Meanings of "acceptance" for patients with long-term pain when starting rehabilitation

An ecosystem of accepting life with chronic pain: A meta-ethnography

Background

Chronic pain is a highly prevalent long-term condition, experienced unequally, impacting both the individual living with pain, and wider society. 'Acceptance' of chronic pain is relevant to improved consultations in pain care, and navigating an approach towards evidence-based, long-term management and associated improvements in health. However, the concept proves difficult to measure, and primary qualitative studies of lived experiences show complexity related to our socio-cultural-political worlds, healthcare experiences, and difficulties with language and meaning. We framed acceptance of chronic pain as socially constructed and aimed to conceptualise the lived experiences of acceptance of chronic pain in adults.

Methods

We conducted a systematic search and screening process, followed by qualitative, interpretive, literature synthesis using Meta-ethnography. We included qualitative studies using chronic pain as the primary condition, where the study included an aim to research the acceptance concept. We conducted each stage of the synthesis with co-researchers of differing disciplinary backgrounds, and with lived experiences of chronic pain.

Findings

We included 10 qualitative studies from Canada, Sweden, The Netherlands, Ireland, UK, Australia and New Zealand. Our 'lines of argument' include a fluid and continuous journey with fluctuating states of acceptance; language and meaning of acceptance and chronic pain, a challenge to identity in a capitalist, ableist society and the limits to individualism; a caring, supportive and coherent system. The conceptual framework of the meta-ethnography is represented by a rosebush with interconnected branches, holding both roses and thorns, such is the nature of accepting life with chronic pain.

Conclusion

Our findings broaden conceptualisation of 'acceptance of chronic pain' beyond an individual factor, to a fluid and continuous journey, interconnected with our socio-cultural-political worlds; an ecosystem.

Patients' experiences of temporomandibular disorders and related treatment

BACKGROUND

Temporomandibular disorders (TMD) are common and therefore managed by dentists on a daily basis. However, patients with TMD consistently go undetected and therefore untreated in dentistry. The reasons for these shortcomings have not been fully explored, specifically with regard to patients' perspectives. Therefore, this study aimed to explore patients' experiences of TMD and related treatment, with special focus on the experiences of having TMD, factors related to seeking care, and perspectives on received treatment.

METHODS

Purposive sampling was used to recruit adult patients at the Public Dental Health services (PDHS) in the Region of Västerbotten, Sweden, during 2019. Individual semi-structured interviews were conducted and analysed using Qualitative Content Analysis. Sixteen patients were interviewed (ten women and six men, 20-65 years). The interviews probed the patients' perspectives of having TMD, seeking care, and receiving treatment. All participants were also examined according to the Diagnostic Criteria for TMD (DC/TMD) and qualified for at least one DC/TMD diagnosis.

RESULTS

The data analysis led to the main theme Seeking care when the situation becomes untenable, but dental care fails to meet all needs. The patients expressed worry and social discomfort because of the symptoms but still strived to have an as normal daily life as possible. However, severe symptoms and associated consequences compelled them to seek professional help. Experiences of distrust together with challenges to access the PDHS were identified and related to the patients' unfulfilled expectations.

CONCLUSIONS

Patients' reported experiences indicate that receiving timely and appropriate care is more of an unfulfilled expectation than the current state of management of patients with TMD in dentistry.

Body awareness and cognitive behavioral therapy for multisite musculoskeletal pain: patients` experiences with group rehabilitation

BACKGROUND

An extended group program called Mind and Body (MB), based on body awareness exercises and cognitive behavioral therapy (CBT), was offered to a subgroup of patients who had completed their traditional outpatient multidisciplinary rehabilitation and were motivated for further treatment.

PURPOSE

To explore how patients with multisite musculoskeletal pain experienced participation in the MB program with respect to usefulness, meaningfulness, behavioral changes, and transferability to daily life and work.

METHOD

The study is rooted in the phenomenological tradition. Individual, semi-structured interviews were performed with eight patients aged 29-56 years. The data were analyzed using systematic text condensation.

RESULTS

Two main themes emerged: 1) New knowledge provided increased body awareness, new ways of thinking, and acceptance of one's own situation. This theme reflected how new knowledge and MB coping strategies were useful in the process of changing problematic thoughts, increasing body awareness, and facilitating acceptance; and 2) Implementing new habits and strategies in daily life revealed how demanding it was to alter behavior, a process that unfolded over time.

CONCLUSION

A combination of body awareness exercises and cognitive coping strategies was described as helpful in further improving function and coping with pain and stress in daily life and work.

