Physical Therapy Informed by Acceptance and Commitment Therapy (PACT) Versus Usual Care Physical Therapy for Adults With Chronic Low Back Pain: A Randomized Controlled Trial

Effect of Personalized Nutrition Combined with Acceptance and Commitment Therapy on Psychological Resilience, Quality of Life and Side Effects of Chemotherapy in Patients with Advanced Gastric Cancer

Aims/Background Gastric cancer is a common and life-threatening cancer, which predisposes patients to certain psychological problems. Implementation of both personalized nutrition and acceptance and commitment therapy (ACT) have shown unique advantages in the treatment of cancer patients. This study aims to evaluate the effects of this comprehensive therapy on psychological resilience, quality of life and side effects of chemotherapy in patients with advanced gastric cancer (AGC), yielding findings that can inform the development of holistic and effective treatment methods. Methods The clinical data of 240 AGC patients who underwent chemotherapy in the Fourth Hospital of Hebei Medical University from February 2021 to February 2023 were retrospectively analyzed. After excluding 15 patients who did not meet the inclusion criteria, 225 patients were included in the study. According to the management methods, the patients were divided into three groups: group A receiving routine management (n = 76), group B receiving routine management plus personalized nutrition (n = 75), and group C receiving routine management, personalized nutrition and ACT (n = 74). The psychological resilience, quality of life and side effects of chemotherapy were evaluated in the three groups. Results There was no difference in the Connor-Davidson resilience scale (CD-RISC) scores and quality of life questionnaire-core 30 (QLQ-C30) scores among the three groups at admission (p > 0.05). After chemotherapy, compared with the group C, the CD-RISC scores of group A and group B were significantly lower (p < 0.001), and the scores of physical function, cancer-related symptoms and overall health in group A and group B were significantly lower (p < 0.001). The incidence of side effects of chemotherapy in group C was 25.68%, which was significantly lower than that in group A and group B (p < 0.05); there was no statistical difference in this regard between group A and group B (p > 0.05), and the same parameter was significantly different between group A and group C (p < 0.05). Conclusion Personalized nutrition management plus ACT has a significant favorable effect on improving psychological resilience, alleviating the side effects of chemotherapy, and enhancing the quality of life in patients with AGC undergoing chemotherapy.

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.

Cognitive behavioural interventions led by a physiotherapist in chronic non-specific low back pain: A systematic review and meta-analysis

BACKGROUND

The effectiveness of physiotherapist-led Cognitive Behavioural Interventions (CBI) with or without physiotherapy is still unclear.

OBJECTIVE

This systematic review (PROSPERO registration number CRD42022321073) aims to determine the effectiveness of physiotherapist-led CBI with or without physiotherapy in comparison to physiotherapy alone on quality of life, disabilities and catastrophization.

METHODS

MEDLINE, Web of Science, Science Direct, and PEDro were searched for randomized controlled trials that investigate the use of CBI versus conventional physiotherapy in chronic NSLBP. To be included CBI had to be performed by a physiotherapist. The primary and secondary outcomes were respectively quality of life and disability.

RESULTS

Fourteen studies were included in qualitative analysis, in which 4 did not meet the PEDro score of 6 or higher. Pooled standardized mean differences from 3 studies showed no difference in quality of life between groups for mental and physical sub-scores at 3 months (SMD 0.02, 95% CI -0.17 to 0.21 and SMD 0.07, 95% CI -0.12 to 0.26 respectively). Pooled standardized mean differences from 9 studies showed no difference in disability between groups at 3, 6 and 12 months (SMD = - 0.40, CI 95% -0.80 to 0.01; SMD -0.18, CI 95% = -0.41 to 0.05; and SMD -0.24, CI 95% = -0.48 to 0.00 respectively).

CONCLUSION

Results of CBI, especially cognitive functional therapy, seem promising in disability management despite a substantial heterogeneity. Furthermore, we found no difference in quality of life.

Cognitive Functional Therapy compared with usual physiotherapy care in people with persistent low back pain: a mixed methods feasibility randomised controlled trial in the United Kingdom National Health Service

OBJECTIVES

To determine the feasibility of completing a definitive randomised controlled trial (RCT), evaluating the clinical and cost-effectiveness of Cognitive Functional Therapy (CFT) in comparison to usual physiotherapy care (UPC), for people with persistent low back pain (LBP).

DESIGN AND SETTING

A two-arm parallel feasibility RCT completed in a United Kingdom (UK) Secondary Care National Health Service (NHS) physiotherapy service.

PARTICIPANTS

Sixty adult participants who reported LBP lasting for more than three months, that was not attributable to a serious (e.g. cancer) or specific (e.g. radiculopathy) underlying cause, were invited to participate. Participants were allocated at random to receive CFT or UPC.

INTERVENTIONS

Cognitive Functional Therapy and Usual Physiotherapy Care for persistent LBP.

MAIN OUTCOME MEASURES

The primary outcome was the feasibility of completing a definitive RCT, defined by recruitment of at least 5 participants per month, delivery of CFT per protocol and securing relevant and acceptable outcome measures. Data concerning study processes, resources, management and participant reported outcome measures were collected at baseline, 3, 6 and 12-month follow-up.

RESULTS

Sixty participants (n = 30 CFT and n = 30 UPC) were recruited with 80% (n = 48), 72% (n = 43) and 53% (n = 32) retained at 3, 6 and 12-month follow-up respectively. NHS physiotherapists were trained to competence and delivered CFT with fidelity. CFT was tolerated by participants with no adverse events. Relevant and clinically important outcome data were collected at all time points (0.4%, 3%, 1% and 0.8% of data was missing from the returned outcome measure booklets at baseline and 3, 6 and 12-month follow-up respectively). The Roland-Morris disability questionnaire was considered the most suitable primary outcome measure with a proposed sample size of 540 participants for a definitive cluster RCT.

CONCLUSION

It is feasible to conduct a randomised study of CFT in comparison to UPC for NHS patients. A future study should incorporate an internal pilot to address aspects of feasibility further, including participant retention strategies.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN12965286 CONTRIBUTION OF THE PAPER.

Qualitative study exploring the views of patients and healthcare providers on current rehabilitation practices after lumbar fusion surgery

OBJECTIVES

To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway.

DESIGN

A cross-sectional, qualitative study with an interpretive descriptive design.

SETTING

Academic and non-academic hospital setting in Belgium.

PARTICIPANTS

31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed.

RESULTS

Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS.

CONCLUSIONS

This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness.

TRIAL REGISTRATION NUMBER

This study was registered at clinicaltrials.gov (NCT03427294).

Individual's experiences of adjusting to changes in body image after spinal cord injury: a literature review and thematic synthesis

PURPOSE

To understand how individuals experience and adjust to changes in body image after spinal cord injury (SCI).

METHODS

A systematic search using four databases identified eleven articles that met the inclusion criteria. The studies were critically appraised to determine quality. Interpretative thematic synthesis was used to explore adults' experiences of adjusting to changes in body image after SCI.

RESULTS

Three themes described the influence of sociocultural factors on body image: 'Sociocultural influences', 'Responses of others' and 'Experience of rehabilitation'. Six themes described individuals' experiences of body image. 'Loss and threat of difference', 'Discomfort and disconnection' and 'Resistance' negatively influenced body image. 'Reconnecting with the body and re-negotiating identity', 'Support network' and 'Challenging beliefs about disability' promoted positive body image. Adjustment was a dynamic process, influenced by interactions between individual, relational and sociocultural factors.

CONCLUSIONS

The physical impacts of SCI, individual's perceptions, relationships and sociocultural discourses influenced body image. Rehabilitation professionals could support adjustment to changes in body image by considering individual, relational and systemic influences. Furthermore, it is important to include an individual's support network within their care as social factors influenced body image experiences. Peer support could promote hope and challenge negative sociocultural beliefs about disability.

Comparative efficacy of acupuncture, venesection, and physical therapy on chronic low back pain outcomes: a randomized clinical trial

Objective

Chronic low back pain (CLBP) imposes considerable financial and social burden with poor response to medical and surgical treatments. Alternatively, acupuncture and venesection(Fasd) are traditionally used to alleviate nociceptive and musculoskeletal pains. This study aimed to evaluate the effectiveness and the safety of acupuncture and venesection on CLBP and patient functionality.

Methods

The current study was a single-blinded, randomized clinical trial with balanced allocation, conducted in the Department of Physical Medicine & Rehabilitation Medicine, in 2022. One hundred five CLBP patients who had no back pain-attributable structural or major diseases were randomly allocated into three parallel arms and received either physical therapy (PTG), acupuncture (APG), or venesection (VSG). Pain severity and functional aspects were evaluated using the visual analogue scale (VAS) and Oswestry disability index (ODI) during the study. VAS and ODI scores were defined as the primary outcomes.

