A systematic review of randomised controlled trials using Acceptance and commitment therapy as an intervention in the management of non-malignant, chronic pain in adults

Emotion regulation skills-focused interventions for chronic pain: A systematic review and meta-analysis

OBJECTIVES

To investigate the effect of emotion regulation skills-focused (ERSF) interventions to reduce pain intensity and improve psychological outcomes for people with chronic pain and to narratively report on safety and intervention compliance.

METHODS

Six databases and four registries were searched for randomized controlled trials (RCTs) up to 29 April 2022. Risk of bias was evaluated using the Cochrane RoB 2.0 tool, and certainty of evidence was assessed according to the Grading, Assessment, Development and Evaluation (GRADE). Meta-analyses for eight studies (902 participants) assessed pain intensity (primary outcome), emotion regulation, affect, symptoms of depression and anxiety, and pain interference (secondary outcomes), at two time points when available, post-intervention (closest to intervention end) and follow-up (the first measurement after the post-intervention assessment).

RESULTS

Compared to TAU, pain intensity improved post-intervention (weighted mean difference [WMD] = -10.86; 95% confidence interval [CI] [-17.55, -2.56]) and at follow-up (WMD = -11.38; 95% CI [-13.55, -9.21]). Emotion regulation improved post-intervention (standard mean difference [SMD] = 0.57; 95% CI [0.14, 1.01]), and depressive symptoms improved at follow-up (SMD = -0.45; 95% CI [-0.66, -0.24]). Compared to active comparators, anxiety symptoms improved favouring the comparator post-intervention (SMD = 0.10; 95% CI [0.03, 0.18]), and compared to CBT, pain interference improved post-intervention (SMD = -0.37; 95% CI [-0.69, -0.04]). Certainty of evidence ranged from very low to moderate.

SIGNIFICANCE

The findings provide evidence that ERSF interventions reduce pain intensity for people with chronic pain compared to usual treatment. These interventions are at least as beneficial to reduce pain intensity as the current gold standard psychological intervention, CBT. However, the limited number of studies and certainty of evidence mean further high-quality RCTs are warranted. Additionally, further research is needed to identify whether ERSF interventions may be more beneficial for specific chronic pain conditions.

Benefits, Recruitment, Dropout, and Acceptability of the Strength Back Digital Health Intervention for Patients Undergoing Spinal Surgery: Nonrandomized, Qualitative, and Quantitative Pilot Feasibility Study

BACKGROUND

Patients undergoing spinal surgery report high levels of insecurity, pain, stress, and anxiety before and after surgery. Unfortunately, there is no guarantee that surgery will resolve all issues; postsurgical recovery often entails moderate to severe postoperative pain, and some patients undergoing spinal surgery do not experience (long-term) pain relief after surgery. Therefore, focusing on sustainable coping skills and resilience is crucial for these patients. A digital health intervention based on acceptance and commitment therapy (ACT) and positive psychology (PP) was developed to enhance psychological flexibility and well-being and reduce postsurgical pain.

OBJECTIVE

The objective of this study was 3-fold: to explore the potential benefits for patients undergoing spinal surgery of the digital ACT and PP intervention Strength Back (research question [RQ] 1), explore the feasibility of a future randomized controlled trial in terms of recruitment and dropout (RQ 2), and assess the acceptability of Strength Back by patients undergoing spinal surgery (RQ 3).

METHODS

We used a nonrandomized experimental design with an intervention group (n=17) and a control group (n=20). To explore the potential benefits of the intervention, participants in both groups filled out questionnaires before and after surgery. These questionnaires included measurements of pain intensity (Numeric Pain Rating Scale), pain interference (Multidimensional Pain Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), valued living (Engaged Living Scale), psychological flexibility (Psychological Inflexibility in Pain Scale), and mental well-being (Mental Health Continuum-Short Form). Semistructured interviews combined with log data and scores on the Twente Engagement With eHealth Technologies Scale were used to assess the acceptability of the intervention.

