Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: an investigation of change processes

Effects of acceptance and commitment therapy plus exercise for older adults with chronic low back pain: A preliminary cluster randomized controlled trial with qualitative interviews

Chronic low back pain (CLBP) is increasingly prevalent in older adults and often leads to functional disability and depressive symptoms. This 2-arm, double-blinded, pilot cluster RCT, with semi-structured interviews, aimed to evaluate the acceptability, feasibility, and preliminary clinical efficacy of ACT plus exercise training (ACT+Ex) on improving pain-related outcomes, psychological outcomes, and physical fitness in older adults with CLBP at post-treatment and 6-month follow-up. Forty community-dwelling older adults (62-85 years) with CLBP, predominantly female, were randomized to ACT+Ex (n=20) or Education plus exercise program (Edu+Ex) (n=20) for 8 weekly group-based sessions, with assessments at baseline, post-treatment, and 6-month follow-up (primary endpoint). Self-reported outcomes included pain intensity, functional disability (Roland Morris Disability Questionnaires, RMDQ), health-related quality of life (EuroQol-5 Dimensions, EQ-5D-5L), psychological inflexibility (Acceptance and Action Questionnaire-Version 2, AAQ-II), and psychological well-being (Depression Anxiety Stress Scale). Physical fitness was assessed using the functional reach test (FRT), Timed Up and Go test (TUG), 6-minute walk test (6MWT), hand grip strength (HGS), and 30-second sit-to-stand (STS-30) test. This trial achieved high recruitment (23.5 participants per week) and completion rates (92.5%). Exploratory analyses revealed that ACT+Ex significantly improved pain intensity, disability, psychological inflexibility, HRQoL, and physical fitness at post-treatment and 6-month follow-up. Qualitative data identified 3 superordinate themes: previous healthcare experience affecting pain beliefs; acceptance strategies guiding behavioral changes; and facilitators and barriers to treatment compliance. These findings support the need for a definitive RCT and form a valuable basis for future exploration regarding the behavioral mechanisms of ACT in clinical applications. PERSPECTIVE: A multimodal therapy incorporating ACT and exercise promotes positive behavioral changes and its treatment effects are maintained at the 6-month follow-up especially for physical performance.

The association between quality of life and psychological flexibility, depressive, anxiety or insomnia symptoms in patients with persistent indoor environment-related symptoms or chronic fatigue

BACKGROUND

Persistent physical symptoms (PPS) can significantly impair health-related quality of life (HRQoL) and are often accompanied by psychiatric comorbidity. Psychological flexibility (PF), characterized by the ability to adapt functionally and congruently to diverse situations based on personal values, may play a crucial role in determining HRQoL. This study aims to examine the associations between symptoms of depression, anxiety or insomnia or PF and HRQoL among individuals with PPS associated with (i) the indoor environment (IE), (ii) chronic fatigue, or (iii) both.

METHODS

We utilized the baseline data (n = 103) from a randomized controlled trial focused on improving the HRQoL of individuals (mean age 46.1, SD 7.8, 86% women) experiencing PPS associated with IE or chronic fatigue. Self-report questionnaires were administered to evaluate symptoms of depression, anxiety, insomnia, and dimensions of PF, including acceptance, cognitive fusion, and thought suppression. The primary outcome was HRQoL, assessed using a 15D questionnaire. The association between symptoms, PF dimensions, and HRQoL was examined using Pearson's correlation and ANCOVA.

RESULTS

Symptoms of depression, anxiety, and insomnia were negatively associated with HRQoL (p <.001) across all participants. Among individuals with PPS associated with IE, higher PF was significantly associated with higher HRQoL. No association was found between PF and HRQoL in those with chronic fatigue-associated PPS or both conditions.

CONCLUSIONS

PF associated with positive outcomes in HRQoL in individuals with PPS associated with the indoor environment, but not in those with chronic fatigue. Further research on the differences between these groups is warranted to enhance treatment targeting.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04532827 (registered 26.08.2020).

Biopsychosocial based machine learning models predict patient improvement after total knee arthroplasty

Total knee arthroplasty (TKA) is an effective treatment for end stage osteoarthritis. However, biopsychosocial features are not routinely considered in TKA clinical decision-making, despite increasing evidence to support their role in patient recovery. We have developed a more holistic model of patient care by using machine learning and Bayesian inference methods to build patient-centred predictive models, enhanced by a comprehensive battery of biopsychosocial features. Data from 863 patients with TKA (mean age 68 years (SD 8), 50% women), identified between 2019 and 2022 from four hospitals in NSW, Australia, was included in model development. Predictive models for improvement in patient quality-of-life and knee symptomology at three months post-TKA were developed, as measured by a change in the Short Form-12 Physical Composite Score (PCS) or Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), respectively. Retained predictive variables in the quality-of-life model included pre-surgery PCS, knee symptomology, nutrition, alcohol consumption, employment, committed action, pain improvement expectation, pain in other places, and hand grip strength. Retained variables for the knee symptomology model were comparable, but also included pre-surgery WOMAC, pain catastrophizing, and exhaustion. Bayesian machine learning methods generated predictive distributions, enabling outcomes and uncertainty to be determined on an individual basis to further inform decision-making.

An ACT self-help intervention for adults with a visible difference in appearance: A pilot feasibility and acceptability randomized controlled study

Individuals living with a visible difference in appearance experience high levels of social anxiety, yet self-help interventions for this heterogeneous population are not available. We conducted a pilot trial of a novel Acceptance and Commitment Therapy (ACT) based self-help intervention.Individuals with anxiety about having a visible difference in appearance (n = 284) were randomized to an ACT-based four-week intervention (n = 145) or a waitlist control condition (n = 139). We collected pre and follow-up (four-weeks after the completion of the intervention) data. Primary outcomes included social anxiety and impairments in functioning. Psychological flexibility (PF) was also examined. ANCOVAs, controlling for pre scores, indicated significant improvements in functioning by the intervention group. No significant differences were observed for anxiety and PF between conditions at follow-up. Drop out was 68% for the intervention and 41% for the control group, with no differences in the groups in age, origin, gender, or type of visible difference. Participants in the intervention group found the intervention almost equally, useful (77%) and helpful (73%). An ACT-based self-help intervention can alleviate distress related to visible difference in appearance. More sophisticated designs are needed now, to collect idiographic and longitudinal data and examine personalized changes across time in this population.

Psychological therapies delivered remotely for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic pain (pain lasting three months or more) is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Common types (excluding headache) include back pain, fibromyalgia, and neuropathic pain. Access to traditional face-to-face therapies can be restricted by healthcare resources, geography, and cost. Remote technology-based delivery of psychological therapies has the potential to overcome treatment barriers. However, their therapeutic effectiveness compared to traditional delivery methods requires further investigation.

OBJECTIVES

To determine the benefits and harms of remotely-delivered psychological therapies compared to active control, waiting list, or treatment as usual for the management of chronic pain in adults.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, and PsycINFO to 29 June 2022. We also searched clinical trials registers and reference lists. We conducted a citation search of included trials to identify any further eligible trials.