Portraying improvement in the management of chronic pain: A multi-modal longitudinal interpretative phenomenological analysis study

Chronic pain is a common, profoundly disabling and complex condition whose effects on identity may explain the distress experienced by those affected by it. This paper concerns a study exploring how the relationship with pain and sense of self evolved following participation in a pain management program (PMP). Participants were interviewed at three timepoints: before attending a PMP, 1 month after the PMP and 6 months after the PMP. To facilitate a deep experiential description of pain and its effects, interviews were guided by participant-generated drawings of pain and Self. Interviews and drawings were analyzed longitudinally using interpretative phenomenological analysis. The evolving experience of participants was outlined through different trajectory types. Here we describe the upward and positive trajectory of three female participants who were able to regain control over their lives. From a state of psychological stress where pain was represented as an aggressive and oppressive presence, participants' drawings, their narratives and indeed their lives, changed for the best. Pain stopped being the main feature, they were able to integrate it into their lives, make important changes and find a new balance. The results demonstrate the idiosyncratic nature of chronic pain and offer a nuanced account of its links to the lifeworld of those living with it.

Experiences with an educational program for patients with chronic widespread pain: a qualitative interview study

OBJECTIVES

Chronic widespread pain (CWP) is a common problem in primary health care, with a prevalence of 10-15%. An educational program called Pain School has been developed for use in primary health care, comprising four educational group sessions and 10 weeks of physical activity. The purpose of this study was to explore patients' experiences with participating in an educational program that aims to increase their understanding of pain, self-efficacy, tools in daily life, and physical activity.

METHODS

Twelve women (age 25-72 years) with CWP were included in this qualitative interview study set in primary health care. Semi-structured individual interviews were held 10 weeks after the completion of the four educational group sessions. Data was analyzed through the established method of content analysis, and the results are presented as a theme with categories and subcategories.

RESULTS

An overarching theme that described the participants' experiences with the educational program was evolvement of skills and perspectives to master pain. This theme covered four categories: understanding one's body and mind, experiencing the value of participation, applying strategies and ways of thinking, and evaluating and adding to one's personal framework. Participation contributed to an increased understanding of one's body and mind and to experiencing the individual and social value of participation. The participants applied new strategies and ways of thinking related to pain and physical activity. An evaluation of the relevance for the individual and the value of being in the group could reinforce or add to the participants' personal framework.

CONCLUSIONS

The educational program Pain School that was used in this study appears to give knowledge and support for women with CWP in primary health care and provide them with applicable skills and perspectives to manage pain.

Retrospective experiences of individuals two decades after anterior cruciate ligament injury - a process of re-orientation towards acceptance

PURPOSE

Individual perspectives of long-term consequences decades after anterior cruciate ligament (ACL) injury are unexplored. We addressed experiences and the impact on life of former athletes >20 years post-ACL injury.

METHODS

Individual interviews, analysed using Grounded Theory, were conducted with 18 persons injured mainly during soccer 20-29 years ago.

RESULTS

A theoretical model was developed with the core category Re-orientation towards acceptance, overarching three categories illustrating the long-term process post-injury. Initially the persons felt like disaster had struck; their main recall was strong pain followed by reduced physical ability and fear of movement and re-injury. In the aftermaths of injury, no participant reached the pre-injury level of physical activity. Over the years, they struggled with difficult decisions, such as whether to partake or refrain from different physical activities, often ending-up being less physically active and thereby gaining body weight. Fear of pain and re-injury was however perceived mainly as psychological rather than resulting from physical limitations. Despite negative consequences and adjustments over the years, participants still found their present life situation manageable or even satisfying.

CONCLUSION

ACL injury rehabilitation should support coping strategies e.g., also related to fear of re-injury and desirable physical activity levels, also with increasing age.IMPLICATIONS FOR REHABILITATIONMore than 20 years after the ACL injury, the individuals despite re-orientation towards acceptance and a settlement with their life situation, still had fear of both pain and re-injury of the knee, with concerns about physical activity and gaining of body weight.Patients with ACL injury may need better individual guidance and health advice on how to remain physically active, to find suitable exercises and to maintain a healthy body weight.Education related to pain, treatment choices, physical activity, injury mechanisms in participatory discussions with the patient about the ACL injury may be beneficial early in the rehabilitation process to avoid catastrophizing and avoidance behaviour.ACL injury rehabilitation needs to address coping strategies incorporating the psychological aspects of suffering an ACL injury, including fear of movement/secondary injury, in order to support return-to-sport and/or re-orientation over time.