RESULTS

A significant improvement over time in emotional (V=99; P=.03) and overall (V=55; P=.004) well-being (Mental Health Continuum-Short Form) was observed only in the intervention group. In addition, the intervention group showed a significantly larger decline in pain intensity (Numeric Pain Rating Scale) than did the control group (U=75; P=.003). Of the available weekly modules on average 80% (12/15) was completed by patients undergoing spinal fusion and 67% (6/9) was completed by patients undergoing decompression surgery. A total of 68% (17/25) of the participants used the intervention until the final interview. Most participants (15/17, 88%) in the intervention group would recommend the intervention to future patients.

CONCLUSIONS

This pilot feasibility study showed that combining ACT and PP in a digital health intervention is promising for patients undergoing spinal surgery as the content was accepted by most of the participants and (larger) improvements in pain intensity and well-being were observed in the intervention group. A digital intervention for patients undergoing (spinal) surgery can use teachable moments, when patients are open to learning more about the surgery and rehabilitation afterward. A larger randomized controlled trial is now warranted.

Internet-Delivered Dialectical Behavioral Therapy Skills Training for Chronic Pain: Protocol for a Randomized Controlled Trial

BACKGROUND

Emotion dysregulation is key to the development and maintenance of chronic pain, feeding into a cycle of worsening pain and disability. Dialectical behavioral therapy (DBT), an evidence-based treatment for complex transdiagnostic conditions presenting with high emotion dysregulation, may be beneficial to manage and mitigate the emotional and sensory aspects of chronic pain. Increasingly, DBT skills training as a key component of standard DBT is being delivered as a stand-alone intervention without concurrent therapy to help develop skills for effective emotion regulation. A previous repeated-measure single-case trial investigating a novel technologically driven DBT skills training, internet-delivered DBT skills training for chronic pain (iDBT-Pain), revealed promising findings to improve both emotion dysregulation and pain intensity.

OBJECTIVE

This randomized controlled trial aims to examine the efficacy of iDBT-Pain in comparison with treatment as usual to reduce emotion dysregulation (primary outcome) for individuals with chronic pain after 9 weeks and at the 21-week follow-up. The secondary outcomes include pain intensity, pain interference, anxiety symptoms, depressive symptoms, perceived stress, posttraumatic stress, harm avoidance, social cognition, sleep quality, life satisfaction, and well-being. The trial also examines the acceptability of the iDBT-Pain intervention for future development and testing.

METHODS

A total of 48 people with chronic pain will be randomly assigned to 1 of 2 conditions: treatment and treatment as usual. Participants in the treatment condition will receive iDBT-Pain, consisting of 6 live web-based group sessions led by a DBT skills trainer and supervised by a registered psychologist and the iDBT-Pain app. Participants in the treatment-as-usual condition will not receive iDBT-Pain but will still access their usual medication and health interventions. We predict that iDBT-Pain will improve the primary outcome of emotion dysregulation and the secondary outcomes of pain intensity, pain interference, anxiety symptoms, depressive symptoms, perceived stress, harm avoidance, social cognition, sleep quality, life satisfaction, and well-being. A linear mixed model with random effects of individuals will be conducted to investigate the differences between the baseline, 9-week (primary end point), and 21-week (follow-up) assessments as a function of experimental condition.

RESULTS

Recruitment started in February 2023, and the clinical trial started in March 2023. Data collection for the final assessment is planned to be completed by July 2024.

CONCLUSIONS

If our hypothesis is confirmed, our findings will contribute to the evidence for the efficacy and acceptability of a viable intervention that may be used by health care professionals for people with chronic pain. The results will add to the chronic pain literature to inform about the potential benefits of DBT skills training for chronic pain and will contribute evidence about technologically driven interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12622000113752; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383208&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/41890.

