Exercise combined with Acceptance and Commitment Therapy compared with a standalone supervised exercise programme for adults with chronic pain: a randomised controlled trial

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.

Use of patient-reported global assessment measures in clinical trials of chronic pain treatments: ACTTION systematic review and considerations

ABSTRACT

Establishing clinically meaningful changes in pain experiences remains important for clinical trials of chronic pain treatments. Regulatory guidance and pain measurement initiatives have recommended including patient-reported global assessment measures (eg, Patient-Global Impression of Change [PGIC]) to aid interpretation of within-patient differences in domain-specific clinical trial outcomes (eg, pain intensity). The objectives of this systematic review were to determine the frequency of global assessment measures inclusion, types of measures, domains assessed, number and types of response options, and how measures were analyzed. Of 4172 abstracts screened across 6 pain specialty journals, we reviewed 96 clinical trials of chronic pain treatments. Fifty-two (54.2%) studies included a global assessment measure. The PGIC was most common (n = 28; 53.8%), with relatively infrequent use of other measures. The majority of studies that used a global assessment measure (n = 31; 59.6%) assessed change or improvement in an unspecified domain. Others assessed overall condition severity (n = 9; 17.3%), satisfaction (n = 8; 15.4%), or overall health status/recovery (n = 5; 9.6%). The number, range, and type of response options were variable and frequently not reported. Response options and reference periods even differed within the PGIC. Global assessment measures were most commonly analyzed as continuous variables (n = 24; 46.2%) or as dichotomous variables with positive categories combined to calculate the proportion of participants with a positive response to treatment (n = 18; 34.6%). This review highlights the substantial work necessary to clarify measurement and use of patient global assessment in chronic pain trials and provides short- and long-term considerations for measure selection, reporting and analysis, and measure development.

Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial

BACKGROUND

Acceptance and Commitment Therapy (ACT) is a type of Cognitive Behavioural Therapy, which has demonstrated positive outcomes in individuals with chronic pain. The purpose of this study was to compare the effect of an 8-week programme combining Exercise with Acceptance and Commitment Therapy (ExACT) with a standalone supervised exercise programme at 1-year follow-up.

METHODS

One hundred and seventy-five people with chronic pain were randomly assigned to ExACT or supervised exercise only. The primary outcome was pain interference measured with the Brief Pain Inventory-Interference Scale. Secondary and treatment process outcomes included pain severity, depression, anxiety, pain catastrophizing, pain self-efficacy, fear avoidance, pain acceptance, committed action, healthcare utilization, patient satisfaction, and global impression of change. Estimates of treatment effects at 1-year follow-up were based on intention-to-treat analyses, implemented using a linear mixed-effects model.

RESULTS

Eighty-three participants (47.4%) returned the outcome measures at 1-year follow-up. No significant difference was observed between the groups for the primary outcome, pain interference. There was a statistically significant difference between the groups, in favour of ExACT for pain catastrophizing. Within group improvements that were observed within both groups at earlier timepoints were maintained at 1-year follow-up for many of the secondary and treatment process outcomes. ExACT group participants reported higher levels of satisfaction with treatment and global perceived change.

CONCLUSIONS

The study results showed no significant difference between the two groups for the primary outcome pain interference at 1-year follow-up. Future research could investigate factors that may predict and optimize outcomes from these types of intervention for people living with chronic pain.

SIGNIFICANCE

Few previous randomized controlled trials investigating ACT for chronic pain have included long-term follow-up. This study found that Exercise combined with ACT was not superior to supervised exercise alone for reducing pain interference at 1-year follow-up. Further research is necessary to identify key processes of therapeutic change and to explore how interventions may be modified to enhance clinical outcomes for people with chronic pain.

The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials

The current study included randomized controlled trials (RCTs) to assess the benefits of Acceptance and commitment therapy (ACT) for chronic pain. Searches were conducted in Web of Science, PsycINFO, PubMed, Scopus, Cochrane Library, and Embase from inception until September 30, 2022. Thirty-three RCTs, including 2293 participants, were included. Small to medium effect sizes for pain intensity/physical function favoring ACT were found both at post-treatment (pain intensity: g = 0.44; physical function: g = 0.59) and follow-up (pain intensity: g = 0.34; physical function: g = 0.56). The effect sizes on psychological outcomes were significant at post-treatment (depression: g = 0.43; anxiety: g = 0.43; quality of life: g = 0.45) and follow-up (depression: g = 0.43; anxiety: g = 0.35; quality of life: g = 0.43). The results of the trial sequential analyses indicated that pooled estimates were unlikely to be incidental findings, as effects of multiple testing were controlled and power was adequate. Face-to-face ACT yielded significantly larger effects on physical outcomes than internet-delivered ACT. Participants with chronic headache and fibromyalgia showed greater benefit from ACT compared to those with non-specific pain or mixed pain. In addition, the longer the follow-up duration, the smaller the effect sizes for pain intensity/physical function at follow-up. The present meta-analysis suggests sufficient evidence for the significant benefits of ACT for people with chronic pain.

Chronische Schmerzen: Benefit durch Kombination von ACT und Trainingsprogramm?

Chronische Schmerzen belasten die Lebensqualität der Betroffenen und gehen mit hohen sozioökonomischen Kosten einher. Obgleich es heute eine Vielzahl von Behandlungsansätzen gibt, bleibt insbesondere die Langzeitwirksamkeit häufig unklar. Vor diesem Hintergrund wollten Casey und Kollegium eine Lücke schließen, und haben den möglichen Benefit durch eine Kombination aus Akzeptanz- und Commitmenttherapie (ACT) und körperlichem Training untersucht.