SELECTION CRITERIA

We included RCTs in adults (≥ 18 years old) with chronic pain. Interventions included psychological therapies with recognisable psychotherapeutic content or based on psychological theory. Trials had to have delivered therapy remote from the therapist (e.g. Internet, smartphone application) and involve no more than 30% contact time with a clinician. Comparators included treatment as usual (including waiting-list controls) and active controls (e.g. education).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 32 trials (4924 participants) in the analyses. Twenty-five studies delivered cognitive behavioural therapy (CBT) to participants, and seven delivered acceptance and commitment therapy (ACT). Participants had back pain, musculoskeletal pain, opioid-treated chronic pain, mixed chronic pain, hip or knee osteoarthritis, spinal cord injury, fibromyalgia, provoked vestibulodynia, or rheumatoid arthritis. We assessed 25 studies as having an unclear or high risk of bias for selective reporting. However, across studies overall, risk of bias was generally low. We downgraded evidence certainty for primary outcomes for inconsistency, imprecision, and study limitations. Certainty of evidence ranged from moderate to very low. Adverse events were inadequately reported or recorded across studies. We report results only for studies in CBT here. Cognitive behavioural therapy (CBT) versus treatment as usual (TAU) Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to TAU (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.39 to -0.16; 20 studies, 3206 participants; moderate-certainty evidence). Participants receiving CBT are probably more likely to achieve a 30% improvement in pain intensity compared to TAU (23% versus 11%; risk ratio (RR) 2.15, 95% CI 1.62 to 2.85; 5 studies, 1347 participants; moderate-certainty evidence). They may also be more likely to achieve a 50% improvement in pain intensity (6% versus 2%; RR 2.31, 95% CI 1.14 to 4.66; 4 studies, 1229 participants), but the evidence is of low certainty. At follow-up, there is likely little to no difference in pain intensity between CBT and TAU (SMD -0.04, 95% CI -0.17 to 0.09; 8 studies, 959 participants; moderate-certainty evidence). The evidence comparing CBT to TAU on achieving a 30% improvement in pain is very uncertain (40% versus 24%; RR 1.70, 95% CI 0.82 to 3.53; 1 study, 69 participants). No evidence was available regarding a 50% improvement in pain. Functional disability Immediately after treatment, CBT may demonstrate a small beneficial improvement compared to TAU (SMD -0.38, 95% CI -0.53 to -0.22; 14 studies, 2672 participants; low-certainty evidence). At follow-up, there is likely little to no difference between treatments (SMD -0.05, 95% CI -0.23 to 0.14; 3 studies, 461 participants; moderate-certainty evidence). Quality of life Immediately after treatment, CBT may not have resulted in a beneficial effect on quality of life compared to TAU, but the evidence is very uncertain (SMD -0.16, 95% CI -0.43 to 0.11; 7 studies, 1423 participants). There is likely little to no difference between CBT and TAU on quality of life at follow-up (SMD -0.16, 95% CI -0.37 to 0.05; 3 studies, 352 participants; moderate-certainty evidence). Adverse events Immediately after treatment, evidence about the number of people experiencing adverse events is very uncertain (34% in TAU versus 6% in CBT; RR 6.00, 95% CI 2.2 to 16.40; 1 study, 140 participants). No evidence was available at follow-up. Cognitive behavioural therapy (CBT) versus active control Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to active control (SMD -0.28, 95% CI -0.52 to -0.04; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (mean difference (MD) 0.50, 95% CI -0.30 to 1.30; 1 study, 127 participants). No evidence was available for a 30% or 50% pain intensity improvement. Functional disability Immediately after treatment, there may be little to no difference between CBT and active control on functional disability (SMD -0.26, 95% CI -0.55 to 0.02; 2 studies, 189 participants; low-certainty evidence). The evidence at follow-up is very uncertain (MD 3.40, 95% CI -1.15 to 7.95; 1 study, 127 participants). Quality of life Immediately after treatment, there is likely little to no difference in CBT and active control (SMD -0.22, 95% CI -1.11 to 0.66; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (MD 0.00, 95% CI -0.06 to 0.06; 1 study, 127 participants). Adverse events Immediately after treatment, the evidence comparing CBT to active control is very uncertain (2% versus 0%; RR 3.23, 95% CI 0.13 to 77.84; 1 study, 135 participants). No evidence was available at follow-up.

AUTHORS' CONCLUSIONS

Currently, evidence about remotely-delivered psychological therapies is largely limited to Internet-based delivery of CBT. We found evidence that remotely-delivered CBT has small benefits for pain intensity (moderate certainty) and functional disability (moderate to low certainty) in adults experiencing chronic pain. Benefits were not maintained at follow-up. Our appraisal of quality of life and adverse events outcomes post-treatment were limited by study numbers, evidence certainty, or both. We found limited research (mostly low to very low certainty) exploring other psychological therapies (i.e. ACT). More high-quality studies are needed to assess the broad translatability of psychological therapies to remote delivery, the different delivery technologies, treatment longevity, comparison with active control, and adverse events.

Overcoming challenges in adherence and engagement digital interventions: The development of the ALGEApp for chronic pain management

Despite the growing body of evidence for the effectiveness of clinic-based interventions in increasing daily functioning in individuals with chronic pain, many sufferers still remain untreated or inadequately treated. Digital psychological interventions have been proposed as a means to overcome many of the barriers to face-to-face treatment (e.g., access, mobility, transportation problems) with the aim to improve health care for persons with chronic conditions in the convenience of their own space and time (home care). The main challenge of digital interventions however, is low user engagement and adherence. Focusing on users' engagement during the design phase of a digital intervention development can increase adherence, effectiveness, and acceptability. The purpose of this paper is to illustrate how we leveraged a recently proposed four-dimensional framework with evidence-based best practices and recommendations to develop a new digital intervention for chronic pain management, called the ALGEApp. A detailed presentation of how ALGEApp was designed and developed to adopt the recommendations and how this can aid engagement within digital interventions is proposed.

The Efficacy of Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-analysis

OBJECTIVES

Previous meta-analyses of a small number of trials showed that acceptance and commitment therapy (ACT) might improve chronic pain. Many new trials have been published afterward, and the factors that may impact the efficacy of ACT are less understood. We, therefore, conducted an updated systematic review with meta-analysis to investigate the efficacy of ACT for people with chronic pain.

METHODS

Randomized controlled trials that investigated the efficacy of ACT in clinical or community setting for adult populations with chronic pain were included. The methodological quality of trials was assessed with the Cochrane Risk of Bias tool. Standardized mean differences between ACT and comparison groups in their effects on 6 outcomes (ie, pain acceptance, quality of life, pain-related functioning, pain intensity, anxiety, and depression) were pooled across studies.

RESULTS

Of the 3171 records identified, 21 trials with 1962 participants were included for analysis. The comparison groups included active treatment and waitlist control/usual care. The standardized mean difference was 0.67 (95% CI: 0.48, 0.87) for pain acceptance, 0.43 (95% CI: 0.29, 0.57) for quality of life, -0.88 (95% CI: -1.14, -0.63) for pain-related functioning, -0.45 (95% CI: -0.62, -0.27) for pain intensity, -0.35 (95% CI: -0.54, -0.15) for anxiety, and -0.74 (95% CI, -0.98, -0.50) for depression, all favoring ACT. Subgroup analyses showed that the effects were statistically significant across almost all subgroups and for some outcomes were greater in the trials conducted in people with a specific diagnosis (as compared with those conducted in people with general chronic pain), the trials with waitlist or usual care control, the trials with a greater number of sessions of ACT, and the trials with a longer ACT intervention.

DISCUSSION

ACT is effective and comparable to, if not better than, some other available active treatments for chronic pain.

MANIFESTATIONS AND TREATMENT OF LOWER BACK PAIN SYNDROME IN WARTIME

OBJECTIVE

The aim: To improve treatment of patients with lower back pain through identification of pathogenetic factors in its formation.

PATIENTS AND METHODS

Materials and methods: The early results of treatment of 84 patients with lower back pain (main group) were analysed. Patients of the main group were divided into two subgroups: one group involved patients with mental disorders, the other - patients not suffering from such disorders (the Spielberger-Hanin Anxiety Test used). The patients of the main group with mental disorders (49 patients) were administered with epidural steroid injections and antidepressants. The patients with no mental disorders (35 patients) were administered with epidural steroid injections only. The control group involved 36 patients with lower back pain who did not undergo any psychological testing and were administered with epidural steroid injections only. The Visual Analog Scale (VAS) and the Oswestry Disability Index questionnaire were used to assess pain syndrome. The assessment was carried out twice: in the pre-operative period and in three months after the treatment.

RESULTS

Results: A significant difference in the early treatment results between the main and control groups was established according to both the Visual Analog Scale and the Oswestry Disability Index in favour of the main group patients, who were differentiated by pathogenetic factors of the pain syndrome formation.

CONCLUSION

Conclusions: Lower back pain syndrome necessitates clarification of its components in order to develop pathogenically based treatment.

Profiles of Pain Acceptance and Values-Based Action in the Assessment and Treatment of Chronic Pain

Pain acceptance and values-based action are relevant to treatment outcomes in those with chronic pain. It is unclear if patterns of responding in these two behavioral processes can be used to classify patients into distinct classes at treatment onset and used to predict treatment response. This observational cohort study had two distinct goals. First, it sought to classify patients at assessment based on pain acceptance and values-based action (N = 1746). Second, it sought to examine treatment outcomes based on class membership in a sub-set of patients completing an interdisciplinary pain rehabilitation program of Acceptance and Commitment Therapy for chronic pain (N = 343). Latent profile analysis was used in the larger sample to identify three distinct patient classes: low acceptance and values-based (AV) action (Low AV; n = 424), moderate acceptance and values-based action (Moderate AV; n = 983) and high acceptance and values-based action (High AV; n = 339). In the smaller treated sample, participants in the Low AV and Moderate AV class demonstrated improvements across all outcome variables, whereas those in the High AV class did not. These findings support the role of pain acceptance and values-based action in those with chronic pain.