Results

Ninety-five patients were reviewed in the final analysis (PTG=33, APG=30, VSG=31). Demographic data showed equal group distribution. Statistical analysis showed all procedures had reduced VAS score immediately after the first session, after the last session, and after follow-up; however, APG and VSG values were significantly lower (P<0.05). Pain reduction results in follow-up period were more sustainable in APG and VSG as compared to PTG (P<0.01). ODI results revealed global improvement after the last session of the treatment in all groups, while APG had more significant results (P<0.05). During the follow-up period, ODI still tended to decrease in VSG, non-significantly increased in APG, and significantly increased in PTG. Only two patients reported fainting after receiving venesection.

Conclusion

Considering the pain and functional scores, both acupuncture and venesection can reproduce reliable results. Acupuncture and venesection both have sustained effects on pain and daily function of the patients even after treatment termination, while physical therapy had more relapse in pain and functional limitations.

A Single-Session Process-Based Cognitive-Behavioral Intervention Combined with Multimodal Rehabilitation Treatment for Chronic Pain Associated with Emotional Disorders

BACKGROUND AND OBJECTIVES

Defined by chronic pain, rheumatic diseases are often co-occurring with anxiety and depression. Among the available psychological interventions, cognitive-behavioral therapies have an already-proven efficiency in these cases. However, the need to adjust their structure became ubiquitous during the post-pandemic period. Hence, the objective of this study was to investigate the impact of a single-session, process-based cognitive-behavioral intervention for patients with rheumatic conditions within an in-patient setting.

MATERIALS AND METHODS

A total of 31 participants (mean age 58.9 years) completed the single-session intervention. Assessments were conducted prior to the intervention, post-intervention and after one month.

RESULTS

Pearson's correlations, paired samples T tests and a covariance analysis based on the Linear Mixed Model were performed for exploring the relations between baseline variables and evaluating the impact of the SSI intervention. Immediately after the intervention, a significant reduction in cognitive fusion (p = 0.001, d = 1.78), experiential avoidance (p = 0.001, d = 1.4) and dysfunctional behavioral processes was observed. At the one-month evaluation, participants reported decreased pain (p = 0.001, d = 1.11), anxiety (p = 0.004, d = 0.55) and depression (p = 0.001, d = 0.72).

CONCLUSIONS

The single-session, process-based approach represents a promising intervention in healthcare contexts, as an integrative part of a multimodal rehabilitation treatment in patients with rheumatic conditions.

Understanding the Role of Therapist Quality in Accounting for Heterogeneity of Patient Outcomes in Psychosocial Chronic Pain Treatments

A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.

Acceptance and Commitment Therapy for Chronic Pain: An Overview of Systematic Reviews with Meta-Analysis of Randomized Clinical Trials

This overview of reviews aimed to summarize the evidence from systematic reviews and meta-analyses of randomized clinical trials of the efficacy of acceptance and commitment therapy (ACT) for adults with chronic pain in relation to pain intensity, pain-related functioning, quality of life, and psychological factors. The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, PubMed, and the Cochrane Library databases were searched from inception to July 2, 2023. AMSTAR 2 was used to assess the methodological quality of systematic reviews. The overlap among reviews was calculated. Nine reviews comprising 84 meta-analyses of interest were included. At post-treatment, some meta-analyses mainly showed that ACT can reduce depression symptoms, anxiety symptoms, psychological inflexibility, and pain catastrophizing; and can improve mindfulness, pain acceptance, and psychological flexibility. At three-month follow-up, ACT can reduce depression symptoms and psychological inflexibility, as well as improve pain-related functioning and psychological flexibility. At six-month follow-up, ACT can improve mindfulness, pain-related functioning, pain acceptance, psychological flexibility, and quality of life. At six-twelve-month follow-up, ACT can reduce pain catastrophizing and can improve pain-related functioning. Some methodological and clinical issues are identified in the reviews, such as a very high overlap between systematic reviews, the fact that the certainty of the evidence is often not rated and specific details needed to replicate the interventions reviewed are often not reported. Overall, however, randomized clinical trials and systematic reviews show that ACT can improve outcomes related to chronic pain (eg, pain-related functioning). Future systematic reviews should address the methodological and clinical concerns identified here to produce higher-quality findings. PERSPECTIVE: Despite certain methodological and clinical issues, randomized clinical trials and systematic reviews of ACT appear to show that it can improve outcomes related to chronic pain (eg, psychological factors).

First trans-diagnostic experiences with a novel micro-choice based concentrated group rehabilitation for patients with low back pain, long COVID, and type 2 diabetes: a pilot study

BACKGROUND

The health care is likely to break down unless we are able to increase the level of functioning for the growing number of patients with complex, chronic illnesses. Hence, novel high-capacity and cost-effective treatments with trans-diagnostic effects are warranted. In accordance with the protocol paper, we aimed to examine the acceptability, satisfaction, and effectiveness of an interdisciplinary micro-choice based concentrated group rehabilitation for patients with chronic low back pain, long COVID, and type 2 diabetes.

METHODS

Patients with low back pain > 4 months sick-leave, long COVID, or type 2 diabetes were included in this clinical trial with pre-post design and 3-month follow-up. The treatment consisted of three phases: (1) preparing for change, (2) the concentrated intervention for 3-4 days, and (3) integrating change into everyday life. Patients were taught and practiced how to monitor and target seemingly insignificant everyday micro-choices, in order to break the patterns where symptoms or habits contributed to decreased levels of functioning or increased health problems. The treatment was delivered to groups (max 10 people) with similar illnesses. Client Satisfaction Questionnaire (CSQ-8)) (1 week), Work and Social Adjustment Scale (WSAS), Brief Illness Perception Questionnaire (BIPQ), and self-rated health status (EQ-5D-5L) were registered at baseline and 3-month follow-up.

RESULTS

Of the 241 included participants (57% women, mean age 48 years, range 19-84), 99% completed the concentrated treatment. Treatment satisfaction was high with a 28.9 (3.2) mean CSQ-8-score. WSAS improved significantly from baseline to follow-up across diagnoses 20.59 (0.56) to 15.76 (0.56). BIPQ improved from: 22.30 (0.43) to 14.88 (0.47) and EQ-5D-5L: 0.715 (0.01) to 0.779 (0.01)), all P<0.001.

CONCLUSIONS

Across disorders, the novel approach was associated with high acceptability and clinically important improvements in functional levels, illness perception, and health status. As the concentrated micro-choice based treatment format might have the potential to change the way we deliver rehabilitation across diagnoses, we suggest to proceed with a controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05234281.

The relationship between changes in pain intensity and functional disability in persistent disabling low back pain during a course of cognitive functional therapy

OBJECTIVES

Pain relief and reduced disability are both common treatment targets for persistent disabling low back pain (LBP). Cross-sectional studies show a moderate relationship between functional disability and pain intensity, but little is known about the relationship between changes in pain intensity and functional disability over multiple time points. The objective of this study was to investigate the associations between changes in functional disability and pain intensity and whether changes occurred simultaneously or differentially during a course of cognitive functional therapy for people with persistent disabling LBP.

METHODS

Self-reported measures of pain intensity and patient-specific functional disability were collected prior to each treatment session from 40 participants during a 12-week intervention period. Linear mixed modeling was used to assess simultaneous and lagged associations between pain intensity and functional disability over time. Sensitivity analysis using nonparametric subject-specific methods (simulation modeling analysis) was also performed.

RESULTS

Thirty-five participants had sufficient data for analysis. Using the linear mixed-model approach, there was evidence of a moderate and simultaneous association between pain intensity and functional disability over time (regression coefficient = 0.56, 95% confidence interval: 0.44-0.68, p < 0.001). Simulation modeling analysis supported weak to mostly strong associations and supported for simultaneous change in pain and disability for the majority of participants (22 of 35, 64%).

CONCLUSION

Changes in pain intensity and functional disability were moderately related across the intervention. Visual inspection of graphs indicated a very close relationship in some individuals and a decoupling of pain intensity and functional disability in others. The changes in pain intensity and functional disability seem to occur simultaneously in most individuals.

"Learning by osmosis": the transformative social identity journey of physiotherapists developing psychologically-informed practice, a reflexive thematic analysis

BACKGROUND

Despite efforts to support physiotherapists in integrating psychosocial aspects of care to biological ones, clinical practice remains dominated by biomechanistic priorities. To facilitate change, attention and actions need to consider not only the individual level of the therapists but also the cultural and structural levels of the profession. How these multi-layered social dynamics shape practice have not previously been investigated. The Social Identity Approach (SIA) provides a relevant framework to this exploration.

AIM

This study aimed to identify the social identity processes involved in the development of psychologically-informed physiotherapy (PIP) to understand how they may influence practice change.

METHODS

Nine semi-structured interviews were conducted with self-identified psychologically-informed physiotherapists. A Reflexive Thematic Analysis informed by SIA principles enabled to consider meaning as the product of social processes.

FINDINGS

The analysis of participants' experiences in moving from a primarily biomechanistic practice toward the integration of psychosocial aspects of health demonstrated: 1) a transformative "mind-blowing" identity journey; 2) a journey that is not made in isolation; and 3) where leadership matters.