Development and preliminary validation of the Chronic Pain Acceptance Questionnaire for Clinicians

Background and Aims Higher chronic pain acceptance is associated with lower pain and disability. Clinician beliefs are associated with patients' beliefs. This study therefore aimed to develop the Chronic Pain Acceptance Questionnaire for Clinicians (CPAQ-C) to measure clinicians' beliefs regarding the importance of levels of acceptance in patients with chronic pain, and to examine the questionnaire's psychometric properties. Methods Phase one: the CPAQ-C was adapted from the Chronic Pain Acceptance Questionnaire. Data on 162 completed questionnaires were analysed using Rasch analysis. Phase Two: the cohort completed the Healthcare Providers Pain and Impairment Relationship Scale, and the association (Pearson's correlation co-efficient) between these questionnaires examined to assist CPAQ-C validation. Twenty-four participants completed the CPAQ-C one-week later. Test re-test reliability was examined using intraclass correlation co-efficient (2,1) and standard error of measurement. Phase Three: to examine responsiveness 17 clinicians attending a workshop on Acceptance and Commitment Therapy completed the CPAQ-C before and immediately after the workshop, and six-months later. The Skillings Mack test was used to determine whether CPAQ-C scores differed across different timepoints. Results Rasch analysis supported two subscales: activity engagement and pain willingness. Five poorly functioning items were excluded. There was good correlation between the CPAQ-C and Healthcare Providers Pain and Impairment Relationship Scale (-.54). The CPAQ-C demonstrated good reliability (ICC (2,1): .81; standard error of measurement: 4.76). There was significant improvement in CPAQ-C scores following the workshop (p=<.001). Conclusions The CPAQ-C appears a valid, reliable and responsive measure of clinicians' beliefs regarding the importance of levels of acceptance in patients with chronic pain. Implications Where the CPAQ-C reveals that clinicians have low perceived levels of importance regarding acceptance in patients with chronic pain those clinicians may benefit from specific education, however, this requires further examination.

Breaking the vicious circle: Experiences of people in chronic pain on the pain rehabilitation journey

Aim

To explore the lived experience of individuals' in chronic pain of participating in a pain rehabilitation programme in Iceland.

Design

Phenomenological research.

Method

The Vancouver School of Doing Phenomenology. Eleven participants were interviewed.

Results

The overarching theme was as follows: "the journey of breaking the vicious circle of chronic pain." Before the programme, the participants felt they were in survival mode, trying to survive each day; they were stuck in a vicious circle of chronic pain, simultaneously trying to ease and conceal the pain. Reaching out for professional help was a turning point. While attending the programme, participants began deconstructing their old ways of dealing with chronic pain. After completing the programme, they were still reconstructing their daily lives. In conclusion, pain rehabilitation programmes can be the first step towards breaking the vicious circle of chronic pain.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Women's experiences of the journey to chronic widespread pain: a qualitative study

BACKGROUND

Chronic widespread pain (CWP) is a musculoskeletal disorder that affects approximately 10% of the population. It is more common in women than in men. It is important to understand how CWP develops and how it is maintained in order to prevent poor pain prognosis. Long term studies have shown that a mere part improves over time or fluctuates in their CWP condition. Female gender is one of the factors associated with persistence of CWP, suggesting men and women may experience their journey to CWP differently. The aim of the study was to explore women's experiences of the journey to CWP.

METHODS

19 women between 45 and 67 years of age who had not reported CWP in the EPIPAIN survey in 1995, but reported CWP in 2016, participated in the study. Data was collected through individual interviews, where open-ended questions were used to explore the women's experiences of their pain journey. The interviews were analyzed with a manifest qualitative content analysis.

RESULTS

The women described their journey to CWP in terms of triggering, aggravating, and consolidating factors, from which three different categories emerged. Experiencing that environmental circumstances affect the pain journey refers to factors outside the women's immediate control, which appeared as unmanageable work-related demands, lack of social support, unfavorable physical environments, and traumatic events. Experiencing that lifestyle affects the pain journey refers to events that are consciously or unconsciously carried out by the women, including different levels of physical efforts and unfavorable behaviors. Experiencing that personal attributes affect the pain journey refers to the women's characteristics in terms of an anxious state of mind and adverse biological impact.

CONCLUSIONS

The women experienced that environmental circumstances, lifestyle, and personal attributes affected their CWP. How these adversities influenced the pain journey varied among the women. These findings show that women are conscious of the complexity of the condition and can describe the broad context of their pain journey. This study confirms the complexity of pain progress and highlights the individual's awareness of this complexity, which is important to consider when introducing interventions, and when expecting compliance to interventions.

Recovery despite everyday pain: Women's experiences of living with whiplash-associated disorder

INTRODUCTION

Living with whiplash-associated disorders (WAD) means living every day under the influence of pain and limitations. As the incidence of WAD and the related intensity of pain are somewhat higher among women than men, the aim of the present study was to describe women's experiences of living with WAD.

METHODS

A purposive sample of seven women participated in individual in-depth qualitative interviews, the transcripts of which were subjected to qualitative content analysis.

RESULTS

The results of the analysis suggested six themes of women's experiences with WAD: living with unpredictable pain; trying to manage the pain; living with limitations; being unable to work as before; needing support and understanding; and learning to live with limitations. The findings showed that unpredictable pain limited women's strength to engage in activities of daily life and be as active as before. Support and understanding were important for their ability to manage changes in their daily lives.