How do psychologically based interventions for chronic musculoskeletal pain work? A systematic review and meta-analysis of specific moderators and mediators of treatment

Psychologically based interventions aim to improve pain-related functioning by targeting pain-related fears, cognitions and behaviors. Mediation and moderation analyses permit further examination of the effect of treatment on an outcome. This systematic review and meta-analysis aims to synthetize the evidence of specific mediators and moderators (i.e., treatment targets) of psychologically based treatment effects on pain and disability. A total of 28 mediation and 11 moderation analyses were included. Thirteen mediation studies were included in a meta-analysis, and the rest was narratively synthetized. Reductions in pain-related fear (indirect effect [IE]: -0.07; 95% confidence interval [CI]: -0.11, -0.04) and catastrophizing (IE: -0.07; 95%CI: -0.14, -0.00), as well as increases in self-efficacy (IE: -0.07; 95%CI: -0.11, -0.04), mediated effects of cognitive behavioral therapy on disability but not on pain intensity, when compared to control treatments. Enhancing pain acceptance (IE: -0.17; 95%CI: -0.31, -0.03) and psychological flexibility (IE: -0.30; 95%CI: -0.41, -0.18) mediated acceptance and commitment therapy effects on disability. The narrative synthesis showed conflicting evidence, which did not support a robust moderated effect for any of the examined constructs. Overall, the methodological quality regarding mediation was low, and some key pitfalls are highlighted alongside recommendations to provide a platform for future research.

Predictors of Outcomes Following Interdisciplinary Acceptance and Commitment Therapy for Chronic Pain: Profiling Psychological Flexibility

Background

Growing evidence demonstrates the benefit of acceptance and commitment therapy (ACT) for people with chronic pain. However, there remain people with chronic pain who do not benefit from ACT, and predicting treatment response is difficult.

Aims

This aim of this study was to investigate if baseline psychological flexibility (PF) profiles predict responses to an ACT‐based pain management programme.

Methods

Data from 415 participants attending an interdisciplinary pain management programme were included. Participants completed measures of PF processes and outcomes pre‐ and post‐treatment. Latent profile analysis was used to identify subgroups of participants based on their baseline PF scores. ANOVAs were conducted to compare subgroups of participants on outcome variables at baseline, and changes from pre‐ to post‐treatment.

Results

Three subgroups of participants were identified: (a) low PF, (b) low openness and (c) high awareness and action. The three subgroups significantly differed on all outcome measures at pre‐treatment, supporting the clinical relevance of these PF profiles. However, participants with different baseline PF profiles did not appear to differ in terms of changes in outcome variables.

Conclusions

People with chronic pain demonstrate different PF profiles, but appear to respond to ACT similarly regardless of these profiles. Future studies with a more individualized focus are needed to further understand which components of ACT work for whom on which outcome and how.

Significance

There remain people with chronic pain who do not benefit from acceptance and commitment therapy (ACT), and predicting treatment response is difficult. This is the first study to identify psychological flexibility (PF) profiles along multiple PF processes using latent class analysis, and the first longitudinal study to investigate PF profiles in relation to outcomes in ACT for chronic pain. The findings contribute to the understanding of theoretically consistent predictors of outcomes in ACT, which in turn can inform treatment development.

New generation psychological treatments in chronic pain

Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called "third wave" CBT. In this review, we examine the evidence for application of acceptance and commitment therapy (ACT), a principal example of this new wave or latest generation of treatment approaches, in people with chronic pain. We identified 25 randomized controlled trials of ACT for adults with chronic pain. Across the included trials, small to large effect sizes favoring ACT were reported for key outcomes including pain interference, disability, depression, and quality of life. Evidence from three studies provided some support for the cost effectiveness of ACT for chronic pain. Evidence also supported the mediating role of theoretically consistent processes of change (psychological flexibility) in relation to treatment outcomes. Investigation of moderators and predictors of outcomes was limited and inconsistent. In future, a greater focus on process based treatments is recommended. This should include continued identification of evidence based processes of change, and research methods more suited to understanding the experience and needs of individual people.

Examining the association between group context effects and individual outcomes in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy

Background: Although cognitive-behavioural treatments for chronic pain are delivered in groups, there is little research investigating group effects in these treatments. Purpose: The aim of this study was to investigate associations between group composition variables at the start of treatment and individual outcomes following intensive interdisciplinary treatment for pain based on Acceptance and Commitment Therapy. Methods: This was a secondary analysis of routinely collected observational data. Five-hundred and sixteen patients completed a standard set of demographic, pain-related, and psychosocial measures at pre- and post-treatment. Intracluster correlations (ICCs) were computed to examine the clustering of outcomes within groups and multilevel models explored the association between group composition variables and individual level outcomes. Results: The ICCs for pain intensity (0.11) and interference (0.09) suggested that multilevel models were warranted for these outcomes, while a multilevel model for post-treatment depression (ICC=0.04) was not warranted. Group percentage of participants receiving disability 8 benefits and group mean pain intensity at pre-treatment were significantly positively associated with individual level pain intensity at post-treatment, controlling for pre-treatment individual level pain intensity. Group mean pain intensity at pre-treatment was the only group variable that significantly predicted post-treatment pain interference at the individual level. Psychosocial group composition variables were not significantly associated with individual level outcomes. Conclusions: Given the limited predictive utility of group composition variables in the current study, future research should undertake direct assessment of group level therapeutic and counter-therapeutic processes to advance understanding of who benefits from group treatments for pain and how. As the variance in outcomes accounted for by group clustering was relatively small and significant within groups variance remained, research is also needed to further understand individual level factors that influence cognitive-behavioural treatment outcomes for pain.

Validation of the Committed Action Questionnaire-8 and Its Mediating Role Between Experiential Avoidance and Life Satisfaction Among Chinese University Students

Background: Committed action is one of the core processes of psychological flexibility derived from acceptance and commitment therapy. It has not been widely investigated in mainland China as appropriate measures are lacking. The current study aimed to validate a Chinese (Mandarin) version of the Committed Action Questionnaire (CAQ-8) in a non-clinical college sample and to explore whether committed action would have a mediating effect in the association between experiential avoidance (EA) and life satisfaction.

Methods: We translated the CAQ-8 into Chinese (Mandarin). A total of 913 Chinese undergraduates completed a set of questionnaires measuring committed action, EA, mindful awareness, anxiety, depression, stress, and life satisfaction. For test–retest reliability, 167 respondents completed the CAQ-8 again 4 weeks later.

Results: The entire scale of CAQ-8 (Mandarin) and two subscales showed adequate internal consistency and acceptable test–retest reliability. Confirmatory factor analyses confirmed the two-factor structure and the convergent and criterion validity were acceptable. Committed action was correlated with less EA, more mindful awareness, less depressive symptoms, less anxiety, less stress, and more life satisfaction. In bootstrap mediation analyses, committed action partially mediated the association between EA and life satisfaction.

Conclusion: The results suggest that the CAQ-8 (Mandarin) is a brief, psychometrically sound instrument to investigate committed action in Chinese populations, and the relationship between EA and life satisfaction was partially explained by committed action. This study provides new information about the usefulness of CAQ-8 and supports the assumption that committed action may be considered a promising factors for improving life satisfaction who have involved in EA among an educated non-clinical population.

Online Acceptance and Commitment Therapy (ACT) interventions for chronic pain: A systematic literature review

BACKGROUND

We systematically reviewed all literature concerning online Acceptance and Commitment Therapy (ACT) interventions for chronic pain to evaluate their (1) ACT content, (2) design characteristics, (3) design rationales, and (4) adherence.

MATERIAL AND METHODS

A systematic search was performed on July 9th, 2020 in; PubMed, PsycINFO, CINAHL, and Web of Science. Search terms related to: Acceptance and Commitment Therapy, chronic pain, and eHealth. Extracted data concerned ACT content, design characteristics, adherence, and design rationales.

RESULTS

20 articles, in which 14 interventions were described, met all inclusion criteria. Adherence and design rationales were described to a limited extent in the included studies. In total, the majority provided an overview of the included ACT processes. In 10 articles it was described that the intervention was delivered via a dedicated website (n = 10), which was sometimes combined with an app (n = 3). Guidance was included in most studies (n = 19). Studies including RCT's (n = 8) reported online ACT interventions to be effective.

CONCLUSION

Online ACT interventions for chronic pain have been shown to be effective and have generally been constructed in line with ACT theory. However, the majority of studies does not provide information about the choices to optimize the fit between task, technology, and user. Considerations behind the choices for intervention features as well as design rationales could help to optimize future online ACT interventions. Additionally, consistent attention should be paid to measurement and operationalization of adherence, since this is a crucial link between content, design and effectiveness.

Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials

While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N = 6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k = 3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k = 5) and non-clinical samples (k = 3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes.

