample with rheumatoid arthritis

The mediating effect of acceptance and mindfulness in the relationship between pain, depression, and physical disability was examined in 55 rheumatoid arthritis patients. Results showed that the relationship between pain and depression was mediated by both nonreact and acceptance. By contrast, the relationship between pain and physical disability was mediated by acceptance but not by nonreact. This study provides evidences that the influence of these processes is different on depression and on physical disability. These findings support models that take both general measures of mindfulness and content-specific measures of acceptance into account when conceptualizing rheumatoid arthritis. Theoretical and clinical implications are discussed.

Depression and disability in migraine: the role of pain acceptance and values-based action

BACKGROUND

Migraine is a complex neurological disorder that substantially impairs a person's functioning and is often comorbid with depression. Currently, little is known about psychological coping strategies that may underlie disability and depression in patients with migraine.

PURPOSE

This study examines concurrent relations between depression and disability on the one hand and pain acceptance and values-based action on the other hand in patients with migraine.

METHOD

Ninety-three patients with migraine and depressive symptoms-being evaluated for a larger project examining the impact of a behavioral intervention on depression in patients with migraine-completed measures of depression, disability, pain acceptance, and values-based action. Using multiple regression analyses, the contributions of pain acceptance and values-based action to depression and disability were assessed.

RESULTS

Low pain acceptance was strongly associated with depression and disability (r s(2) = .15-.37) in these patients. Low pain acceptance also explained unique variance in disability, beyond that of depression. Values-based action related modestly to depression and disability (r s(2) = .02-.07).

CONCLUSION

Pain acceptance can contribute to our understanding of psychological health and functioning. An important next step would be to examine whether targeting acceptance in treatment of patients with migraine would lead to improvements in their mental health and functioning.

Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review

QUESTION

What are physiotherapists' perceptions about identifying and managing the cognitive, psychological and social factors that may act as barriers to recovery for people with low back pain (LBP)?

DESIGN

Systematic review and qualitative metasynthesis of qualitative studies in which physiotherapists were questioned, using focus groups or semi-structured interviews, about identifying and managing cognitive, psychological and social factors in people with LBP.

PARTICIPANTS

Qualified physiotherapists with experience in treating patients with LBP.

OUTCOME MEASURES

Studies were synthesised in narrative format and thematic analysis was used to provide a collective insight into the physiotherapists' perceptions.

RESULTS

Three main themes emerged: physiotherapists only partially recognised cognitive, psychological and social factors in LBP, with most discussion around factors such as family, work and unhelpful patient expectations; some physiotherapists stigmatised patients with LBP as demanding, attention-seeking and poorly motivated when they presented with behaviours suggestive of these factors; and physiotherapists questioned the relevance of screening for these factors because they were perceived to extend beyond their scope of practice, with many feeling under-skilled in addressing them.

CONCLUSION

Physiotherapists partially recognised cognitive, psychological and social factors in people with LBP. Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP, and some stigmatised the behaviours suggestive of cognitive, psychological and social contributions to LBP. Physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP.

REGISTRATION

CRD 42014009964. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review.Journal of Physiotherapy61: 68-76].

One-Day Acceptance and Commitment Training Workshops in Medical Populations

Chronic medical illnesses often require a high level of self-management, which can be challenging, particularly over extended periods. The challenge is accentuated by comorbid depression or anxiety, which interfere with motivation and drive. Acceptance and Commitment Therapy is an empirically based behavioral intervention aimed at helping individuals develop greater psychological flexibility in the face of life's challenges. It provides a unified model of behavior change and has shown promise in treating depression and anxiety, as well as chronic medical conditions. Importantly, Acceptance and Commitment Therapy has been effectively implemented in various formats, including 1-day group workshops, well-suited for dissemination into medical settings. The purpose of this review is to provide an overview of studies of 1-day group workshops in medical populations and suggest future directions for further development of this promising area.

Pain related catastrophizing on physical limitation in rheumatoid arthritis patients. Is acceptance important?