CONCLUSION

Changes in clinical practice involve dynamics at the collective level of the practice environment and of the physiotherapy profession itself, rather than solely at the individual level of clinicians. An understanding of these complex social processes at a managerial level could be important to better support leaders and clinicians in implementing PIP in clinical practice.

Healthcare-related factors influencing symptom persistence, deterioration, or improvement in patients with persistent somatic symptoms: A scoping review of European studies

OBJECTIVE

This scoping review explored healthcare-related factors associated with symptom persistence, deterioration, or improvement in patients with persistent somatic symptoms (PSS) across Europe.

METHODS

Articles were systematically searched in PubMed, Web of Science, Cochrane Library, and PsycINFO by combining terms of PSS and healthcare-related factors. Studies published in English, German, Polish, or Dutch between 2000 and 2022 were included. Healthcare-related factors associated with PSS symptom course were investigated, and study quality assessed (Center for Evidence-Based Medicine Checklist, Newcastle-Ottawa Scale).

RESULTS

Of 8386 identified studies, 56 were included in the analysis. A significant knowledge gap was evident, as most studies lacked comprehensive healthcare descriptions with particularly unclear definitions of "treatments as usual" in RCTs. The only extractable healthcare factor according to Andersen's Behavioral Model was the treatment setting. Rates of PSS improvement split by care-levels were 38% in primary, 44% in secondary, 25% in mixed, and 71% in specialized care. Persistence rates were 57%, 50%, 75%, and 29% respectively. Deterioration was observed in 5% of primary and 6% of secondary care studies. Studies were skewed toward the United Kingdom, Germany, and the Netherlands.

CONCLUSIONS

This scoping review shed light on the association between care levels and symptom outcomes in PSS patients. However, limited information in the current studies constrained our exploration of associations with other factors and symptom outcomes. Important aspects, like care availability, referral processes, and insurance coverage, are yet to be elucidated. Addressing these gaps is pivotal for developing targeted treatments across Europe, ultimately enhancing PSS patients' outcomes.

Effects of different intervention methods on psychological flexibility, negative emotions and sleep quality in chronic hepatitis B

BACKGROUND

Patients with chronic hepatitis B (CHB) experience various problems, including low psychological flexibility, negative emotions, and poor sleep quality. Therefore, effective nursing interventions are required to reduce adverse events. Acceptance and commitment therapy (ACT) combined with enabling cognitive-behavioral education (ECBE) can improve patients' psychological and sleep. Therefore, we speculate that this may also be effective in patients with CHB.

AIM

To investigate the effects of different intervention methods on psychological flexibility, negative emotions, and sleep quality in patients with CHB.

METHODS

This retrospective study examined clinical and evaluation data of 129 patients with CHB. Intervention methods were divided into a conventional group (routine nursing, n = 69) and a combination group (ACT combined with ECBE, n = 60). We observed changes in psychological flexibility, negative emotions, sleep quality, and self-care ability in both groups. Observation items were evaluated using the Acceptance and Action Questionnaire-2nd Edition (AAQ-II), Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Pittsburgh Sleep Quality Index (PSQI), and Exercise of Self-Care Agency Scale (ESCA).

RESULTS

Compared with the conventional group, the AAQ-II score of the combined group was lower (Fbetween-group effect = 8.548; Ftime effects = 25.020; Finteraction effects = 52.930; all P < 0.001), the SAS score (t = 5.445) and SDS score (t = 7.076) were lower (all P < 0.001), as were the PSQI dimensions (tsleep quality = 4.581, tfall sleep time = 2.826, tsleep time = 2.436, tsleep efficiency = 5.787, tsleep disorder = 5.008, thypnotic drugs = 3.786, tdaytime dysfunction = 4.812); all P < 0.05). The ESCA scores for all dimensions were higher (thealth knowledge level = 6.994, tself-concept = 5.902, tself-responsibility = 19.820, tself-care skills = 8.470; all P < 0.001).

CONCLUSION

ACT combined with ECBE in patients with CHB can improve psychological flexibility and sleep quality, alleviate negative emotions, and improve self-care.

[Remote management of musculoskeletal pain : A pragmatic approach to the implementation of video and phone consultations in musculoskeletal practice. German version]

INTRODUCTION

Remote consultations through phone or video are gaining in importance for the treatment of musculoskeletal pain across a range of health care providers. However, there is a plethora of technical options for practitioners to choose from, and there are various challenges in the adaptation of clinical processes as well as several special considerations regarding regulatory context and patient management. Practitioners are faced with a lack of high-quality peer-reviewed resources to guide the planning and practical implementation of remote consultations.

OBJECTIVES

This Clinical Update seeks to provide practical guidance for the planning and implementation of remote consultations for the management and treatment of people with musculoskeletal pain.

METHODS

Recommendations are based on a brief overview of the relevant research regarding phone and video consultations for musculoskeletal practice and derived from the literature, relevant guidelines, and practical experience.

RESULTS

The technical feasibility of remote consultations for musculoskeletal complaints is good, patient satisfaction is high, and a growing body of evidence supports its comparative effectiveness to in-person consultations in some circumstances for improving pain and functioning. We consider in detail practical aspects such as the choosing of hardware and software, we touch on the legal and regulatory context, and we focus on the adaptation of clinical processes and communication.

CONCLUSION

This Clinical Update draws together best-practice evidence in a practically applicable format, enabling therapists who are working with people with pain to directly apply this knowledge to their individual clinical settings and the requirements of their patients.

The effectiveness of cognitive behavioural therapy in chronic neck pain: A systematic review with meta-analysis

We evaluated the effects of Cognitive Behavioural Therapy (CBT) alone or with additional interventions on pain, disability, kinesiophobia, anxiety, stress, depression, quality of life, and catastrophizing of patients with chronic neck pain (CNP). Nineteen studies met the inclusion criteria, and fourteen studies were quantitatively analysed. Risk of bias was assessed using the PEDro scale and the certainty of evidence using the GRADE approach. Studies were pooled (where applicable) and subgroup analyses were performed for CNP, or whiplash associated disorders. Studies compared-directly or indirectly-CBT interventions to no treatment, conservative interventions such as exercise and/or physiotherapy, or multimodal interventions. We present effect estimates at 8-week, 12-week, 6-month, and 1-year follow-up. Low certainty evidence suggests a clinically significant pain reduction (short-term) favouring CBT with or without additional intervention compared to no intervention SMD = -0.73; 95%CI: -1.23 to -0.23). Very low and low certainty evidence suggest clinically significant improvements in kinesiophobia (very short-term SMD = -0.83; 95%CI: -1.28 to -0.39 and short-term SMD = -1.30, 95%CI: -1.60 to -0.99), depression SMD = -0.74, 95%CI: -1.35 to -0.14) and anxiety SMD = -0.76, 95%CI: -1.34 to -0.18) favouring a multimodal intervention with CBT (short-term) compared to other conservative interventions. Combining different types of CBT interventions resulted in potentially heterogeneous comparisons.

Protocol for a Parallel Group Randomized Clinical Trial Comparing a Culturally Adapted Cognitive Behavioral Telerehabilitation Intervention to Usual Physical Therapy for Latino Patients With Chronic Spine Pain

OBJECTIVE

Disparities exist in health care access, diagnosis, and treatment of chronic pain in Latino populations and other minority populations. Cognitive behavioral-based physical therapy (CBPT) interventions have been shown to be effective in predominantly non-Hispanic white populations with chronic spine pain. However, there is a need for culturally adapted CBPT interventions that focus on the conservative management of chronic spine pain. The primary purpose of the study described in this protocol is to test the efficacy of an adapted cognitive behavioral-based hybrid telerehabilitation intervention for Latino patients with chronic spine pain.

METHODS

A single-blind, 2-arm parallel group, superiority randomized clinical trial is planned to compare an adapted CBPT intervention to Usual Care physical therapy. Goal Oriented Activity for Latinos with chronic Spine pain (GOALS/Metas) is an 8-week hybrid telerehabilitation intervention that integrates guideline-based physical therapy and pain management interventions using cognitive behavioral approaches and has been adapted for Latino patients with chronic spine pain. Usual Care physical therapy will be administered based on institutional standards at the referring health center. Outcome measures will be evaluated preintervention and at 1-week, 3-months, and 6-months postintervention. The primary outcome is pain-related disability 1-week postintervention using the Brief Pain Inventory Pain Interference subscale. Secondary outcome measures include behavioral measures of functional activity, social participation, physical activity, and sleep. Determinants of treatment effect, including pain-related psychological measures, posture and movement, self-efficacy, treatment expectancy, and therapeutic alliance, will be included in the secondary moderation and mediation analyses.

IMPACT

This clinical trial will provide information on the extent to which an adapted CBPT hybrid telerehabilitation intervention is effective in reducing pain-related disability for Latino patients with chronic spine pain. This information will be useful for clinicians to integrate in their practice, given the growing population of Latino patients who experience disparities in health care management of chronic pain.