Special issue on digital health interventions in chronic medical conditions: Editorial

Chronic medical conditions are increasingly common and associated with a high burden for persons affected by them. Digital health interventions might be a viable way to support persons with a chronic illness in their coping and self-management. The present special issue's editorial on digital health interventions in chronic medical conditions summarizes core findings and discusses next steps needed to further the field while avoiding to reinvent the wheel, thereby elaborating on four topics extracted from the special issue's articles: 1) Needs assessment and digital intervention development, 2) Efficacy and (cost-)effectiveness, 3) Dissemination and implementation research: reach and engagement as well as 4) next generation of digital interventions.

Systematic Review and Meta-Analysis of Effectiveness of Acceptance and Commitment Therapy in Patients With Breast Cancer

BACKGROUND

The physical and psychological well-being of patients with breast cancer is an important global issue. Acceptance and commitment therapy (ACT) aims to equip patients with the skills to respond and adapt to difficult circumstances. However, the extent of the physical and psychological outcomes of this therapy in patients with breast cancer remains unclear.

OBJECTIVES

The aim of the study was to summarize available evidence and assess the efficacy of ACT on physiological and psychological outcomes in patients with breast cancer.

METHODS

Published randomized controlled studies were identified in MEDLINE, PsycInfo, Embase, Web of Science, CINAHL, and CNKI from inception to December 2019 and Cochrane Library, AMED, and Clinical trials.gov from inception to September 2020. Methodological rigor was assessed by two reviewers using the Cochrane Handbook for Systematic Review of Interventions. Sufficient data were statistically pooled with review manager; otherwise, a narrative summary was used.

RESULTS

Thirteen trials were included in the review. Methodological quality varied across the studies. Meta-analyses demonstrated that ACT had moderate to large effects on reducing anxiety, depression, and stress and improving hope. Sensitivity analyses reached results similar to those of the meta-analyses. However, the effects of ACT on the physiological symptoms, fear of cancer recurrence, and psychological flexibility of patients with breast cancer remain inconclusive.

DISCUSSION

ACT has beneficial effects on the anxiety, depression, stress, and hope of patients with breast cancer. The evidence of ACT on physiological symptoms, fear of cancer recurrence, and psychological flexibility needs to be treated with caution. Further studies are needed and should consider different delivery forms and also explore the mechanisms of each component of ACT under different cultural contexts.

Mechanisms of change in acceptance and commitment therapy for primary headaches

BACKGROUND

Despite the demonstrated effectiveness of behavioural headache interventions, it is not yet known which intervention processes account for treatment responses. Acceptance and commitment therapy (ACT), an emerging behavioural intervention for headaches, proposes psychological flexibility (PF) processes as the mechanisms via which intervention change occurs. This is the first study examining these processes of change variables on headache-related disability and quality of life (treatment outcome).

METHODS

Data originated from a Randomized Clinical Trial evaluating the efficacy of ACT for primary headaches. Ninety-four individuals with primary headaches (M = 43 y; 84% females; M headache frequency/month = 9.30) were randomized to either an ACT-based or a Wait-list control group (N = 47 in each). Participants completed questionnaires related to their headache experiences and PF processes at pre- (T1), post-treatment (T2), and 3-month follow-up (T3).

RESULTS

Following a bootstrapped cross product of coefficients approach, results demonstrated mediating effects of headache acceptance, cognitive defusion, avoidance of headache, and mindfulness in the ACT group compared to control on parameters of headache-related disability and quality of life at post and 3-month follow-ups.

CONCLUSIONS

These findings demonstrate that changes in certain PF processes lower disability and improve quality of life in headache sufferers, supporting that ACT works via its proposed mechanisms of change. Interventions for headache management may be optimized if they target increases in headache acceptance, defusion from thoughts, and mindfulness.

SIGNIFICANCE

Psychological flexibility (PF) guides the ACT approach, an emerging behavioral headache intervention that focuses on optimizing head pain adjustment via flexible responses to pain. It targets at increasing daily functioning rather than preventing or controlling headache episodes. Pain acceptance, cognitive defusion, and mindfulness act as processes of functional change in ACT, lowering disability and increasing daily functioning and quality of life. These components can upgrade the established effectiveness of behavioral headache interventions with personalized, modularized therapeutic targets that can help headache sufferers re-establish optimal daily functioning even in fluctuating and persistent headache episodes.

TRIAL REGISTRATION

clinical trials.gov registry (NCT02734992).

The Psychological Functioning in the COVID-19 Pandemic and Its Association With Psychological Flexibility and Broader Functioning in People With Chronic Pain

AIMS

People with chronic pain may be particularly vulnerable to the impact of the pandemic COVID-19, and psychological flexibility may protect them. This study investigates psychological functioning in the context of COVID-19, including fear and avoidance in the context of COVID-19, specifically its association with daily functioning, and the role of psychological flexibility, among people with chronic pain.

METHODS

Responses from 555 adults with chronic pain were collected through a cross-sectional online survey and analyzed.

RESULTS

Eight out of 10 participants reported significant depression and nearly 9 out of 10 reported significant functional impairment. COVID-19-related fear and avoidance significantly correlated with pain, pain-related disability, depression, and work and social adjustment (r = 18-.32), as well as psychological flexibility processes, including pain acceptance, self-as-context, and committed action, |r|=.13-.30. COVID-19-related fear and avoidance and COVID-19-related interference were significant predictors of some measures of daily functioning beyond demographics and pain, β = .09-.14. However, these associations weakened when psychological flexibility processes were factored into the models, with fear of COVID-19 no longer being a significant predictor of pain-related disability or depression, and COVID-19 avoidance no longer a significant predictor of depression.

CONCLUSIONS

The psychological functioning in the context of COVID-19 appears to be negatively associated with daily functioning in people with chronic pain, and is statistically significant in this regard. Psychological flexibility may have a role in these associations for people with chronic pain in the pandemic.

PERSPECTIVE

This article demonstrates the psychological implication of COVID-19 and its association with broader emotional and daily functioning in people with chronic pain. It also demonstrates that Psychological flexibility may have a role in these associations for people with chronic pain in the pandemic.

A pilot randomized controlled trial of online acceptance and commitment therapy versus compassion-focused therapy for chronic illness

Literature suggests that acceptance and commitment therapy (ACT) is effective in improving well-being and in reducing psychopathological symptoms commonly experienced by people with chronic illness (CI). Compassion-focused therapy (CFT) reduces psychological distress, especially in individuals with high levels of shame and self-criticism, but few studies have explored CFT in CI. Additionally, studies almost exclusively compared ACT and CFT with inactive controls (wait-list; treatment as usual). Also, there is an interest in developing cost-effective mental health solutions, such as low-intensity online psychological interventions. This randomized controlled trial (RCT) aimed to assess the acceptability and compare the efficacy of four-session online ACT (n = 25) and CFT (n = 24) interventions in a sample of people with CI. Results showed both interventions were acceptable, with attrition rates at post-intervention comparable to those found in similar studies (around 50%). Intention-to-treat analyses showed that participants presented significantly less illness-related shame, less uncompassionate self-responding and more valued living after the intervention, although no difference was found between conditions. Results were sustained at 3- and 6-month follow-up. Results did not find statistical differences between conditions through reliable change index (RCI). Correlation between demographics and RCI showed that, at post-intervention, younger participants presented more behavioural awareness, men presented more valued action, and participants with CI for shorter periods presented less uncompassionate self-responding and less anxiety. Results suggest that low-intensity (four sessions) online ACT and CFT are cost-effective approaches to promote mental health of individuals with CI. Results and limitations are thoroughly discussed.

Effects of Coping Flexibility in Young Women on Depressive Symptoms during Chronic Pain

Chronic pain is a worldwide problem that has a high prevalence rate and is often comorbid with depression. Coping flexibility, which is defined as the ability to discontinue an ineffective coping strategy-evaluation coping-and to produce and implement an alternative strategy-adaptive coping-has attracted much interest as an important factor that attenuates pain-induced stress responses, including depression. This study hypothesized that greater coping flexibility would be associated with lower depression in both women with chronic pain and those with menstrual pain. The participants included women with chronic pain (n = 292) and those with menstrual pain (n = 181) who completed questionnaires on pain intensity, pain acceptance, psychological inflexibility, and coping flexibility for chronic pain. The hierarchical multiple regressions revealed that both evaluation coping and adaptive coping predicted depression even after controlling for the effects of pain intensity, pain acceptance, and psychological inflexibility, which are well-known for their association with depression in patients with chronic pain. The hypothesis was supported in our samples. Our findings may contribute to the development of self-management without self-medication using over-the-counter analgesics by acquiring coping flexibility for chronic pain.