The experience of Rheumatoid Arthritis (RA) includes significant suffering and life disruption. This cross-sectional study examined the associations between pain, catastrophizing, acceptance and physical limitation in 55 individuals (11 males and 44 female; Mean age = 54.37; SD = 18.346), from the Portuguese population with (RA) 2 years after the diagnosis; also explored the role of acceptance as a mediator process between pain, catastrophizing and physical limitation. Results showed positive correlation between pain and catastrophizing (r = .544; p ≤ .001), and also between pain and 2-years' physical limitation (r = .531; p ≤ .001) Results also showed that acceptance was negatively correlated with physical limitation 2 years after the diagnosis (r = -.476; p ≤ .001). Path-analysis was performed to explore the direct effect of pain (ß = -.393; SD = .044; Z = 3.180; p ≤ .001) and catastrophizing (n.sig.) on physical limitation and also to explore the buffer effect of acceptance in this relationship (indirect effect ß = -.080). Results showed that physical limitation is not necessarily a direct product of pain and catastrophizing but acceptance was also involved. Pain and catastrophizing are associated but the influence of catastrophizing on physical limitation is promoted by low levels of acceptance. Results emphasize the relevance of acceptance as the emotional regulation process by which pain and catastrophizing influence physical functioning and establish the basic mechanism by which pain and catastrophizing operate in a contextual-based perspective. Also the study results offer a novel approach that may help behavioral health and medical providers prevent and treat these conditions.

Do fibromyalgia patients benefit from cognitive restructuring and acceptance? An experimental study

BACKGROUND AND OBJECTIVES

The aim of this study was to clarify mechanisms of psychological fibromyalgia treatment by experimentally examining the effectiveness of its core elements. We assessed the effects of cognitive restructuring and acceptance on experimentally-induced heat and cold pain tolerance and pain intensity in fibromyalgia patients.

METHODS

Cold and heat pain were induced in a sample of 60 fibromyalgia patients using a thermode. We conducted ANCOVAs to examine group differences in posttest scores, co-varying for pretest scores. The between-groups factor was the type of instruction provided (acceptance, cognitive restructuring, and a control condition). In addition, we controlled for pain sensitivity, age, and depression.

RESULTS

We found that acceptance and cognitive restructuring were superior to the control condition in increasing heat pain tolerance, but did not differ from one another. With respect to cold pain tolerance, cognitive restructuring was associated with increases in cold pain tolerance compared to the control condition, while acceptance did not differ either from the control condition or from cognitive restructuring.

LIMITATIONS

Further experimental research on chronic pain treatment mechanisms is needed, particularly research on individually tailoring treatment strategies according to patients characteristics.

CONCLUSION

Results show that both, cognitive restructuring and acceptance instructions, enhance pain tolerance in fibromyalgia patients.

Tough guys or sensitive guys? Disentangling the role of examiner sex on patient pain reports

BACKGROUND

Experimental and clinical pain studies are conflicting regarding whether individuals report heightened or dampened pain sensitivity in the presence of other men or women.

OBJECTIVES

In the present preliminary study, two small medical record reviews of patients admitted for emergency care were conducted to examine the possibility that patients may report differential pain intensity to male and female health care examiners. The study also sought to determine whether these effects are moderated by and, thus, only detectable by examining patients at different pain (debilitation) levels.

METHODS

Pain intensity scores were extracted from two medical record reviews of patients admitted for emergency care (n=64 and n=135, respectively). Pain intensity was measured using an 11-point numerical scale during standard triage assessments and the sex of the examiner was recorded.

RESULTS

Mean pain scores reported to male and female emergency staff did not differ in either set of medical records. However, when patients were split between low and high pain levels, male patients reported higher pain scores to male practitioners when experiencing relatively low pain levels, and both male and female patients reported higher pain scores to female practitioners when experiencing relatively high pain levels.

DISCUSSION

The statistical magnitudes of these effects were large, suggesting that this phenomenon may be a pervasive feature in clinical settings and experimental pain studies.

CONCLUSION

These preliminary findings warrant larger-scale investigations of social contextual influences on patient pain reports, which are necessary for creating more standardized protocols for reliably assessing and treating patient pain experiences.

The role of experiential avoidance, resilience and pain acceptance in the adjustment of chronic back pain patients who have experienced a traumatic event: a path analysis

BACKGROUND

The degree to which shared vulnerability and protective factors for chronic pain and trauma-related symptoms contribute to pain adjustment in chronic pain patients who have experienced a traumatic event remains unclear.

PURPOSE

The purpose is to test a hypothetical model of the contribution of experiential avoidance, resilience and pain acceptance to pain adjustment in a sample of 229 chronic back pain patients who experienced a traumatic event before the onset of pain.

METHODS

Structural equation modelling was used to test the linear relationships between the variables.

RESULTS

The empirical model shows significant relationships between the variables: resilience on pain acceptance and trauma-related symptoms, experiential avoidance on trauma-related symptoms and experiential avoidance, pain acceptance and trauma-related symptoms on pain adjustment.