Strength Back - A qualitative study on the co-creation of a positive psychology digital health intervention for spinal surgery patients

Introduction

Spinal surgery patients often experience pain as well as stress, anxiety or even depression before surgery, highlighting the need for better mental preparation before undergoing surgery. Acceptance and Commitment Therapy and positive psychology have proven effective in coping with chronic pain and providing long-term skills that enhance psychological flexibility and mental well-being.The aim of this study is to develop a digital intervention (app) based on Acceptance and Commitment Therapy and positive psychology in co-creation with all stakeholders, including patients and professionals. The aim of the intervention is to increase psychological flexibility and positive skills of spinal surgery patients to promote long-term resilience.

Materials and methods

In this qualitative study, individual, semi-structured interviews were held with healthcare professionals (N = 9) and spinal surgery patients (N = 12) to identify contextual factors and needs for the app. Subsequently, three focus-group sessions were held with healthcare professionals and newly recruited patients to specify relevant values. Also, a first version of the app, named Strength Back, was developed using a participatory design.

Results

The interviews confirmed the need for information and digital support to cope with insecurity, anxiety and pain, both before and after surgery. Based on iterative steps in the focus-group sessions, thirteen modules were developed focusing on procedural information, pain education, psychological flexibility and mental well-being.

Discussion

The intervention Strength Back, containing information as well as Acceptance and Commitment Therapy and positive psychology exercises, has the potential to increase psychological flexibility, enhance well-being and improve postoperative recovery after spinal surgery.

Effectiveness of spontaneous pain coping strategies for acute pain management: A laboratory study

The aim of the present study has been to analyze the relationship between the use of not previously trained, diverse acute pain coping strategies and levels of pain intensity and pain tolerance in a group of healthy participants. Previous research has analyzed the usefulness of the training of these strategies after several training sessions, but adequate patient training requires a great deal of time. Two hundred and forty healthy people participated in the study. Pain coping strategies was evaluated with a version of CSQ-S. Subsequently, the participants completed a cold pressor test and tolerance test. After that, subjects filled in the adaptation of the CSQ-S about the strategies which they had employed throughout the test. Correlation analyses showed a positive relationship between pain intensity and catastrophizing, distractor behaviors, hoping and ignoring the pain. Pain tolerance correlated with self-instructions, ignoring the pain, reinterpreting the pain, catastrophizing and faith and praying. Regression analyses showed that catastrophizing was found to be the strategy that most predicts the variance of pain intensity, and catastrophizing (negative) and ignoring the pain (positive) and praying (negative) were the most predictive ones for pain tolerance. This is the first laboratory study that identifies the more useful pain coping strategies which can be used by patients without previous training in an acute pain context. The results of this study could be useful in the development of protocols for nurses and other health professionals, especially for situations where potentially painful techniques are to be applied to patients.

Which outcome variables are associated with psychological inflexibility/flexibility for chronic pain patients? A three level meta-analysis

The psychological flexibility model can be seen as a basis for an integrated and progressive psychological approach to chronic pain management. Some researchers suggest that psychological flexibility and inflexibility represent distinct processes and constructs. This meta-analysis is the first to provide a summary estimate of the overall effect size for the relationship between psychological (in)flexibility and common outcomes among chronic pain patients. The research protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, https://www.crd.york.ac.uk/PROSPERO/), registration number CRD42021285705. Four databases were searched (PsycINFO; PubMed; Web of Science, CINAHL) along with reference lists. Thirty-six cross-sectional studies were included (7,779 participants). Meta-analyses (random effects model) indicated a significant medium negative association between psychological flexibility and pain intensity or functional impairment. The present study also indicated a significant small to medium association between psychological inflexibility and pain intensity, a nearly large association between psychological inflexibility and functional impairment as well as the quality of life, and a large association between psychological inflexibility and anxiety/depression. Due to the limited number of included studies, the relationship between risk behavior and psychological inflexibility may not be significant. Types of countries and instruments measuring psychological inflexibility may explain part of the heterogeneity. These findings may carry significant implications for chronic pain patients regarding the potential relationship between psychological inflexibility or flexibility and these outcomes. It may consequently form the basis for more robust testing of causal and manipulable relationships.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021285705.