Pain-related beliefs, cognitive processes, and electroencephalography band power as predictors and mediators of the effects of psychological chronic pain interventions

ABSTRACT

The current study used data from a clinical trial to identify variables that are associated with and/or mediate the beneficial effects of 4 psychological chronic pain treatments: one teaching patients self-hypnosis to reduce pain intensity (HYP), one teaching self-hypnosis to change thoughts about pain (hypnotic cognitive therapy [HYP-CT]), one teaching cognitive restructuring skills to change thoughts about pain (cognitive therapy [CT]), and one providing education about pain (ED; included as an active control condition). Of 17 possible mechanism variables examined, and with alpha not corrected for multiple comparisons, significant between-group differences were observed for 3. Two of these (changes in beliefs about control over pain and number of days of skill practice) were supported as mediators of the beneficial effects of HYP, CT, or HYP-CT, relative to ED. Six mechanism variables evidenced significant pretreatment to post-treatment changes in the sample as a whole, without showing significant between-group differences. Pretreatment to post-treatment changes in all 6 were associated with improvements in pain interference, pain intensity, or both. In addition, participant ratings of therapeutic alliance at post-treatment were associated significantly with improvements in both pain intensity and pain interference in the sample as a whole. Thus, of the 17 possible mediators examined, there were relatively few that served as mediators for the beneficial effects of specific treatments; a larger number of variables predicted treatment outcome overall. The extent to which these variables are treatment mediators (ie, are responsible for, rather than merely associated with, treatment-related improvements) will require further research.

Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis

Acceptance and Commitment Therapy (ACT) has been widely tested for chronic pain, with demonstrated efficacy. Nevertheless, although there is meta-analytical evidence on the efficacy of face-to-face ACT, no reviews have been performed on online ACT in this population. The aim of this meta-analysis is to determine the efficacy of online ACT for adults with chronic pain, when compared with controls. PubMed, PsycINFO, CENTRAL, and Web of Knowledge were searched for randomized controlled trials (RCTs) of online-delivered ACT for chronic pain. Effects were analyzed at post-treatment and follow-up, by calculating standardized mean differences. Online-delivered ACT was generally favored over controls (5 RCTs, N = 746). At post-treatment, medium effects for pain interference and pain acceptance, and small effects for depression, mindfulness, and psychological flexibility were found. A medium effect for pain interference and acceptance, and small effects for pain intensity, depression, anxiety, mindfulness, and psychological flexibility were found at follow-up. ACT-related effects for pain interference, pain intensity, mindfulness, and anxiety increased from post-treatment to follow-up. Nevertheless, the current findings also highlight the need for more methodologically robust RCTs. Future trials should compare online ACT with active treatments, and use measurement methods with low bias. PERSPECTIVE: This is the first meta-analytical review on the efficacy of online ACT for people with chronic pain. It comprises 5 RCTs that compared online ACT with active and/or inactive controls. Online ACT was more efficacious than controls regarding pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.

[Measurement of pain-related experiential avoidance: analysis of the Acceptance and Action Questionnaire-II-Pain in patients with chronic pain]

Einleitung und Fragestellung

Erlebensvermeidung („experiential avoidance“) stellt einen zentralen störungsrelevanten Prozess im Rahmen der Akzeptanz- und Commitment-Therapie (ACT) dar. Zur Erfassung wurde der Acceptance and Action Questionnaire II (AAQ-II) entwickelt und in den Niederlanden für eine Patientengruppe mit chronischem Schmerz adaptiert und validiert (AAQ-II‑P). Hohe Werte im AAQ-II‑P bedeuten hohe schmerzbezogene Erlebensvermeidung. Ziel unserer Untersuchung ist die Erfassung von schmerzbezogener Erlebensvermeidung mit einer deutschen Version des AAQ-II‑P bei chronischen Schmerzpatienten und die Prüfung psychometrischer Merkmale des Messverfahrens.

Methodik

Der AAQ-II wurde mittels eines Vorwärts-Rückwärts-Verfahrens ins Deutsche übersetzt, für chronischen Schmerz adaptiert (AAQ-II‑P) und von 168 Patienten einer universitären Schmerzambulanz beantwortet. Zusätzlich wurden Daten zu schmerzbedingter Beeinträchtigung (CPG: Schweregrad nach von Korff) und Schmerzkatastrophisieren (PCS) erhoben sowie zu gesundheitsbezogener Lebensqualität (SF-12), Angst und Depressivität (HADS-D). Ebenfalls erfasst wurden allgemeine Persönlichkeitsmerkmale (BFI‑K) und habituelle Achtsamkeit (KIMS-S). Ausgewertet wurden Reliabilität und faktorielle Validität des AAQ-II‑P sowie seine Beziehung zu den anderen psychometrischen Verfahren.

Ergebnisse

Der AAQ-II‑P erzielte eine hohe interne Konsistenz mit α = 0,89 sowie eine eindimensionale Faktorenstruktur mit 61 % aufgeklärter Varianz. Geringe Korrelationen ergaben sich zu Persönlichkeitsdimensionen (maximal r = 0,44 zu Neurotizismus) und Achtsamkeit (maximal r = −0,43 zu Akzeptanz). Ein hoher Zusammenhang fand sich zu Schmerzkatastrophisieren (r = 0,75), Depression (r = 0,73) und Angst (r = 0,66). Die Beziehung zu Lebensqualität war am stärksten ausgeprägt auf der Psychischen Summenskala (r = −0,58).

Diskussion und Schlussfolgerung

Die deutsche Version des AAQ-II‑P hat eine gute Reliabilität und weist hinsichtlich Zuverlässigkeit und Faktorenstruktur hohe Vergleichbarkeit mit der Originalversion auf. Die Beziehungen zu den Skalen der psychometrischen Verfahren sind zumeist in erwarteter Richtung und Höhe. Patienten mit chronischem Schmerz und hoher schmerzbezogener Erlebensvermeidung tendieren deutlich zum Schmerzkatastrophisieren und zeichnen sich durch schlechtere psychische Lebensqualität aus. Dies spricht für die Relevanz des Konstrukts hinsichtlich therapeutischer Zielvariablen.

Internet-delivered acceptance and commitment therapy as microlearning for chronic pain: A randomized controlled trial with 1-year follow-up

BACKGROUND

Studies of Internet-delivered acceptance and commitment therapy (ACT) for chronic pain have shown small to moderate positive effects for pain interference and pain acceptance. Effects on pain intensity, depression, anxiety and quality of life (QoL) have been less favourable, and improvements for values and sleep are lacking. In this randomized controlled trial iACT - a novel format of Internet-ACT using daily microlearning exercises - was examined for efficacy compared to a waitlist condition.

METHODS

Adult participants (mean age 49.5 years, pain duration 18.1 years) with diverse chronic pain conditions were recruited via self-referral, and randomized to iACT (n = 57) or waitlist (n = 56). The primary outcome was pain interference. The secondary outcomes were QoL, depression, anxiety, insomnia and pain intensity. The process variables included psychological inflexibility and values. Post-assessments were completed by 88% (n = 100) of participants. Twelve-month follow-up assessments were completed by 65% (iACT only, n = 37). Treatment efficacy was analysed using linear mixed models and an intention-to-treat-approach.

RESULTS

Significant improvements in favour of iACT were seen for pain interference, depression, anxiety, pain intensity and insomnia, as well as process variables psychological inflexibility and values. Between-group effect sizes were large for pain interference (d = 0.99) and pain intensity (d = 1.2), moderate for anxiety and depressive symptoms and small for QoL and insomnia. For the process variables, the between-group effect size was large for psychological inflexibility (d = 1.0) and moderate for values. All improvements were maintained at 1-year follow-up.

CONCLUSIONS

Internet-ACT as microlearning may improve a broad range of outcomes in chronic pain.

SIGNIFICANCE

The study evaluates a novel behavioral treatment with positive results on pain interference, mood as well as pain intensity for longtime chronic pain sufferers. The innovative format of a digital ACT intervention delivered in short and experiential daily learnings may be a promising way forward.

Efficacy of acceptance and commitment therapy (ACT) on depression, pain acceptance, and psychological flexibility in married women with breast cancer: a pre- and post-test clinical trial

Objective:

Breast cancer is the most common cancer in women worldwide. Many of these patients suffer from multiple psychological symptoms. The present study aimed to investigate the impact of acceptance and commitment therapy (ACT) on depression, pain acceptance, and psychological flexibility in married women with breast cancer.