CONCLUSIONS

This study demonstrates the role of a vulnerability pathway (i.e. experiential avoidance) and a protective pathway (i.e. resilience and pain acceptance) in adaptation to pain after a traumatic event.

One-day behavioral intervention in depressed migraine patients: effects on headache

OBJECTIVE

To determine whether a 1-day behavioral intervention, aimed at enhancing psychological flexibility, improves headache outcomes of migraine patients with comorbid depression.

BACKGROUND

Migraine is often comorbid with depression, with each disorder increasing the risk for onset and exacerbation of the other. Managing psychological triggers, such as stress and depression, may result in greater success of headache management.

METHOD

Sixty patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop (ACT-ED; N = 38) or to treatment as usual (TAU; N = 22). Patients completed a daily headache diary prior to, and for 3 months following, the intervention. Clinical variables examined included headache frequency/severity, medication use, disability, and visit to a health care professional. Comparisons were made between baseline findings and findings at the 3-month follow up.

RESULTS

Participants assigned to the ACT-ED condition exhibited significant improvements in headache frequency, headache severity, medication use, and headache-related disability. In contrast, the TAU group did not exhibit improvements. The difference in headache outcomes between ACT-ED and TAU was not statistically significant over time (ie, the treatment by time interaction was nonsignificant). These results complement those of a previous report showing effects of ACT-ED vs TAU on depression and disability.

CONCLUSION

A 1-day ACT-ED workshop targeting psychological flexibility may convey benefit for patients with comorbid migraine and depression.These pilot study findings merit further investigation using a more rigorously designed large-scale trial.

The first 2 years of rheumatoid arthritis: The influence of acceptance on pain, physical limitation and depression

The influence of acceptance in the progression of pain, physical limitation and depression was explored in the first 2 years of rheumatoid arthritis. Latent growth curve models showed significant increases in pain, physical limitation and depression. Besides that, the levels of pain and physical limitation at the baseline were associated with acceptance but not its progression across time. Therefore, patients with higher scores of acceptance reported less pain and physical limitation. The progression of depression was associated with acceptance; higher acceptance patients had slower growth rates of depression across time, even when pain and physical limitations increased. The inclusion of pain acceptance in clinical practice is discussed.

Acceptance, cognitive restructuring, and distraction as coping strategies for acute pain

Little is known about treatment mechanisms underlying acceptance strategies. Acceptance is a strategy that is expected to increase pain tolerance more than distraction, while distraction should lead to lower pain intensity. The effect of cognitive restructuring on experimental pain has not yet been investigated. The present study aimed to explore differential short-term effects of acceptance, distraction, and cognitive restructuring on pain tolerance and intensity. Pain was induced in a sample of 109 female students using a thermode. We conducted analyses of covariance with instruction as the independent variable and posttest scores on pain variables as dependent variables, covarying for pretest scores. In addition, adherence to instructions and credibility of instructions were included as covariates. Acceptance led to a higher increase in pain tolerance than did cognitive restructuring of pain-related thoughts. No differences were detected between either acceptance and distraction or distraction and cognitive restructuring with respect to pain tolerance. Distraction led to lower pain intensity compared to acceptance. Cognitive restructuring did not differ from either acceptance or distraction with respect to pain intensity. As a short-term strategy, cognitive restructuring was not as useful as acceptance in increasing pain tolerance. Further studies should evaluate the preconditions under which different strategies are most effective.

PERSPECTIVE

This study demonstrated that acceptance was superior to cognitive restructuring in increasing tolerance for experimentally induced pain, but was inferior to distraction with respect to decreasing pain intensity. Knowledge about the types of strategies that are useful in targeting diverse pain-related outcome measures is important for efforts to refine the treatment of chronic pain.

The impact of treatment components suggested by the psychological flexibility model: a meta-analysis of laboratory-based component studies

An important aspect of psychotherapy research is the examination of the theoretical models underlying intervention approaches. Laboratory-based component research is one useful methodology for this endeavor as it provides an experimental means of testing questions related to intervention components and the change process they engage with a high level of control and precision. A meta-analysis was conducted of 66 laboratory-based component studies evaluating treatment elements and processes that are suggested by the psychological flexibility model that underlies Acceptance and Commitment Therapy (acceptance, defusion, self as context, committed action, values, and present moment), but also touches on a variety of contextual forms of cognitive behavior therapy. Significant positive effect sizes were observed for acceptance, defusion, present moment, values, mixed mindfulness components, and values plus mindfulness component conditions compared to inactive comparison conditions. Additional analyses provided further support for the psychological flexibility model, finding larger effect sizes for theoretically specified outcomes, expected differences between theoretically distinct interventions, and larger effect sizes for component conditions that included experiential methods (e.g., metaphors, exercises) than those with a rationale alone. Effect sizes did not differ between at-risk/distressed and convenience samples. Limitations with the meta-analysis and future directions for laboratory-based component research are discussed.