CONCLUSIONS

Pain considerably affects the daily lives of women with WAD, particularly by limiting their ability to perform activities and to enjoy their professional and social lives. As women with WAD need support with managing their daily lives, nurses and other healthcare personnel should adopt a person-centred approach, in order to support such women according to their individual needs and circumstances.

The associations of acceptance with quality of life and mental health following spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To identify, critically appraise, and synthesize research findings on the associations between acceptance, quality of life (QOL), and mental health outcomes in individuals living with spinal cord injury (SCI).

METHODS

Five databases (PubMed, PsycINFO, Embase, Web of Science, and Scopus) were systematically searched. Studies were included if they provided findings on the association between acceptance and QOL, mental health outcomes, or both in an SCI population aged 16 years or older. Only peer-reviewed original quantitative and qualitative studies were included. Screening, quality assessment, and data extraction were conducted independently by two researchers. Findings were tabulated and synthesized by outcome.

RESULTS

Forty-one studies were included. Greater acceptance was consistently associated with greater global and psychological QOL, life satisfaction, sense of well-being, mental health, and with lower levels of depression and anxiety. Inconsistent evidence was found with regards to social QOL and post-traumatic stress disorder. Acceptance was generally not associated with adjustment outcomes further than 2 years into the future. Study quality of the quantitative studies was mostly fair (n = 17) followed by good (n = 13), and poor (n = 9).

CONCLUSION

Health-care professionals may regard acceptance as a psychological resource they can aim to support in improving QOL and mental health following SCI. A range of methodological and conceptual limitations were present in the research. Future studies should prioritize longitudinal designs, consider dyadic effects, explore subjective meaning(s) of acceptance, and investigate the effectiveness of therapeutic approaches that stimulate the acceptance process.

What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis

BACKGROUND

Self-management interventions fostering self-efficacy improve the well-being of people with chronic pain.

PURPOSE

The purpose of this study was to synthesize the enablers (what works) and barriers (what does not) of incorporating self-management strategies for people in everyday life after completion of a pain self-management intervention.

DATA SOURCES

Major electronic databases (MEDLINE, AMED, PsycINFO, Cochrane Library, PubMed, CINAHL, Scopus, and Google Scholar) were searched from inception to July 2016.

STUDY SELECTION

Study selection included qualitative and mixed-method studies that explored the perceptions of individuals with chronic pain after completion of a self-management intervention.

DATA EXTRACTION

A thematic analysis approach was used to synthesize the review findings, and a Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence.

DATA SYNTHESIS

Thirty-three studies with 512 participants were included. Enablers to self-management included self-discovery-the ability to distinguish self (ie, body, thoughts, and feelings) from pain; feeling empowered by incorporating self-management strategies into practice; and supportive ambience via collaborative relationships with clinicians and support from family and friends. Barriers to self-management included difficulty with sustaining motivation for pain self-management; distress experienced from ongoing pain, anxiety, and depression; and unsupportive relationships with clinicians, family, and friends.

LIMITATIONS

This review only included interventions that involved at least 4 self-management skills; thus, informative studies may have been missed. The follow-up period varied from immediately after the intervention to 72 months following the intervention; therefore, it is uncertain which of the key enablers and barriers were most influential long term. Only articles published in the English language were included; studies conducted in low- and middle-income countries could not be located.

CONCLUSIONS

The sustained effort to self-manage chronic pain could be exhausting, and motivation could wane over time following intervention. Providing intermittent support in the form of booster sessions and peer support groups may be important. Person-centered care via shared decision making and guided problem solving is essential to facilitating ongoing self-management.

“On their own”: social isolation, loneliness and chronic musculoskeletal pain in older adults

Purpose

The purpose of this paper is to explore the concepts of social isolation and loneliness in relation to people with chronic musculoskeletal pain. Through these concepts, biological, psychological and social factors will be examined to consider how we can identify people at risk of social isolation and loneliness who have chronic musculoskeletal pain and then how health professionals may intervene to reduce their effects.

Design/methodology/approach

Conceptual paper.

Findings

Social isolation and loneliness are often evident in the situation of people with chronic musculoskeletal diseases. This may be bi-directional where pains may lead to social isolation and loneliness, but equally, social isolation and loneliness may exacerbate pain. Interventions to improve the symptoms of chronic musculoskeletal pain, and also approaches around social participation and engagement should be adopted in combination to ameliorate this potentially disabling scenario.

Originality/value

There remains limited evidence around the prevalence and management of social isolation and loneliness for people with chronic musculoskeletal pain. By raising awareness of social isolation and loneliness in this population, people with chronic musculoskeletal pain may be better supported to reduce the negative impact that social isolation and loneliness can have on their health and well-being.