Methods:

The present study was a pre- and post-test clinical trial with intervention and control groups. The research population consisted of women with breast cancer referred to the Ayatollah Yasrebi and Shahid Beheshti Hospitals in Kashan in 2018. Through a purposive sampling method, 40 women were selected and randomly divided into two groups, namely, intervention (n = 20) and control (n = 20). The applied tools included the Depression, Anxiety and Stress Scale (DASS-21), Chronic Pain Acceptance Questionnaire 8 (CPAQ-8), and Acceptance and Action Questionnaire - II (AAQ-II). Data were analyzed by SPSS 16 using descriptive statistics and analysis of variance (ANOVA).

Results:

The results showed that ACT treatment significantly reduced the mean scores of depression compared to the control group (F = 107.72, p < 0.001). The mean scores of pain acceptance (F = 9.58, p < 0.05) and psychological flexibility (F = 10.61, p < 0 .05) significantly increased in comparison with the control group.

Conclusion:

ACT can be considered as an effective therapeutic approach to reduce depression and increase pain acceptance and psychological flexibility in women with breast cancer. These changes appear to be due to improved acceptance of thoughts and feelings associated with cancer and increased psychological flexibility, which is the primary goal of ACT treatment.

Clinical trial registration:

Iranian Registry of Clinical Trials (IRCT), IRCT20190518043620N1.

StudiCare mindfulness-study protocol of a randomized controlled trial evaluating an internet- and mobile-based intervention for college students with no and "on demand" guidance

Background

College is an exciting but also challenging time with an increased risk for mental health issues. Only a minority of the college students concerned get professional help, a problem that might be improvable by internet- and mobile-based interventions (IMIs). However, adherence of IMIs is a concern. While guidance might be a solution, it is resource-intensive, derailing potential implementation on population level. The first aim of this trial is to evaluate the efficacy of the IMI StudiCare Mindfulness (StudiCare-M) for college students with “on demand” and no guidance. The second aim is to examine potential moderators and mediators, contributing to the questions of “how” and “for whom” such interventions work.

Methods

In this three-armed randomized controlled trial, both an unguided and “guidance on demand” (GoD) condition of StudiCare-M are compared to a waitlist control group. StudiCare-M is based on principles of acceptance and commitment therapy and stress management and consists of 7 modules plus two booster sessions. Participants in the GoD condition may ask their e-coach for support whenever needed. A total of 387 college students with moderate to low mindfulness are recruited at 15+ cooperating universities in Germany, Austria, and Switzerland via circular emails. Assessments take place before as well as 1, 2, and 6 months after randomization. The primary outcome is mindfulness. Secondary outcomes include stress, depression, anxiety, interoception, presenteeism, wellbeing, intervention satisfaction, adherence, and potential side effects. Among examined moderators and mediators are sociodemographic variables, pre-treatment symptomatology, treatment expectancy, self-efficacy, cognitive fusion, emotion regulation, and alexithymia. All data will be analyzed according to intention-to-treat (ITT) principles.

Discussion

Providing effective interventions to help college students become more resilient can make a valuable contribution to the health and functionality of future society. If effective under the condition of minimal or no guidance, StudiCare-M offers a low-threshold potentially resource-efficient possibility to enhance college student mental health on a population level. Moderation- and mediation analyses will deliver further insights for optimization of target groups and intervention content.

Trial registration

WHO International Clinical Trials Registry Platform via the German Clinical Studies Trial Register DRKS00014774. Registered on 18 May 2018.

Perfectionism and Pain Intensity in Women with Fibromyalgia: Its Influence on Activity Avoidance from The Contextual Perspective

Given the scarcity of studies regarding perfectionism from a contextual perspective, this study aims to analyze its role in the relationship between pain and activity avoidance and its differential effect among patients with different fibromyalgia severity. A cross-sectional study with 228 women with fibromyalgia classified into two disease severity groups (low/moderate vs. high) was carried out. Moderation analyses were conducted; perfectionism was used as moderator, pain (in high and low pain situations) as independent variable, and activity avoidance as the outcome. Among the high disease severity group, analyses showed direct contributions of perfectionism (p < 0.001) but not of pain (p > 0.05); moderation effects were found in high pain situations (p = 0.002) (for low levels of perfectionism, a positive association was found between pain intensity and avoidance). Among the low severity group, direct effects of perfectionism (p < 0.05) and pain intensity (p = 0.04) were found (although the latter only for high pain situations); moderation effects were found in high pain situations (p = 0.018) (for high levels of perfectionism a positive and significant association was found between pain intensity and avoidance). Perfectionism has been found to be a key variable in the differential relationship between pain intensity (in high pain situations) and activity avoidance in groups with high and low disease severity.

Effect of Psychological Inflexibility on Depressive Symptoms and Sleep Disturbance among Japanese Young Women with Chronic Pain

Background: Psychological inflexibility based on an acceptance and commitment therapy model is theoretically well-established as a process to exacerbate psychological distress, such as depressive symptoms and sleep disturbance. This study aimed to examine the associations of psychological inflexibility with depressive symptoms and sleep distribution. We hypothesized that psychological inflexibility would be associated with higher levels of depressive symptoms and sleep disturbance in women with chronic pain. Methods: Female college students in Japan answered a questionnaire on pain status, treatment, and psychological inflexibility as measured by the Acceptance and Action Questionnaire-Ⅱ before answering questionnaires on depressive symptoms and sleep disturbance eight months after. Results: Women with chronic pain (n = 320) reported more severe depressive symptoms and sleep disturbances compared to women without chronic pain (n = 90). Hierarchical multiple regressions revealed that psychological inflexibility predicted higher levels of depressive symptoms and sleep disturbance, independent of the pain intensity, whether they consulted a doctor or used pain medication. Conclusion: Based on our findings self-management interventions aimed at reducing psychological inflexibility should be developed for individuals who are experiencing chronic pain.

The mechanisms of effect of a physiotherapist-delivered integrated psychological and exercise intervention for acute whiplash-associated disorders: secondary mediation analysis of a randomized controlled trial

Supplemental Digital Content is Available in the Text. Stress mediated the effect of a physiotherapist-delivered integrated intervention on multiple health outcomes and pain-related coping mediated the effect on pain self-efficacy only. Changes in depressive and posttraumatic stress symptoms were also mechanisms of effect.

Introduction:

Integrated psychological and physical treatments can improve recovery for whiplash-associated disorders (WADs). Little is known about how these interventions work.

Objective:

To examine the mechanisms by which a physiotherapist-delivered integrated intervention for acute WAD improves health outcomes.

Methods:

Secondary analysis using structural equation modelling of a randomized controlled trial comparing integrated stress inoculation training and exercise to exercise alone for acute WAD. Outcomes were disability, pain self-efficacy, pain intensity, and health-related quality of life at 12 months. The intended intervention target and primary mediator, stress was tested in parallel with pain-related coping, an additional cognitive behavioral mediator that significantly improved at posttreatment (Model 1). Stress-related constructs that commonly co-occur with stress and pain were also tested as parallel mediators: depression and pain-related coping (Model 2); and posttraumatic stress and pain-related coping (Model 3).

Results:

Reductions in stress mediated the effect of the integrated intervention on disability (β = −0.12, confidence interval [CI] = −0.21 to −0.06), pain self-efficacy (β = 0.09, CI = 0.02–0.18), pain (β = −0.12, CI = −0.21 to −0.06), and health-related quality of life (β = 0.11, CI = 0.04–0.21). There was an additional path to pain self-efficacy through pain-related coping (β = 0.06, CI = 0.01–0.12). Similar patterns were found in Models 2 and 3.

Conclusions:

Improvements in stress and related constructs of depression and posttraumatic stress, and pain-related coping were causal mechanisms of effect in a physiotherapist-delivered integrated intervention. As integrated interventions are growing in popularity, it is important to further personalize interventions for improved benefit.

Pain management in hidradenitis suppurativa and a proposed treatment algorithm

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Few HS-specific data exist to guide pharmacologic analgesia; however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning-type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This article incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacologic, and complementary and alternative treatment modalities.

Further development in the assessment of psychological flexibility: validation of the German committed action questionnaire

Background

Psychological flexibility is considered a fundamental aspect of health. It includes six interrelated facets: 1) cognitive defusion, 2) acceptance, 3) contact with the present moment, 4) self-as-context, 5) values, and 6) committed action. To gain further insight into psychological flexibility and its effects on health, reliable and valid instruments to assess all facets are needed. Committed action is one facet that is understudied. A long and short version of a validated measure (CAQ and CAQ-8) have been developed in English. Currently, there are no German versions of the CAQ. Aim of this study is to validate German-language versions of these in a chronic pain population.