How effective are acceptance strategies? A meta-analytic review of experimental results

BACKGROUND AND OBJECTIVES

Experimental research on psychological acceptance strategies revealed discrepant results regarding superiority of these strategies compared to other emotion regulation strategies. A review examining results of experimental comparisons between acceptance and other emotion regulation strategies (e.g. suppression, distraction, reappraisal) is still missing. The present meta-analytic approach aims to fill this gap.

METHOD

A literature search was performed using PsychInfo and PubMed and effect sizes (ES; Hedge's g) were calculated.

RESULTS

The search identified 30 relevant studies. Many studies reported that acceptance strategies were superior when compared to other emotion regulation strategies for the outcomes of pain tolerance, negative affect and believability of thoughts. Meta-analytic results replicate findings of primary studies for pain tolerance: A small to medium between-group ES was found favoring acceptance strategies (g = 0.43, p < 0.01, 95% CI[0.12, 0.73]). With respect to pain intensity and negative affect, meta-analysis did not show any significant differences between acceptance and other emotion regulation strategies. In sum, acceptance strategies proved to be superior to other emotion regulation strategies with respect to pain tolerance but not for pain intensity and negative affect.

LIMITATIONS

Future research should address which characteristics of participants lead to respond to either acceptance or to other emotion regulation strategies.

CONCLUSIONS

Acceptance strategies are at least as useful in treatments for chronic pain and depression as other emotion regulation strategies.

One-day behavioral treatment for patients with comorbid depression and migraine: a pilot study

BACKGROUND

Migraine is a common and disabling disorder that is highly comorbid with depression. The comorbidity of depression and migraine is a major health concern as it results in poorer prognosis and quality of life. Yet, effective treatments have rarely been investigated.

METHOD

45 patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop (ACT-ED; N = 31) or to Wait List/Treatment as Usual (WL/TAU; N = 14). Assessment of depressive symptoms, general functioning, and migraine related disability were completed at baseline and 2-, 6-, and 12 weeks after the workshop.

RESULTS

At the 3-month follow up, participants in the ACT-ED condition exhibited significantly greater improvements in depressive symptoms, general functioning, and migraine-related disability than patients in the WL/TAU group.

CONCLUSION

A 1-day ACT-ED workshop is a promising approach to the treatment for depression and disability in migraineurs that merits further investigation.

Acceptance and related processes in adjustment to chronic pain

Chronic pain poses significant challenges in the lives of many people. At the root of many of these challenges are the behavior patterns pain naturally coordinates. For example, in some cases, attempts to control, reduce, or cure pain through medication, medical procedures, or lifestyle changes can prove unsuccessful, and can dominate all other potential goals. The experience of chronic pain also includes other discouraging, painful, or unwanted psychological experiences, such as thoughts, feelings, and memories. Attempts to control or reduce some of these psychological experiences also can prove unsuccessful and even harmful, further reducing quality of life. This review highlights recent evidence for the utility of acceptance as an alternative when control-based methods are unsuccessful. It describes evidence from experimental, clinical, and treatment outcome studies. The review also notes how work in this area is drawing attention to the wider concept of "psychological flexibility," an overarching process that includes other component processes, such as mindfulness and values.

Empirical evidence of the validity of the Spanish version of the pain vigilance awareness questionnaire

BACKGROUND

The Spanish version of the Pain Vigilance and Awareness Questionnaire has not been validated.

PURPOSE

The aims of this study were to examine the factor structure of the Spanish version of the Pain Vigilance and Awareness Questionnaire and present empirical evidence regarding its validity.

METHOD

A sample of 468 chronic back pain patients completed a battery of instruments to assess fear-avoidance beliefs, pain anxiety, pain catastrophizing, pain vigilance and awareness, pain acceptance, depression, anxiety, disability, and pain intensity.