A randomised controlled trial of acceptance and commitment therapy for improving quality of life in people with muscle diseases

Abstract.

BACKGROUND

Chronic muscle diseases (MD) are progressive and cause wasting and weakness in muscles and are associated with reduced quality of life (QoL). The ACTMuS trial examined whether Acceptance and Commitment Therapy (ACT) as an adjunct to usual care improved QoL for such patients as compared to usual care alone.

METHODS

This two-arm, randomised, multicentre, parallel design recruited 155 patients with MD (Hospital and Depression Scale ⩾ 8 for depression or ⩾ 8 for anxiety and Montreal Cognitive Assessment ⩾ 21/30). Participants were randomised, using random block sizes, to one of two groups: standard medical care (SMC) (n = 78) or to ACT in addition to SMC (n = 77), and were followed up to 9 weeks. The primary outcome was QoL, assessed by the Individualised Neuromuscular Quality of Life Questionnaire (INQoL), the average of five subscales, at 9-weeks. Trial registration was NCT02810028.

RESULTS

138 people (89.0%) were followed up at 9-weeks. At all three time points, the adjusted group difference favoured the intervention group and was significant with moderate to large effect sizes. Secondary outcomes (mood, functional impairment, aspects of psychological flexibility) also showed significant differences between groups at week 9.

CONCLUSIONS

ACT in addition to usual care was effective in improving QoL and other psychological and social outcomes in patients with MD. A 6 month follow up will determine the extent to which gains are maintained.

Digital Therapeutics (DTx) Expand Multimodal Treatment Options for Chronic Low Back Pain: The Nexus of Precision Medicine, Patient Education, and Public Health

Digital therapeutics (DTx, software as a medical device) provide personalized treatments for chronic diseases and expand precision medicine beyond pharmacogenomics-based pharmacotherapies. In this perspective article, we describe how DTx for chronic low back pain (CLBP) can be integrated with pharmaceutical drugs (e.g., NSAIDs, opioids), physical therapy (PT), cognitive behavioral therapy (CBT), and patient empowerment. An example of an FDA-authorized DTx for CLBP is RelieVRx, a prescription virtual reality (VR) app that reduces pain severity as an adjunct treatment for moderate to severe low back pain. RelieVRx is an immersive VR system that delivers at-home pain management modalities, including relaxation, self-awareness, pain distraction, guided breathing, and patient education. The mechanism of action of DTx is aligned with recommendations from the American College of Physicians to use non-pharmacological modalities as the first-line therapy for CLBP. Herein, we discuss how DTx can provide multimodal therapy options integrating conventional treatments with exposome-responsive, just-in-time adaptive interventions (JITAI). Given the flexibility of software-based therapies to accommodate diverse digital content, we also suggest that music-induced analgesia can increase the clinical effectiveness of digital interventions for chronic pain. DTx offers opportunities to simultaneously address the chronic pain crisis and opioid epidemic while supporting patients and healthcare providers to improve therapy outcomes.

The effectiveness of low-dosed outpatient biopsychosocial interventions compared to active physical interventions on pain and disability in adults with nonspecific chronic low back pain: A systematic review with meta-analysis

OBJECTIVE

To evaluate the effectiveness of low-dosed outpatient biopsychosocial interventions versus active physical interventions on pain intensity and disability in adults with nonspecific chronic low back pain.

INTRODUCTION

Research has shown that primary care biopsychosocial interventions (PCBI) can reduce pain intensity and disability. While scattered studies support low-dosed (≤ 15 treatment hours) PCBI, no systematic review exists comparing the effectiveness of low-dosed PCBI treatment with traditional physical activity interventions in adults with nonspecific chronic low back pain (CLBP).

INCLUSION CRITERIA

Randomized controlled trials that evaluate low-dosed PCBI compared to physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment for adult participants (18 years or older), who suffer from CLBP were included. Not recommended interventions that feature only passive therapies, spinal surgery or pharmacological treatment, and studies with inpatient multidisciplinary-based rehabilitation (MBR) were excluded.

METHODS

Databases were searched from inception to December 31, 2021. Language was restricted to English or German. Keywords and derivatives of "chronic back pain", "exercise intervention", "cognitive-behavioral therapy", "primary care" and "randomized controlled trials" were used. Sources were CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science. Search was finished on March 08, 2022. Data appraisal, extraction and synthesis followed JBI guidance for systematic reviews of effectiveness. Risk of Bias was assessed using JBI 13-item checklist for randomized controlled trials. The GRADE approach for grading the certainty of evidence was followed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2022 CRD42022302771.

RESULTS

Eighteen RCTs were found eligible and 15 trials comprising a total of 1531 participants suffering from CLBP were entered in the meta-analyses. Risk of Bias was low. Overall evidence was moderate. Significant effects in favor of PCBI were found for pain intensity post-treatment (standardized mean difference (SMD) = -1.09, 95% confidence interval (CI) = -1.84 to -0.34, I2  = 97%, p = 0.004) as well as at short-term (SMD = -0.23, 95% CI = -0.39 to -0.08, I2  = 0%, p = 0.004), long term (SMD = -0.79, 95% CI = -1.42 to -0.17, I2  = 96%, p = 0.01) and very long-term (SMD = -1.13, 95% CI = -1.93 to -0.33, I2  = 94%, p = 0.005) follow-up. Significant effects in favor of PCBI for physical function were found post-treatment (SMD = -1.33, 95% CI = -2.17 to -0.49, I2  = 97%, p = 0.002) at short-term (SMD = -0.20, 95% CI = -0.36 to -0.04, I2  = 0%, p = 0.01) and at long-term follow-up (SMD = -1.17, 95% CI = -2.06 to -0.28, I2  = 98%, p = 0.01). The results were characterized by high heterogeneity due to different types (cognitive behavioral therapy, pain-neuroscience education, mindfulness, and motivation), delivery modes (individual and/or group), durations (3-12 weeks) and contact times (2-15 h) of PCBI. In sensitivity analysis outliers were removed to reduce heterogeneity. The results remained significant for pain intensity at short-term (SMD = -0.23, 95% CI = -0.39 to -0.08, I2  = 0%, p = 0.004) and long-term follow-up (SMD = -0.22, 95% CI = -0.41 to -0.03, I2  = 39%, p = 0.02).

CONCLUSIONS

This meta-analysis suggests that low-dosed PCBI has favorable effects in terms of disability and pain intensity compared to active physical treatments alone. All conducted meta-analyses indicate that biopsychosocial interventions produce better outcomes than active physical treatment alone. Therefore, we strongly recommend decision makers and clinical practitioners to analyze how psychosocial elements can be introduced into outpatient (low-dosed) CLBP interventions.

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.

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.

Effect of integrated exercise therapy and psychosocial interventions on self-efficacy in patients with chronic low back pain: A systematic review

OBJECTIVE

Investigate if integrated exercise and psychosocial (EP) interventions effect self-efficacy to manage pain and self-efficacy for physical functioning compared to alternate interventions, usual care, waitlists and attention controls for individuals with chronic low back pain (CLBP).

METHODS

MEDLINE, Embase, CINAHL, Web of Science, PsychINFO, PEDro, and Cochrane Library were searched. Included randomized controlled trials utilized an EP intervention for CLBP and measured self-efficacy. Independent reviewers screened abstracts, reviewed full-texts, extracted data, and assessed risk of bias. GRADE, synthesis without meta-analysis, and ranges of effects (Hedges' g) were used.

RESULTS

2207 Participants were included (22-studies). EP interventions positively effected self-efficacy to manage pain short-term compared to usual care (range of effects: -0.02, 0.94) and controls (range of effects: 0.69, 0.80) and intermediately compared to usual care (range of effects: 0.11, 0.29); however, no differences were found when compared to alternate interventions. EP interventions positively effected self-efficacy for physical functioning short-term compared to alternate interventions (range of effects: 0.57, 0.71), usual care (range of effects: -0.15, 0.94), and controls (range of effects: 0.31, 0.56), and intermediately compared to alternate interventions (1-study, effect: 0.57) and controls (1-study, effect: 0.56). Conclusions were limited by low to very low-quality-evidence often from risk of bias, imprecision, and clinical/statistical heterogeneity.

CONCLUSIONS

EP interventions may be more effective short-term for self-efficacy to manage pain than usual care and waitlists, but not alternate interventions. EP interventions may be effective for self-efficacy for physical functioning at short- and intermediate-term compared to alternate interventions, usual care, waitlist and attention controls. Considerations for future research include methods for blinding and measurement of self-efficacy for physical functioning.

Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization

Background

While there is recognition by the greater medical community and physical therapists to address the biopsychosocial needs of people with chronic, persistent pain, there are challenges in implementation and delivery including wide variability in interventions, lack of clear rationale, and absence of clinical models that are feasible and acceptable on a large scale. Important components for psychologically informed physical therapy (PiPT) for pain care include behavioral approaches (e.g., Acceptance and Commitment Therapy), mindfulness, pain neuroscience education, motivational interviewing (MI), and interoceptive skills-building. The Empower Veterans Program (EVP) Mindful Movement framework blends these components and emphasizes a mindfulness and self-compassion approach with MI and body-based experiential learning. This program was offered in-person at the Atlanta and Maryland VA Health Care Centers with published positive Patient Reported Outcomes (PRO) pre-COVID 19 crisis and shifted to entirely remote delivery in March 2020.

Objective

This paper offers an evidence-based and theory driven framework to operationalize a remotely delivered group-based psychologically informed mindful movement physical therapy intervention as part of an interdisciplinary pain care program.

Methods

Since 2021 PRO and demographics are collected using a survey administered through Qualtrics over a 12-month period at baseline, immediately post TelePain EVP, at 6 months, and at 12 months, with findings forthcoming.

Discussion/Results

Tele-pain EVP offers 6-9 groups a week with 7-9 veterans from Atlanta based team and 3-4 groups a week with 5-9 veterans from Maryland based team. Adaptations for remote delivery optimized mindfulness and active learning strategies including interoceptive skills-building and use of MI to support self-efficacy to trust, restore a sense of safety in the body, and explore adaptations for safe movement.

Conclusion

TelePain-EVP Mindful Movement provides a framework for other programs to translate for their populations and systems to further develop best practices in PiPT for pain care and integration into interdisciplinary care.

Physical therapist-delivered acceptance and commitment therapy and exercise for older outpatients with knee osteoarthritis: a pilot randomized controlled trial

[Purpose] In this pilot study, we investigated the effectiveness of physical therapist-delivered acceptance and commitment therapy in older outpatients with knee osteoarthritis and chronic pain. [Participants and Methods] This single-center, open-label, parallel-group pilot randomized controlled trial included 30 patients assigned to the physical therapist-delivered acceptance and commitment therapy group (n=15) and the usual care physical therapy-only group (n=15). Both treatments were administered once a week for 8 weeks. Evaluation was performed 4 weeks before intervention, pre-intervention, post-intervention, and 4 weeks after intervention. The primary outcome was diagnosis of a physical disability, and secondary outcomes included psychological inflexibility, pain intensity, anxiety, depression, physical function, and objectively measured physical activity. [Results] Physical therapist-delivered acceptance and commitment therapy had a limited effect on physical disability, although we observed a favorable tendency. With regard to secondary outcomes, physical therapist-delivered acceptance and commitment therapy did not show significant effects. Notably, 15 patients withdrew from this study and 6 were diagnosed with coronavirus disease. [Conclusion] Physical therapist-delivered acceptance and commitment therapy did not appear to show significant effects in the present study. It is necessary to correct these issues in this study, and future studies are warranted to investigate the effects of this therapy.

Effect of a self-help group intervention using Teaching Recovery Techniques to improve mental health among Syrian refugees in Norway: a randomized controlled trial

Background

Mental health symptoms among refugees are common, often related to chronic pain disorders, and their management is usually challenging. Studies evaluating the effect of group therapies among adult refugees to improve mental health symptoms are scarce.

Aims

To assess the effect of Teaching Recovery Techniques (TRT) on mental health and to reduce pain disorder among adult Syrian refugees.

Method

A randomized controlled trial was designed to study the effect of a self-help group intervention using TRT. The outcomes, mental health symptoms measured by Impact of Event Scale-Revised (IES-R) and General Health Questionnaire (GHQ-12) and chronic pain measured by Brief Pain Inventory (BPI), were reported as regression coefficients (B) with 95% confidence intervals.

Results

Seventy-six adults participated: 38 in the intervention and 38 in the control groups. Intention-to-treat analyses showed a significant effect on general mental health as measured by GHQ-12 with B (95% CI) of -3.8 (-7.2, -0.4). There was no effect of TRT on mental health when assessed by IES-R (-1.3 (-8.7, 6.2)) or on pain levels assessed by BPI (-0.04 (-4.0, 3.9)).

Conclusions

This self-help group intervention significantly improved general mental health symptoms among adult refugees but had no effect on trauma symptoms or chronic pain. Higher participation rates might be necessary to achieve the full potential of TRT.

Trial registration: The trial was registered with Clinical Trials.gov at https://clinicaltrials.gov/ct2/show/NCT03951909. To include user participation in the design of the interventions, the study was retrospectively registered on 19 February 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00557-4.

Patient Experiences of Self-Management for Chronic Low Back Pain: A Qualitative Study

OBJECTIVE

Chronic low back pain (CLBP) is a lifelong condition causing disability and distress. One aim of treatment is to enhance self-management. To date, self-management interventions have had limited effectiveness. A greater understanding of self-management for CLBP has the potential to improve future interventional trials. The purpose of this study was to identify the experience of CLBP self-management for patients attending outpatient physical therapy and assess how the experience of CLBP self-management changes over time.

METHODS

This qualitative study used constructivist grounded theory. Patients with CLBP who were attending an outpatient physical therapy department were recruited using convenience sampling. Each participant attended a semistructured interview. These were audio recorded and transcribed verbatim. The data were coded and thematically analyzed by the lead researcher. Recruitment continued until data saturation. Participants reviewed preliminary themes for validation.

RESULTS

Six subthemes emerged from 9 interviews: (1) self-doubt, (2) coping day to day, (3) independent discovery, (4) developing resilience, (5) health care: opportunity and threat, and (6) living with pain differently. Two themes took on greatest significance. Self-doubt appeared most strongly and was prevalent in all experiences. However, living with pain differently appeared in those who had developed a level of pain acceptance. These themes formed a conceptual model, "Fluctuating Uncertainty."

CONCLUSION

The experience of CLBP self-management is one of fluctuating self-doubt. Self-doubt is the predominant experience and is characterized by the perception of pain as a threat and low pain self-efficacy. During times of greater clarity, individuals develop strategies that increase pain self-efficacy and reinforce the perception of pain without threat. These are features of learning to live well with pain.

IMPACT

CLBP is a lifelong condition requiring self-management. The current study characterizes the self-management strategies used by patients attending physical therapy. The fluctuating nature of these strategies is dependent upon perception of pain and pain self-efficacy.

LAY SUMMARY

People with CLBP who self-manage their pain fluctuate between attempting to control pain and learning to live with pain. People who understand their condition develop wider-ranging self-management strategies.

A Systematic Review and Meta-Analysis Exploring Effects of Third-Wave Psychological Therapies on Hearing-Related Distress, Depression, Anxiety, and Quality of Life in People With Audiological Problems

PURPOSE

There is growing evidence supporting the use of third-wave psychological therapies, such as mindfulness-based interventions (MBIs) and acceptance and commitment therapy (ACT), for people with long-term or chronic physical health conditions. We conducted a systematic review and meta-analysis to critically evaluate the effectiveness of third-wave interventions for improving hearing-related distress and psychological well-being in people with audiological problems.

METHOD

We searched online bibliographic databases and assessed study quality. We conducted random-effects meta-analyses if at least two randomized controlled trials (RCTs) examined hearing-related distress, depression, anxiety, or quality of life in people with audiological problems. Findings of pre-post studies were summarized narratively.

RESULTS

We identified 15 studies: six RCTs and nine pre-post studies. The methodological quality of studies was mostly poor to moderate, and sample sizes were typically small (overall n = 750). Most studies focused on tinnitus (n = 12), MBIs (n = 8), and ACT (n = 6). Statistically significant improvements in hearing-related distress were found with ACT and MBIs versus controls and other treatments at post-intervention in people with tinnitus, while improvements in depression and anxiety were only found for ACT versus controls at post-intervention. However, gains were either not maintained or not examined at follow-up, and there was no evidence for improvements in quality of life.

CONCLUSIONS

At present, there is insufficient evidence to recommend the use of third-wave interventions for improving hearing-related distress or psychological well-being in people with audiological problems. There is some evidence that ACT and MBIs may be useful in addressing hearing-related distress in people with tinnitus, but only in the short term. However, findings should be interpreted with caution given the small number of studies with generally small sample sizes and mostly poor-to-moderate methodological quality. More high-quality, adequately powered, double-blind RCTs, particularly in audiological problems other than tinnitus, are needed to draw firm conclusions and meaningful clinical recommendations.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19735975.

Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis

OBJECTIVE

To determine the comparative effectiveness and safety of psychological interventions for chronic low back pain.

DESIGN

Systematic review with network meta-analysis.

DATA SOURCES

Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, and CINAHL from database inception to 31 January 2021.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, non-specific low back pain. Two reviewers independently screened studies, extracted data, and assessed risk of bias and confidence in the evidence. Primary outcomes were physical function and pain intensity. A random effects network meta-analysis using a frequentist approach was performed at post-intervention (from the end of treatment to <2 months post-intervention); and at short term (≥2 to <6 months post-intervention), mid-term (≥6 to <12 months post-intervention), and long term follow-up (≥12 months post-intervention). Physiotherapy care was the reference comparison intervention. The design-by-treatment interaction model was used to assess global inconsistency and the Bucher method was used to assess local inconsistency.