Evaluation of emotion-centric psychological interventions for chronic pain: protocol for a systematic review and meta-analysis

INTRODUCTION

Chronic pain, defined as pain persisting longer than 3 months, is more than an unpleasant sensory experience. Persistent negative emotions and emotional comorbidities, such as depression and anxiety, plague people with chronic pain leading to worsening pain intensity and increasing disability. While cognitive-behavioural therapy (CBT) is the gold standard psychological treatment, recent evidence highlights that CBT lacks efficacy for the physical and emotional aspects of chronic pain. Increasingly, researchers are investigating emotion-centric psychological therapies. While treatment modalities vary, these interventions frequently target understanding emotions, and train individuals for an emotionally adaptive response. The aim of this systematic review and meta-analysis is to quantify the efficacy of emotion-centric interventions for the physical and emotional characteristics of chronic pain.

METHODS/ANALYSIS

Electronic databases (EMBASE, PubMed, PsychINFO, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science) will be systematically searched from inception to 28 April 2022 for randomised controlled trials. Studies that compare an emotion-centric intervention with another form of treatment or placebo/control for adults (≥18 years old) with chronic pain will be included. All treatment modes (eg, online or in-person), any duration and group-based or individual treatments will be included. Studies that do not investigate at least one emotion-centric treatment will be excluded. The primary outcome is pain intensity. Secondary outcomes include emotion dysregulation, depression, anxiety, affect, safety and intervention compliance. A quantitative synthesis using a random effects meta-analysis will be adopted. Risk of bias will be evaluated using Cochrane Risk of Bias V.2.0 with the certainty of evidence assessed according to Recommendation, Assessment, Development and Evaluation. Data permitting, subgroup analysis will be conducted for intervention type and pain condition.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. Results may inform an efficacy study examining a new emotion-centric intervention for chronic pain. Dissemination will be through peer-reviewed publications and in conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021266815.

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.

Measuring 'self': preliminary validation of a short form of the Self Experiences Questionnaire in people with chronic pain

BACKGROUND

People with chronic pain often struggle with their sense of self and this can adversely impact their functioning and well-being. Acceptance and Commitment Therapy particularly includes a process related to this struggle with self. A measure for this process, the Self Experiences Questionnaire (SEQ), was previously developed in people with chronic pain.

PURPOSE

The aim of the current study was to validate a shorter version of the SEQ in people with chronic pain to reduce respondent burden and facilitate further research.

METHODS

Data from 477 participants attending an interdisciplinary pain management programme were included. Participants completed measures of treatment processes (self-as-context, pain acceptance, cognitive fusion and committed action) and outcomes (pain, pain interference, work and social adjustment and depression) at baseline and post-treatment. Confirmatory factor analysis was used for item reduction. Correlations between scores from the shorter SEQ and other process and outcome variables were calculated to examine validity. Change scores of the shorter SEQ and their correlations with changes in outcome variables were examined for responsiveness.

RESULTS

An eight-item SEQ (SEQ-8) scale including two factors, namely Self-as-Distinction and Self-as-Observer, emerged, demonstrating good reliability (Cronbach's α = .87-.90) and validity (|r| = .14-.52). Scores from SEQ-8 significantly improved after the treatment (d = .15-21), and these improvements correlated with improvements in most outcomes.

CONCLUSIONS

The SEQ-8 appears to be a reliable and valid measure of self. This shorter format may facilitate intensive longitudinal investigation into sense of self and functioning and well-being.

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.

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.