RESULTS

Confirmatory factor analysis supported the validity of a nine-item version with two subscales: Active Vigilance and Passive Awareness. Both subscales and the total score were positively and significantly correlated with other fear-related constructs: fear-avoidance beliefs, pain anxiety, and pain catastrophizing. Regression analyses showed that Active Vigilance and the two subscales of the Fear-Avoidance Beliefs Questionnaire were significantly associated with higher anxiety and that the Acceptance Activity Engagement subscale was significantly associated with lower anxiety. The Fear-Avoidance Beliefs Questionnaire-Physical subscale was associated with higher disability and the Acceptance Pain Willingness subscale was associated with lower disability. The Fear-Avoidance Beliefs Questionnaire-Work subscale was significantly associated with higher pain intensity and depression; the Acceptance Activity Engagement and Pain Willingness subscales were significantly associated with lower pain intensity and depression.

CONCLUSION

The Spanish version of the Pain Vigilance and Awareness Questionnaire is a reliable and valid instrument. Pain Acceptance and Fear Avoidance beliefs are better predictors of adjustment to pain than pain hypervigilance.

Experiential avoidance and anxiety sensitivity as dispositional variables and their relationship to the adjustment to chronic pain

Anxiety sensitivity has been included in the fear-avoidance model as a vulnerability factor to explain individual differences in fear of pain. Several studies have suggested that the relationship between anxiety sensitivity and some psychopathological disorders is mediated by experiential avoidance, an affect-related regulatory process that involves unwillingness to endure private experiences. The role of these constructs as vulnerability variables has not been investigated in chronic pain patients. The aim of this study was to investigate the role of anxiety sensitivity and experiential avoidance as dispositional variables in pain fear-avoidance. Two alternative hypothetical models were tested: one in which anxiety sensitivity and experiential avoidance would be independently associated with pain fear-avoidance; and second, one in which experiential avoidance would mediate the relationship between anxiety sensitivity and pain fear-avoidance. The sample was composed of 299 patients with chronic back pain. The postulated relationships were tested using LISREL 8.20 software (Scientific Software International, Chicago, IL, USA) and the generally weighted least squares. The structural equation modelling analyses showed that experiential avoidance and anxiety sensitivity were independently associated with pain fear-avoidance and that anxiety sensitivity had a stronger association with pain fear-avoidance than experiential avoidance. The alternative model, in which experiential avoidance mediates the relationship between anxiety sensitivity and pain fear-avoidance, gave a much worse fit. These results highlight the importance of both anxiety sensitivity and experiential avoidance as variables which could explain individual differences in pain fear-avoidance. Thus, in terms of prevention, it should be a priority to identify patients with increased anxiety sensitivity and experiential avoidance during the first stages of the development of chronic pain conditions.

New empirical evidence of the validity of the Chronic Pain Acceptance Questionnaire: the differential influence of activity engagement and pain willingness on adjustment to chronic pain

OBJECTIVE

The aims of this study were to examine the internal structure of the Spanish version of the Chronic Pain Acceptance Questionnaire and present new empirical evidence regarding its validity.

DESIGN AND METHODS

A sample of 315 chronic pain patients attending a pain clinic completed a battery of instruments to assess pain acceptance, general psychological acceptance, depression, anxiety, pain intensity, functional impairment, and current functioning.

RESULTS

Confirmatory factor analysis supported the validity of a 20-item version with two subscales corresponding to two independent factors: Activity Engagement and Pain Willingness. Structural Equation Modelling showed that the association between pain intensity and anxiety and depression was fully mediated by Activity Engagement which partially mediated the association between pain intensity and functioning. Pain Willingness partially mediated the influence of pain intensity on functional impairment.

CONCLUSIONS

These findings indicate the differential influence of both components on adjustment to chronic pain.

The mediation effect of experiential avoidance between coping and psychopathology in chronic pain

This study explores experiential avoidance as a mediator in the relationship between coping (rational coping, avoidant coping and detached/ emotional coping) and psychopathology (depression, anxiety and stress). A battery of self-report questionnaires was used to assess coping, experiential avoidance and depression, anxiety and stress in 70 participants with a chronic pain from Portuguese primary health care units. Regression analyses were performed and showed preliminary evidence supporting the mediation role of experiential avoidance in a Portuguese sample with chronic pain. Results show that experiential avoidance partially or fully mediate the effects of rational coping and detached/emotional coping on depression and stress. Implications for clinical practice were discussed and suggest that psychopathology is not necessary direct product of coping and other processes, such as experiential avoidance, are likely involved.