RESULTS

97 randomised controlled trials involving 13 136 participants and 17 treatment nodes were included. Inconsistency was detected at short term and mid-term follow-up for physical function, and short term follow-up for pain intensity, and were resolved through sensitivity analyses. For physical function, cognitive behavioural therapy (standardised mean difference 1.01, 95% confidence interval 0.58 to 1.44), and pain education (0.62, 0.08 to 1.17), delivered with physiotherapy care, resulted in clinically important improvements at post-intervention (moderate quality evidence). The most sustainable effects of treatment for improving physical function were reported with pain education delivered with physiotherapy care, at least until mid-term follow-up (0.63, 0.25 to 1.00; low quality evidence). No studies investigated the long term effectiveness of pain education delivered with physiotherapy care. For pain intensity, behavioural therapy (1.08, 0.22 to 1.94), cognitive behavioural therapy (0.92, 0.43 to 1.42), and pain education (0.91, 0.37 to 1.45), delivered with physiotherapy care, resulted in clinically important effects at post-intervention (low to moderate quality evidence). Only behavioural therapy delivered with physiotherapy care maintained clinically important effects on reducing pain intensity until mid-term follow-up (1.01, 0.41 to 1.60; high quality evidence).

CONCLUSIONS

For people with chronic, non-specific low back pain, psychological interventions are most effective when delivered in conjunction with physiotherapy care (mainly structured exercise). Pain education programmes (low to moderate quality evidence) and behavioural therapy (low to high quality evidence) result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness. Although inconsistency was detected, potential sources were identified and resolved.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019138074.

Evaluation of Cognitive Behavioral Therapy on Improving Pain, Fear Avoidance, and Self-Efficacy in Patients with Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Background. Cognitive-behavioral therapy (CBT) is commonly adopted in pain management programs for patients with chronic low back pain (CLBP). However, the benefits of CBT are still unclear. Objectives. This review investigated the effectiveness of CBT on pain, disability, fear avoidance, and self-efficacy in patients with CLBP. Methods. Databases including PubMed, EMBASE, Web of Science, Cochrane Library, and PsycINFO were searched. RCTs examining the effects of CBT in adults with CLBP were included. The data about the outcome of pain, disability, fear avoidance, and self-efficacy were retained. Subgroup analysis about the effects of CBT on posttreatment was conducted according to CBT versus control groups (waiting list/usual care, active therapy) and concurrent CBT versus CBT alone. A random-effects model was used, and statistical heterogeneity was explored. Results. 22 articles were included. The results indicated that CBT was superior to other therapies in improving disability (SMD −0.44, 95% CI −0.71 to −0.17, $P<0.05$ ), pain (SMD −0.32, 95% CI −0.57 to −0.06, $P<0.05$ ), fear avoidance (SMD −1.24, 95% CI −2.25 to −0.23, $P<0.05$ ), and self-efficacy (SMD 0.27, 95% CI 0.15 to 0.40, $P<0.05$ ) after intervention. No different effect was observed between CBT and other therapies in all the follow-up terms. Subgroup analysis suggested that CBT in conjunction with other interventions was in favor of other interventions alone to reduce pain and disability ( $P<0.05$ ). Conclusion. CBT is beneficial in patients with CLBP for improving pain, disability, fear avoidance, and self-efficacy in CLBP patients. Further study is recommended to investigate the long-term benefits of CBT. This meta-analysis is registered with Prospero (registration number CRD42021224837).

Acceptance and Commitment Coaching for Music Performance Anxiety: Piloting a 6-Week Group Course With Undergraduate Dance and Musical Theatre Students

Treatments for students with problematic levels of music performance anxiety (MPA) commonly rely on approaches in which students are referred to psychotherapists or other clinical professionals for individual care that falls outside of their music training experience. However, a more transdisciplinary approach in which MPA treatment is effectively integrated into students' training in music/performing arts colleges by teachers who work in consultation with clinical psychologists may prove more beneficial, given the resistance students often experience toward psychotherapy. Training singing teachers, and perhaps music teachers at large, to use an evidence-based coaching strategy like Acceptance and Commitment Coaching (ACC) to directly manage students' MPA is one such approach. Building on the work of a previous study in which ACC was administered by a singing teacher to a musical theatre student with problematic MPA, we piloted the effectiveness of a six-session, group ACC course for a sample of performing arts students (N = 6) with MPA related to vocal performances, using a mixed-methods design. The coach here was also a singing teacher without a clinical background, and her training in ACC by a clinical psychologist was of a similar duration (8 h) as the previous teacher's (7 h). Similar to the musical theatre student, the students reported being significantly less fused with their MPA-related cognitions, more accepting of their MPA-related physiological symptoms, and more psychologically flexible while performing in general, and these improvements were maintained after 3 months. Furthermore, they appeared to lower their shame over having MPA and change how they thought in relation to one another. Of note, these improvements were similar to those shown by seven vocal students with MPA after they received Acceptance and Commitment Therapy from a clinical psychologist, but with larger reductions in shame and better acceptance of MPA, which suggests a non-clinical, group ACC intervention that includes supportive discussions to normalize MPA and challenges attempts to control it may be more helpful than individual psychotherapy. These results are promising and indicate a brief training in ACC (<10 h) may be sufficient for singing teachers to provide significant benefit for students with problematic MPA.

Mindfulness and Acceptance-Based Interventions in Physical Therapist Practice: The Time Is Now

One in 5 adults in the United States lives with a mental illness, and many more struggle with stress-related chronic illnesses. Physical therapists often see the physical effects that stress has on the body, but there is an underutilization of evidence-based stress management strategies with patients and clients. Mindfulness and acceptance-based interventions (MABIs) constitute a family of methods that emphasize present-moment awareness, nonjudgment, and values-based living. They operate by teaching patients to cope with stressful thoughts, emotions, and physical sensations. MABIs are associated with improved health outcomes in areas commonly seen in physical therapist practice, including health promotion, physical function, injury prevention, pain management, immune function, and noncommunicable diseases. The purpose of this Perspective article is to (1) describe MABIs; (2) discuss the relevance of MABIs to physical therapist practice; (3) discuss the positive impact of MABIs for pain, sports, immune function, physical and mental health promotion, and wellness; and (4) identify MABI outcome measures related to health behavior change. It is time.

IMPACT

Contemporary practice requires that physical therapists manage patient care by addressing both the mind and body. Given the existing research on MABIs, it is time to translate the evidence into minimum accreditable standards for health promotion and prevention of chronic, noncommunicable disease. This approach would have far-reaching benefits for individuals, family units, communities, and society as a whole.

LAY SUMMARY

Mindfulness instruction delivered by a physical therapist can help improve physical and mental well-being.

Physiotherapy informed by Acceptance and Commitment Therapy for chronic low back pain: A mixed-methods treatment fidelity evaluation

OBJECTIVES

A randomized controlled trial of a new type of Physiotherapy informed by Acceptance and Commitment Therapy (PACT), found that it improved functioning in people with chronic low back pain compared to usual physiotherapy care. Fidelity evaluation is necessary to understand trial processes and outcomes. This study evaluated PACT treatment fidelity including delivery, receipt, and enactment.

DESIGN

A mixed-methods study nested within a randomized controlled trial was conducted.

METHODS

A total of 72 (20% of total) PACT treatment audio files were independently assessed by two raters, according to a novel framework developed to measure PACT treatment content adherence, therapeutic alliance, ACT competence, and treatment enactment. Interview transcripts from 19 trial participants randomized to PACT were analysed thematically for evidence of treatment receipt and enactment.

RESULTS

PACT physiotherapists delivered treatment as intended with high content adherence and satisfactory therapeutic alliance, but ACT competence was low. Qualitative findings indicated participant receipt of 11/17 and enactment of 3/17 components; 89% (n = 17) and 47% (n = 9) of participants reported treatment receipt and enactment of at least one component, respectively.

CONCLUSIONS

This mixed-methods study of PACT treatment demonstrated high fidelity reflecting treatment content delivery and receipt, and therapeutic alliance. There was some evidence of treatment enactment in participants with chronic low back pain. Low ACT competence could be addressed through additional support and adaptations to therapeutic processes for delivery by physiotherapists.

"I don't opt out of things because I think I will get a sore knee, but I don't expose myself to stupid risks either": patients' experiences of a second ACL injury-an interview study

PURPOSE

The purpose of this qualitative study was to describe women's experiences with anterior cruciate ligament reconstruction (ACLR) and a subsequent ACL rupture, and to identify potential facilitators and barriers for coping with rehabilitation after the second injury.

METHODS

Eight women between 17 and 36 years (mean 26, SD 6.5) who had experienced ACLR, followed by another ACL rupture, participated in the study. Semi-structured interviews were conducted, and data were analyzed using qualitative content analysis.