Methods

The CAQ instructions and items were translated and evaluated in a chronic pain population (N = 181). Confirmatory factor analysis and Mokken scale analysis were conducted to evaluate the German questionnaires. Correlations with health outcomes, including quality of life (SF-12), physical and emotional functioning (MPI, BPI, PHQ-9, GAD-7), pain intensity, and with other facets of psychological flexibility (CPAQ, FAH-II) were investigated for convergent validity purposes. Scale reliability was assessed by the alpha, MS, lambda-2, LCRC, and omega coefficient.

Results

A bifactor model consisting of one general factor and two methodological factors emerged from the analysis. Criteria for reliability and validity were met. Medium to strong correlations to health outcomes and other facets of psychological flexibility were found. Results were similar to the original English version.

Conclusions

The present study presents a valid and reliable instrument to investigate committed action in German populations. Future studies could expand the present findings by evaluating the German CAQ versions in non-pain populations. The role of committed action and the wider psychological flexibility model in pain and other conditions deserves further investigation.

Anxiety in Informal Dementia Carers: A Meta-Analysis of Prevalence

Much of the carer literature has focused on depression and burden as primary outcomes and anxiety appear somewhat neglected. Providing evidence on the prevalence of carer anxiety is critical as it can enhance awareness among professionals, which in turn can lead to improved access to efficacious treatments. This meta-analysis updated the previous review conducted in 2007 to estimate the up-to-date prevalence of anxiety in informal carers for people with dementia. Literature searches were conducted in databases of published and unpublished literature. Events and sample size data were pooled using a random effects model to obtain an overall prevalence percentage. A total of 10 studies were included, resulting in a pooled estimate of anxiety prevalence at 32.1% (95% confidence interval: 20.6%-46.2%, P = .01). Significant heterogeneity was found, which was not reduced following sensitivity analysis. This study suggests anxiety is a prevalent difficulty experienced by dementia carers. Additional research recommendations and clinical implications are discussed.

Psychosocial dimensions of hand transplantation: lessons learned from solid organ transplantation

PURPOSE OF REVIEW

The present review examines psychosocial factors emerging as predictive of clinical outcomes among solid organ transplant (SOT) recipients, with possible extensions to vascular composite allograft (VCA) and hand transplantation, in particular. The Chauvet Workgroup report and International Society of Heart and Lung Transplantation consensus guidelines are used to delineate areas of commonality between SOT and VCA, as well as unique features contributing to post-VCA psychosocial risk.

RECENT FINDINGS

Increasing evidence suggests that depression, cognitive function, and other posttransplant psychosocial factors consistently associate with clinical risk in SOT. However, the mechanisms precipitating these psychosocial risk factors are likely diverse in their cause, with large individual differences across SOT and VCA. Transdiagnostic dimensions may serve as mechanistic factors, increasing the risk of adverse clinical outcomes and suggesting potential treatment strategies for risk mitigation. Psychosocial dimensions including psychological flexibility, self-efficacy, and posttraumatic growth are discussed as potential contributory factors.

SUMMARY

Psychosocial factors hold importance in predicting posttransplant clinical outcomes. Emerging transdiagnostic factors may provide insight into mechanisms and potential treatments.

Early Changes in Pain Acceptance Predict Pain Outcomes in Interdisciplinary Treatment for Chronic Pain

Studies have shown that pain acceptance is associated with a better pain outcome. The current study explored whether changes in pain acceptance in the very early treatment phase of an interdisciplinary cognitive-behavioral therapy (CBT)-based treatment program for chronic pain predict pain outcomes. A total of 69 patients with chronic, non-malignant pain (at least 6 months) were treated in a day-clinic for four-weeks. Pain acceptance was measured with the Chronic Pain Acceptance Questionnaire (CPAQ), pain outcomes included pain intensity (Numeric Rating Scale, NRS) as well as affective and sensory pain perception (Pain Perception Scale, SES-A and SES-S). Regression analyses controlling for the pre-treatment values of the pain outcomes, age, and gender were performed. Early changes in pain acceptance predicted pain intensity at post-treatment measured with the NRS (B = −0.04 (SE = 0.02); T = −2.28; p = 0.026), affective pain perception at post-treatment assessed with the SES-A (B = −0.26 (SE = 0.10); T = −2.79; p = 0.007), and sensory pain perception at post-treatment measured with the SES-S (B = −0.19 (SE = 0.08); T = −2.44; p = 0.017). Yet, a binary logistic regression analysis revealed that early changes in pain acceptance did not predict clinically relevant pre-post changes in pain intensity (at least 2 points on the NRS). Early changes in pain acceptance were associated with pain outcomes, however, the impact was beneath the threshold defined as clinically relevant.

Best-Evidence for the Rehabilitation of Chronic Pain Part 1: Pediatric Pain

Chronic pain is a prevalent and persistent problem in middle childhood and adolescence. The biopsychosocial model of pain, which accounts for the complex interplay of the biological, psychological, social, and environmental factors that contribute to and maintain pain symptoms and related disability has guided our understanding and treatment of pediatric pain. Consequently, many interventions for chronic pain are within the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain management. These treatments are typically delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or occupational therapy. Current data suggest that multidisciplinary treatment is important, with intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients with high levels of functional disability. The following review describes the current state of the art of rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas of interventions are also highlighted to guide future research and clinical practice.

Acceptance and commitment therapy for chronic pain: protocol of a systematic review and individual participant data meta-analysis

BACKGROUND

Acceptance and commitment therapy (ACT) can be effective in treating chronic pain. Despite evidence supporting the effectiveness of ACT, uncertainties remain regarding which subgroups in the chronic pain population are likely to benefit most and least. This protocol describes the application for two meta-analytic approaches, one at the level of individual participant data and the other at the level of aggregated data, from randomized controlled trials of ACT for chronic pain (ACT-CP-MA).

METHODS

We will systematically conduct literature searches in CENTRAL, MEDLINE, EMBASE, PsycINFO, and trial registers. Two reviewers will independently select studies for inclusion and data extraction. ACT-CP-MA will include randomized controlled trials with ACT for chronic pain compared to control conditions for adults (≥ 18 years) with chronic pain (> 3 months). We will invite the authors of all eligible trials to share individual participant data. Outcomes will include standardized measures of pain interference, pain intensity, depression, anxiety, health-related quality of life, participants' rating of overall improvement, and ACT-related process variables. Using the Cochrane Collaboration's tool and GRADE, reviewers will independently check for risk of bias, quality of evidence, and strength of recommendations. In the individual participant data meta-analysis, we will use a one-step approach where participants are clustered with studies and data from all studies are modeled simultaneously. For analyses, we will use mixed-effects models. Additionally, we will employ a meta-analysis with aggregate data and compare the results of both meta-analyses.

DISCUSSION

This collaborative meta-analysis of individual participant data from randomized controlled trials of ACT for chronic pain versus control conditions will demonstrate how the known benefits of ACT for chronic pain vary across different subtypes of the chronic pain population. The results of the meta-analyses will be based on a comprehensive search of multiple databases and will help to inform future clinical trials and decision-making on the use of ACT in chronic pain and improve the quality, design, and reporting of future trials in this field.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120901.

Age, Pain Intensity, Values-Discrepancy, and Mindfulness as Predictors for Mental Health and Cognitive Fusion: Hierarchical Regressions With Mediation Analysis

Background: Several studies have confirmed that higher levels of psychological flexibility predict better functioning for those suffering with chronic pain. However, few studies have investigated the role of the individual components of psychological flexibility within a chronic pain population in relation to aging specifically and the related indirect mediational processes.

Aim: The present study aimed to compare how age, pain intensity, mindfulness, and values-discrepancy predicted mental health and cognitive fusion separately. It also explored the indirect process relations through the use of a mediated analysis.

Methods: Two hundred and thirty three participants completed an online survey which included demographical questions as well as the following questionnaires; Short Form McGill Pain Questionnaire (SF-MPQ); General Health Questionnaire 12; Cognitive Fusion 7-Item Questionnaire (CFQ-7); Mindfulness Attention Awareness Scale (MAAS); and the Chronic Pain Values Inventory (CPVI). The relationships from the responses of the questionnaires and demographics were then analyzed through two hierarchical regression models followed by further mediation analysis.

Results: In the first model, values-discrepancy, pain intensity, and mindfulness all predicted mental health, but age did not. However, age did account for a significant portion of the variance in the second model when cognitive fusion was used as the dependent measure. It was also found that cognitive fusion mediated the relationship between age and mental health.

Conclusion: These results are discussed within the context of using indirect process relations of psychological flexibility and third wave therapies such as acceptance and commitment therapy for a chronic pain population.