Acceptance and commitment therapy for people with rheumatic disease: Existing evidence and future directions

INTRODUCTION

Despite advances in the management of rheumatic diseases, many patients experience persistent pain and fatigue. Psychological interventions are useful adjunctive treatments, but improvements tend to be small, and progress in this area is needed. The aim of this review was to evaluate the effectiveness of acceptance and commitment therapy (ACT) for the treatment of chronic pain and fatigue in patients with rheumatic disease.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE, and PsycINFO for randomised controlled trials (RCTs) of ACT for the treatment of chronic pain and fatigue in patients with rheumatic disease. Ten RCTs that included people with rheumatic disease were identified, rated for risk of bias, and summarised in terms of effects on relevant outcomes (disability, emotional functioning, pain, and quality of life).

RESULTS

Treatment with ACT was associated with improvements in physical and emotional functioning, pain, and quality of life in chronic pain patients. The favourable effects of ACT were evident when compared with those of treatment as usual or active control conditions (e.g., pain education and novel medication). There was consistent evidence to show that ACT is beneficial in improving physical and emotional functioning in patients with fibromyalgia but a lack of evidence pertaining to patients with other forms of rheumatic disease.

CONCLUSION

ACT provides benefit for fibromyalgia patients. Further high-quality research is needed to develop ACT interventions for people with inflammatory rheumatic diseases and to evaluate their effectiveness for managing the pain and fatigue associated with these conditions.

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

BACKGROUND

Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012.

OBJECTIVES

To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU).

SEARCH METHODS

We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials.

SELECTION CRITERIA

RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end.

DATA COLLECTION AND ANALYSIS

Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment.

MAIN RESULTS

We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned.

AUTHORS' CONCLUSIONS

We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.

Patients' experiences of internet-based Acceptance and commitment therapy for chronic pain: a qualitative study

Background

Chronic pain is a globally widespread condition with complex clusters of symptoms within a heterogeneous patient group. Internet-delivered Acceptance and Commitment Therapy (IACT) has shown promising results in the treatment of chronic pain. How IACT is experienced by patients is less well known. Qualitative studies of patients’ experiences are needed to further understand factors behind both engagement and negative effects. The aim of this study was to explore how IACT was experienced by chronic pain patients who had participated in a controlled trial.

Methods

Through an open and exploratory approach this study aimed to investigate how IACT was experienced when delivered as a guided self-help program to persons with chronic pain. Eleven participants were interviewed over telephone after completing IACT.

Results

Qualitative analysis based on grounded theory resulted in 2 core categories and 8 subcategories. In treatment: Physical and cognitive restraints, Time and deadline, Therapist contact, and Self-confrontation. After treatment: Attitude to pain, Image of pain, Control or Command, and Acting with pain. Individual differences as well as specific conditions of the treatment may explain variations in how the treatment was approached, experienced and what consequences it led to. Therapist guidance and deadlines for homework play complex roles in relation to autonomy and change.

Conclusions

Adjusting treatment content and format based on participants’ characteristics, such as expectations, motivation and restraints, might positively affect engagement, autonomy and change. Further research on attrition and negative effects of treatment might clarify what enables chronic pain patients to benefit from IACT.

Trial registration

clinicaltrials.gov (NCT01603797). Registered 22 May 2012. Retrospectively registered.

Support for the Spanish version of the CPAQ-8 as a measure of chronic pain acceptance

AIM AND OBJECTIVE

To provide evidence regarding the psychometric properties of the Spanish eight-item version of the Chronic Pain Acceptance Questionnaire (CPAQ-8).

METHOD

Three hundred adults with chronic pain completed measures of pain acceptance, committed action, fear of movement, anxiety, depression, and health-related quality of life. A confirmatory factor analysis (CFA) of the CPAQ-8 was performed. Reliability and validity were also evaluated.

RESULTS

The CFA confirmed a two-factor structure. The CPAQ-8 Total and subscale scores showed acceptable-to-good internal consistency. Furthermore, the Total and the Activity Engagement scale scores showed moderate associations with Committed Action scores, supporting construct validity. Both the Total and the two subscale scores showed good criterion validity.

CONCLUSION

The findings provide further support for the reliability and validity of the Spanish version of the CPAQ-8 Total and subscale scores.