RESULTS

One overarching theme, "Rehabilitation after a second ACL injury-A lifelong adaptive coping process", emerged from analyses. Undergoing a second rehabilitation is described as a process of adaptation, beginning with the first injury and still ongoing, more than 5 years later. Participants applied different coping strategies to adapt to these life-altering injuries, but the common denominator was of major life adjustments with no return to previous activity levels. Initially, after the reinjury, it was about coping with the catastrophe of the dreaded second injury. Over time, they accepted their "new" life and reset their recovery/rehabilitation goal not just as "return to sport" but rather as a "personal life goal".

CONCLUSION

Undergoing a second ACL injury is a long process that challenges the patient's coping skills. Given these results, rehabilitation programs need to be more person centred according to the patients-adjusted life goals.

Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go?

Low back pain continues to be a leading cause of disability and cost throughout the world. Evidence-based guidelines recommend use of non-pharmacological interventions to address decreases in physical function due to low back pain. Psychologically informed physical therapy (PIPT) is one way to effectively and efficiently address the need for non-pharmacological approaches. However, adoption of psychologically informed practice (PiP) by physical therapists has shown mixed results due to implementation challenges. In this perspective, we discuss the current state of PIPT training and implementation. We also propose a conceptual roadmap for future implementation needs related to increasing delivery of PIPT-informed approaches.

Association of Self-Rated Health With Functional Limitations in Patients With CKD

Rationale & Objective

In patients with chronic kidney disease (CKD), self-rated health ("In general, how do you rate your health?") is associated with mortality. The association of self-rated health with functional status is unknown. We evaluated the association of limitations in activities of daily living (ADLs) with self-rated health and clinical correlates in a cohort of patients with CKD stages 1-5.

Study Design

Prospective cohort study.

Setting & Participants

Patients with CKD at a nephrology outpatient clinic in western Pennsylvania.

Outcome

Patients participated in a survey assessing their self-rated health (5-point Likert scale) and physical (ambulation, dressing, shopping) and cognitive (executive and memory) ADLs. Adjusted analysis was performed using logistic regression models.

Analytical Approach

Logistic regression was conducted to examine the adjusted association of 3 dependent variables (sum of total, physical, and cognitive ADL limitations) with self-rated health (independent variable of interest).

Results

The survey was completed by 1,268 participants (mean age, 60 years; 49% females, and 74% CKD stages 3-5), of which 41% reported poor-to-fair health. Overall, 35.9% had at least 1 physical ADL limitation, 22.1% had at least 1 cognitive ADL limitation, and 12.5% had at least 3 ADL limitations. Ambulation was the most frequently reported limitation and was more common in patients reporting poor-to-fair self-rated health compared with those with good-to-excellent self-rated health (58.1% vs 17.4%, P < 0.001). In our fully adjusted model, poor-to-fair self-rated health was strongly associated with limitations in at least 3 ADLs (total ADL) [OR 8.29 (95% CI, 5.23-13.12)]. There was no significant association of eGFR with ADL limitations.

Limitations

Selection bias due to optional survey completion, residual confounding, and use of abbreviated (as opposed to full) ADL questionnaires.

Conclusions

Poor-to-fair self-rated health is strongly associated with physical ADL limitations in patients with CKD. Future studies should evaluate whether self-rated health questions may be useful for identifying patients who can benefit from additional evaluation and treatment of functional limitations to improve patient-centered outcomes.

Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review

OBJECTIVE

Current guidelines recommend management of musculoskeletal pain conditions from a biopsychosocial approach; however, biopsychosocial interventions delivered by physical therapists vary considerably in effectiveness. It is unknown whether the differences are explained by the intervention itself, the training and/or competency of physical therapists delivering the intervention, or fidelity of the intervention. The aim was to investigate and map the training, competency assessments, and fidelity checking of individualized biopsychosocial interventions delivered by physical therapists to treat musculoskeletal pain conditions.

METHODS

A scoping review methodology was employed, using Arksey and O'Malley's framework. Seven electronic databases were searched between January and March 2019, with a bridge search completed in January 2020. Full-text peer-reviewed articles, with an individualized biopsychosocial intervention were considered, and 35 studies were included.

RESULTS

Reporting overall was sparse and highly variable. There was a broad spectrum of training. More sophisticated training involved workshops combining didactic and experiential learning over longer durations with supervision and feedback. Less sophisticated training was brief, involving lectures or seminars, with no supervision or feedback. Competency assessments and fidelity testing were underperformed.

CONCLUSIONS

Training in some interventions might not have facilitated the implementation of skills or techniques to enable the paradigm shift and behavior change required for physical therapists to effectively deliver a biopsychosocial intervention. Lack of competency assessments and fidelity checking could have impacted the methodological quality of biopsychosocial interventions.

IMPACT

This study highlighted problematic reporting, training, assessment of competency, and fidelity checking of physical therapist-delivered individualized biopsychosocial interventions. Findings here highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions. These findings can help inform future research and facilitate more widespread implementation of physical therapist-delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life.

Acceptance and Commitment Therapy for chronic pain on functioning: A systematic review of randomized controlled trials

Chronic pain is a worldwide health problem, Acceptance and Commitment Therapy (ACT) is regarded as one of the promising interventions. ACT aims to help chronic pain patients to create space for pursuing valued life activities in spite of pain. This systematic review of randomized controlled trials (RCTs) examined the efficacy of ACT on functioning for chronic pain. Literature search was performed among seven databases, and 12 RCTs were retrieved. The revised Cochrane risk of bias tool (RoB 2.0) was employed to assess the quality of the 12 RCTs, of which 10 were rated as "low risks", and 2 as "some concerns". Effect sizes of single RCTs and the pooled effect sizes of meta analyses were all rated by Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Low to moderate evidence showed that ACT played a positive immediate role in functioning for patients with chronic pain; however, it is inconsistent whether the effect can be sustained. More RCTs are warranted within specific chronic pain conditions.

Psychological flexibility and fear of recurrence in prostate cancer

OBJECTIVE

Psychological flexibility and fear of cancer recurrence are important variables that influence psychosocial outcomes in individuals diagnosed with a range of different types of cancer. Their role and how they impact on psychological distress and quality of life in men with prostate cancer specifically have not been established.

METHODS

A cross-sectional sample of 144 men with prostate cancer was recruited. Multiple regression and conditional process analysis were used to assess whether psychological flexibility moderates the relationship between fear of recurrence and distress and quality of life.

RESULTS

Psychological flexibility significantly predicted psychological distress (β = -0.56, p < 0.0001) and quality of life (β = 0.21, p < 0.0001), appearing a stronger predictor of psychological distress than fear of recurrence (β = 0.25, p < 0.0001). Fear of recurrence was a stronger predictor of quality of life (β = -0.41, p < 0.0001) than psychological flexibility. Psychological flexibility moderated the relationship between fear of recurrence and psychological distress (β = -0.01, p < 0.001). At low and average levels of psychological flexibility, psychological distress mediated the relationship between fear of recurrence and quality of life (β = -0.33 to -0.16, p < 0.05). At high levels of psychological flexibility, distress no longer mediated this relationship (β = 0.01, ns), supporting the role of psychological flexibility as a moderator.

CONCLUSIONS

These findings suggest that psychological flexibility might be a useful treatment target, through interventions such as Acceptance and Commitment Therapy, to buffer the effects of fear of recurrence and distress and improve psychosocial outcomes in this population.

Communication skills in the context of psychological flexibility: training is associated with changes in responses to chronic pain in physiotherapy students in Spain

Introduction

The aim of this study is to explore the effectiveness of a training programme aimed at managing patients' chronic pain in physiotherapy students in Spain. The programme addressed providing them with efficient skills to manage patients' chronic pain from psychological flexibility (PF) perspective.

Methods

The programme integrates communication skills training into PF-based training. It sought to contribute to better recognise the role of psychosocial factors in chronic pain and to better promote adherence to treatment. This is an observational study with a pre- and post-training programme design and a 2-month follow-up. A total of 35 physiotherapy students, divided into three groups, participated in a 10-hour training course. Training focused on three areas: (1) communication skills, (2) therapeutic adherence and (3) managing distress and pain. The three areas were addressed from the PF point of view. Impact of training was measured through standardised questionnaires that assessed attitudes towards chronic pain, an ad hoc questionnaire that assessed responses to difficult communicative situations and a training satisfaction scale.

Results

Final analyses showed that attitudes changed significantly after training, biomedical attitude scores decreased and biopsychosocial attitude increased, while pain was considered less disabling, and informed empathic responses in communication situations increased. These changes were maintained at 2-month follow-up. Satisfaction with the training was high.

Conclusion

We conclude that a brief training programme based on the PF model may help students develop a more comprehensive approach and improve their skills for managing chronic pain.