Baseline Psychological Inflexibility Moderates the Outcome Pain Interference in a Randomized Controlled Trial on Internet-based Acceptance and Commitment Therapy for Chronic Pain

This study re-investigated data of a randomized controlled trial on Internet-based Acceptance and Commitment Therapy for chronic pain (ACTonPain). Baseline psychological inflexibility was examined as a moderator of the outcome pain interference. In the ACTonPain trial, participants with chronic pain were randomized to one of three conditions: guided Internet-based ACT (n = 100), unguided Internet-based ACT (n = 101), and waitlist (n = 101). Moderation analyses were performed with the SPSS macro PROCESS. Pain interference according to the Multidimensional Pain Inventory (MPI) was the primary outcome in this trial, and the potential moderator psychological inflexibility was measured with the Acceptance and Action Questionnaire (AAQ-II). Psychological inflexibility at baseline moderated the outcome between guided Internet-based ACT and waitlist 9-weeks as well as 6-months after randomization. (both p < 0.05). Between unguided Internet-based ACT and waitlist, psychological inflexibility moderated the outcome 6-months after randomization (p < 0.05). Internet-based ACT was superior to waitlist for participants with less psychological inflexibility at baseline, but Internet-based ACT became increasingly comparable to waitlist at higher AAQ-II baseline values. Future research should investigate whether the results can be replicated in more individualized and tailored face-to-face settings.

Baseline Psychological Inflexibility Moderates the Outcome Pain Interference in a Randomized Controlled Trial on Internet-based Acceptance and Commitment Therapy for Chronic Pain

This study re-investigated data of a randomized controlled trial on Internet-based Acceptance and Commitment Therapy for chronic pain (ACTonPain). Baseline psychological inflexibility was examined as a moderator of the outcome pain interference. In the ACTonPain trial, participants with chronic pain were randomized to one of three conditions: guided Internet-based ACT (n = 100), unguided Internet-based ACT (n = 101), and waitlist (n = 101). Moderation analyses were performed with the SPSS macro PROCESS. Pain interference according to the Multidimensional Pain Inventory (MPI) was the primary outcome in this trial, and the potential moderator psychological inflexibility was measured with the Acceptance and Action Questionnaire (AAQ-II). Psychological inflexibility at baseline moderated the outcome between guided Internet-based ACT and waitlist 9-weeks as well as 6-months after randomization. (both p < 0.05). Between unguided Internet-based ACT and waitlist, psychological inflexibility moderated the outcome 6-months after randomization (p < 0.05). Internet-based ACT was superior to waitlist for participants with less psychological inflexibility at baseline, but Internet-based ACT became increasingly comparable to waitlist at higher AAQ-II baseline values. Future research should investigate whether the results can be replicated in more individualized and tailored face-to-face settings.

Current status of acceptance and commitment therapy for chronic pain: a narrative review

It is well known that chronic pain is prevalent, complex to manage, and associated with high costs, in health care and society in general. Thanks to advances in new forms of cognitive behavioral therapy (known as third-wave CBT), currently clinicians and researchers have an empirically validated psychological treatment with increasing research support for the treatment of chronic pain. This treatment is called acceptance and commitment therapy (ACT). The main aim of this paper is to provide a narrative review that summarizes and integrates the current state of knowledge of ACT in the management of chronic pain as well as discuss current challenges and opportunities for progress. Based on the psychological flexibility model, ACT extends previous forms of CBT and integrates many CBT-related variables into six core therapeutic processes. ACT is a process-based therapy that fosters openness, awareness, and engagement through a wide range of methods, including exposure-based and experiential methods, metaphors, and values clarification. To our knowledge, there are three published systematic reviews and meta-analyses that support the effectiveness of ACT for chronic pain and many studies focused on specific processes derived from the psychological flexibility model. There is also promising support for the cost-effectiveness of ACT; however, the current evidence is still insufficient to establish firm conclusions about cost-effectiveness and the most efficient means of delivery. Additional well-designed economic evaluations are needed. Other research aims include delineating the neurobiological underpinnings of ACT, refining available outcome and process measures or develop new ones for ACT trials, and meeting the challenge of wide dissemination and implementation in real-world clinical practice.

A Web-Based Acceptance-Facilitating Intervention for Identifying Patients' Acceptance, Uptake, and Adherence of Internet- and Mobile-Based Pain Interventions: Randomized Controlled Trial

Background

Internet- and mobile-based interventions are effective for the treatment of chronic pain. However, little is known about patients’ willingness to engage with these types of interventions and how the uptake of such interventions can be improved.

Objective

The aim of this study was to identify people’s acceptance, uptake, and adherence (primary outcomes) with regard to an internet- and mobile-based intervention for chronic pain and the influence of an information video as an acceptance-facilitating intervention (AFI).

Methods

In this randomized controlled trial with a parallel design, we invited 489 individuals with chronic pain to participate in a Web-based survey assessing the acceptance of internet- and mobile-based interventions with the offer to receive an unguided internet- and mobile-based intervention for chronic pain after completion. Two versions of the Web-based survey (with and without AFI) were randomly sent to two groups: one with AFI (n=245) and one without AFI (n=244). Participants who completed the Web-based survey with or without AFI entered the intervention group or the control group, respectively. In the survey, the individuals’ acceptance of pain interventions, measured with a 4-item scale (sum score ranging from 4 to 20), predictors of acceptance, sociodemographic and pain-related variables, and physical and emotional functioning were assessed. Uptake rates (log in to the intervention) and adherence (number of completed modules) to the intervention was assessed 4 months after intervention access. To examine which factors influence acceptance, uptake rate, and adherence in the internet- and mobile-based interventions, we conducted additional exploratory subgroup analyses.

Results

In total, 57 (intervention group) and 58 (control group) participants in each group completed the survey and were included in the analyses. The groups did not differ with regard to acceptance, uptake rate, or adherence (P=.64, P=.56, P=.75, respectively). Most participants reported moderate (68/115, 59.1%) to high (36/115, 31.3%) acceptance, with 9.6% (11/115) showing low acceptance (intervention group: mean 13.91, SD 3.47; control group: mean 13.61, SD 3.50). Further, 67% (38/57, intervention group) and 62% (36/58, control group) had logged into the intervention. In both groups, an average of 1.04 (SD 1.51) and 1.14 (SD 1.90) modules were completed, respectively.

Conclusions

The informational video was not effective with regard to acceptance, uptake rate, or adherence. Despite the high acceptance, the uptake rate was only moderate and adherence was remarkably low. This study shows that acceptance can be much higher in a sample participating in an internet- and mobile-based intervention efficacy trial than in the target population in routine health care settings. Thus, future research should focus not only on acceptance and uptake facilitating interventions but also on ways to influence adherence. Further research should be conducted within routine health care settings with more representative samples of the target population.

Trial Registration

German Clinical Trial Registration DRKS00006183; http://www.drks.de/drks_web/navigate.do ?navigationId=trial.HTML&TRIAL_ID=DRKS00006183 (Archived by WebCite at http://www.webcitation.org/70ebHDhne)

Exploring psychological mechanisms of clinical response to an internet-delivered psychological pain management program

BACKGROUND

The evidence for Internet-delivered pain management programs for chronic pain is growing, but there is little empirical understanding of how they effect change. Understanding mechanisms of clinical response to these programs could inform their effective development and delivery.

METHODS

A large sample (n = 396) from a previous randomized controlled trial of a validated internet-delivered psychological pain management program, the Pain Course, was used to examine the influence of three potential psychological mechanisms (pain acceptance, pain self-efficacy, fear of movement/re-injury) on treatment-related change in disability, depression, anxiety and average pain. Analyses involved generalized estimating equation models for clinical outcomes that adjusted for co-occurring change in psychological variables. This was paired with cross-lagged analysis to assess for evidence of causality. Analyses involved two time points, pre-treatment and post-treatment.

RESULTS

Changes in pain-acceptance were strongly associated with changes in three (depression, anxiety and average pain) of the four clinical outcomes. Changes in self-efficacy were also strongly associated with two (anxiety and average pain) clinical outcomes. These findings suggest that participants were unlikely to improve in these clinical outcomes without also experiencing increases in their pain self-efficacy and pain acceptance. However, there was no clear evidence from cross-lagged analyses to currently support these psychological variables as direct mechanisms of clinical improvements. There was only statistical evidence to suggest higher levels of self-efficacy moderated improvements in depression.

CONCLUSIONS

The findings suggest that, while clinical improvements are closely associated with improvements in pain acceptance and self-efficacy, these psychological variables may not drive the treatment effects observed.

SIGNIFICANCE

This study employed robust statistical techniques to assess the psychological mechanisms of an established internet-delivered pain management program. While clinical improvements (e.g. depression, anxiety, pain) were closely associated with improvements in psychological variables (e.g. pain self-efficacy and pain acceptance), these variables do not appear to be treatment mechanisms.