Experiences of training and delivery of Physical therapy informed by Acceptance and Commitment Therapy (PACT): a longitudinal qualitative study

OBJECTIVES

Physiotherapy informed by Acceptance and Commitment Therapy (PACT) is a novel intervention that is related to improved disability and functioning in people with chronic lowback pain. This study explored physiotherapists experiences over time of the PACT training programme and intervention delivery.

DESIGN

A longitudinal qualitative study using semi-structured, in-depth, individual interviews at three time points was conducted.

METHODS

A phenomenological approach underpinned the methods. Interviews followed topic-guides developed a priori. Transcribed interviews were coded inductively to generate themes. Data were member checked by participants and validated by two researchers.

PARTICIPANTS

Eight clinical physiotherapists from three secondary care centres in the United Kingdom (n = 5 female; age, 24 to 44 years; duration of practice, 3 to 14 years) were included.

RESULTS

Five themes emerged from the data. Experiential learning techniques were challenging but valued because they bridged theoretical principles and concepts with practice. Ongoing individual and group supervision was beneficial, but required tailoring and tapering. PACT delivery extended physiotherapy skills and practice, including techniques that acknowledged and addressed patient treatment expectations. With experience, participants desired greater flexibility and autonomy to tailor PACT delivery.

CONCLUSIONS

PACT training and delivery were acceptable to physiotherapists. Existing skills were developed and additional, applicable approaches were provided that addressed psychosocial and behavioural aspects of chronic low back pain.

Remote management of musculoskeletal pain: a pragmatic approach to the implementation of video and phone consultations in musculoskeletal practice

Video and phone consultations for musculoskeletal pain are effective, safe, and appreciated by patients. Implementation and execution require special consideration and such guidance is provided.

Introduction:

Remote consultations through phone or video are gaining in importance for the treatment of musculoskeletal pain across a range of health care providers. However, there is a plethora of technical options for practitioners to choose from, and there are various challenges in the adaptation of clinical processes as well as several special considerations regarding regulatory context and patient management. Practitioners are faced with a lack of high-quality peer-reviewed resources to guide the planning and practical implementation of remote consultations.

Objectives:

This Clinical Update seeks to provide practical guidance for the planning and implementation of remote consultations for the management and treatment of people with musculoskeletal pain.

Methods:

Recommendations are based on a brief overview of the relevant research regarding phone and video consultations for musculoskeletal practice and derived from the literature, relevant guidelines, and practical experience.

Results:

The technical feasibility of remote consultations for musculoskeletal complaints is good, patient satisfaction is high, and a growing body of evidence supports its comparative effectiveness to in-person consultations in some circumstances for improving pain and functioning. We consider in detail practical aspects such as the choosing of hardware and software, we touch on the legal and regulatory context, and we focus on the adaptation of clinical processes and communication.

Conclusion:

This Clinical Update draws together best-practice evidence in a practically applicable format, enabling therapists who are working with people with pain to directly apply this knowledge to their individual clinical settings and the requirements of their patients.

An Innovative Physical Therapy Intervention for Chronic Pain Management and Opioid Reduction Among People Living with HIV

Chronic pain management has become a treatment priority for people living with HIV (PLH), and PLH may be at increased risk for opioid addiction. Physical therapy (PT) has been shown to be effective as a nonpharmacological method of chronic pain management; however, there is a gap in research examining the role of PT for chronic pain, especially as it relates to opioid reduction, in this patient population. This retrospective study evaluated pain level and opioid use before and after PT intervention among HIV-positive adults with chronic pain on chronic opioid therapy (n = 22). The study was conducted at a multidisciplinary AIDS clinic in Atlanta, GA. Outcome measures were self-reported pain on the numerical rating scale (0–10) and morphine milligram equivalents (MMEs), which measure opioid use. A majority of patients (77%) demonstrated a decrease in pain by the conclusion of the study period; however, only 18.2% of patients reported decreased pain as well as a decrease in MMEs. The most common PT treatments used among the patients with a decrease in pain and/or opioid use included home exercise programs, manual therapy, and self-pain management education. Eighty percent of the participants who did not decrease opioid use reported a decrease or elimination of pain by the end of the PT intervention. This reflects the need for careful consideration of the complexity of opioid use and addiction, and the importance of a multidisciplinary team to best serve the needs of PLH aiming to decrease chronic pain and opioid use.

Acceptance and commitment therapy for chronic pain conditions on functioning: A systematic review protocol

AIM

To explore the efficacy of acceptance and commitment therapy (ACT) on chronic pain in terms of functioning; and to identify the most promising modes and patterns for implementing ACT.

DESIGN

Systematic review and meta-analysis.

METHODS

We will include randomized controlled trials which focus on the efficacy of ACT on chronic pain conditions with functioning as the primary outcome. Seven databases have been searched and grey literature will also be systematically searched for. Eligible studies will be screened. The newly revised Cochrane risk of bias tool will be used to assess the quality of the included studies. Data will be extracted, and meta-analyses will be performed within specific condition groups of chronic pain. Meta-regression and subgroup analyses will be employed to identify the efficacious modes and patterns for implementing the therapy. Grading of Recommendations Assessment, Development, and Evaluation approach will be applied to reach a convincing conclusion. The study has been funded since July 2018.

DISCUSSION

This systematic review aims to explore the efficacy of ACT for chronic pain on functioning based on the latest evidence. The most promising manners will be identified for designing and delivering the therapy. An accurate, transparent, and standardized review process is expected by adhering to the instructions of relevant guidelines.

IMPACT

Chronic pain is prevalent worldwide and reduced functioning is one of the leading consequences. With the anticipated evidence of high level, this research attempts to examine the role of acceptance and commitment therapy, a promising psychological intervention, in the management of chronic pain for improving individual's functioning status. The systematic review may contribute to a more convincing and targeted conclusion compared with the existing studies of its kind.

Psychologically informed physical therapy for musculoskeletal pain: current approaches, implications, and future directions from recent randomized trials

Supplemental Digital Content is Available in the Text.

Randomized trials have examined the efficacy of psychologically informed physical therapy methods including graded activity or graded exposure, cognitive-behavioral-based physical therapy, acceptance and commitment-based physical therapy, and internet-based psychological programs compared to traditional physical therapy approaches for musculoskeletal pain. Summary findings suggest that psychologically informed physical therapy is a promising care model; however, more convincing evidence is needed to support widespread adoption, especially in light of clinician training demands.

Psychologically informed physical therapy (PIPT) blends psychological strategies within a physical therapist's treatment approach for the prevention and management of chronic musculoskeletal pain. Several randomized trials have been conducted examining the efficacy of PIPT compared to standard physical therapy on important patient-reported outcomes of disability, physical function, and pain. In this review, we examine recent trials published since 2012 to describe current PIPT methods, discuss implications from findings, and offer future directions. Twenty-two studies, representing 18 trials, were identified. The studied PIPT interventions included (1) graded activity or graded exposure (n = 6), (2) cognitive-behavioral-based physical therapy (n = 9), (3) acceptance and commitment-based physical therapy (n = 1), and (4) internet-based psychological programs with physical therapy (n = 2). Consistent with prior reviews, graded activity is not superior to other forms of physical activity or exercise. In a few recent studies, cognitive-behavioral-based physical therapy had short-term efficacy when compared to a program of standardized exercise. There is a need to further examine approaches integrating alternative strategies including acceptance-based therapies (ie, acceptance and commitment therapy or mindfulness) or internet-based cognitive-behavioral programs within physical therapy. Although PIPT remains a promising care model, more convincing evidence is needed to support widespread adoption, especially in light of training demands and implementation challenges.

Psychological interventions for chronic non-specific low back pain: protocol of a systematic review with network meta-analysis

INTRODUCTION

Psychological factors such as fear avoidance beliefs, depression, anxiety, catastrophic thinking and familial and social stress, have been associated with high disability levels in people with chronic low back pain (LBP). Guidelines endorse the integration of psychological interventions in the management of chronic LBP. However, uncertainty surrounds the comparative effectiveness of different psychological approaches. Network meta-analysis (NMA) allows comparison and ranking of numerous competing interventions for a given outcome of interest. Therefore, we will perform a systematic review with a NMA to determine which type of psychological intervention is most effective for adults with chronic non-specific LBP.

METHODS AND ANALYSIS

We will search electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS and CINAHL) from inception until 22 August 2019 for randomised controlled trials comparing psychological interventions to any comparison interventions in adults with chronic non-specific LBP. There will be no restriction on language. The primary outcomes will include physical function and pain intensity, and secondary outcomes will include health-related quality of life, fear avoidance, intervention compliance and safety. Risk of bias will be assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2) tool and confidence in the evidence will be assessed using the Confidence in NMA (CINeMA) framework. We will conduct a random-effects NMA using a frequentist approach to estimate relative effects for all comparisons between treatments and rank treatments according to the mean rank and surface under the cumulative ranking curve values. All analyses will be performed in Stata.

ETHICS AND DISSEMINATION

No ethical approval is required. The research will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019138074.