Evaluation of a group acceptance commitment therapy intervention for people with knee or hip osteoarthritis: a pilot randomized controlled trial

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.

Barriers and facilitators of evidence-based psychotherapies for chronic pain in adults: A systematic review

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n=28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs. individual therapy and telehealth or asynchronous digital approaches. Perspective This systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain. Registration: PROSPERO number CRD42021252038.

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.

Synovial mesenchymal stem cell-derived extracellular vesicles containing microRN555A-26a-5p ameliorate cartilage damage of osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a degenerative disease characterized by cartilage damage. We aimed to improve the understanding of the protective mechanism of synovial mesenchymal stem cell (SMSC)-derived extracellular vesicles (EVs) in cartilage damage of OA.

METHODS

SMSCs and SMSC-EVs were isolated from synovial biopsies of patients without OA and then identified. The pathological microenvironment of chondrocytes in OA was simulated by inducing SW1353 cells with interleukin (IL)-1β, followed by SMSC-EV treatment to assess SW1353 cell proliferation, apoptosis and inflammation. Endocytosis of Dil-labeled EVs by SW1353 cells was observed. microRNA (miR)-26a-5p expression in EVs and EV-treated SW1353 cells was assessed. The effect of miR-26a-5p was evaluated after it was down-regulated in SMSCs, followed by extraction of EVs, which acted on SW1353 cells. The target relationship of miR-26a-5p and phosphatase and tensin homologue (PTEN) was predicted and confirmed. The role of PTEN in OA was evaluated after it was overexpressed. Functional assays were implemented in vivo to certify the role of SMSC-EVs in OA.

RESULTS

SMSC-EVs enhanced IL-1β-induced SW1353 cell proliferation, whereas they inhibited apoptosis and inflammation. EVs were endocytosed by SW1353 cells and delivered miR-26a-5p into SW1353 cells to overexpress miR-26a-5p. Down-regulation of miR-26a-5p in EVs attenuated the protection of EVs against IL-1β-induced cell damage. miR-26a-5p targeted PTEN, for which overexpression spoiled the protection of EVs against IL-1β-induced cell damage. SMSC-EVs carrying miR-26a-5p repaired cartilage damage of OA.

CONCLUSIONS

SMSC-EVs carried miR-26a-5p into chondrocytes to up-regulate miR-26a-5p and inhibit PTEN, thereby inhibiting apoptosis and inflammation and ameliorating cartilage damage of OA.

Exosomes derived from miR-155-5p-overexpressing synovial mesenchymal stem cells prevent osteoarthritis via enhancing proliferation and migration, attenuating apoptosis, and modulating extracellular matrix secretion in chondrocytes

Synovial mesenchymal stem cells (SMSCs) have the potential to attenuate osteoarthritis (OA)-induced injury. The role and mechanism of SMSC-derived exosomes (SMSC-Exos), pivotal paracrine factors of stem cells, in OA-associated injury remain unclear. We aimed to confirm the effect of SMSC-Exos with specific modifications on OA-induced damage and to investigate the potential molecular mechanisms. Exosomes derived from miR-155-5p-overexpressing SMSCs (SMSC-155-5p-Exos) and SMSCs (SMSC-Exos) were isolated and characterized. CCK-8, Transwell, and Western blot analyses were used to detect proliferation, migration, extracellular matrix (ECM) secretion, and apoptosis of osteoarthritic chondrocytes. The therapeutic effect of exosomes in a mouse model of OA was examined using immunohistochemical staining and OARSI scores. SPSS 17.0 and GraphPad software were used for all statistical analyses in this study. The SMSC-Exos enhanced the proliferation and migration and inhibited the apoptosis of osteoarthritic chondrocytes but had no effect on ECM secretion. The miR-155-5p-overexpressing exosomes showed common characteristics of exosomes in vitro and further promoted ECM secretion by targeting Runx2. Thus, the SMSC-155-5p-Exos promoted proliferation and migration, suppressed apoptosis and enhanced ECM secretion of osteoarthritic chondrocytes, and effectively prevented OA in a mouse model. In addition, overexpression of Runx2 partially reversed the effect of the SMSC-155-5p-Exos on osteoarthritic chondrocytes. Given the insufficient effect of the SMSC-Exos on the ECM secretion of osteoarthritic chondrocytes, we modified the SMSM-Exos and demonstrated that the SMSC-155-5p-Exos could prevent OA. Exosomes derived from modified SMSCs may be a new treatment strategy to prevent OA. Graphical abstract.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effect of acceptance and commitment therapy on insomnia and sleep quality: A systematic review

Background

Acceptance and Commitment Therapy (ACT), as a type of behavioral therapy, attempts to respond to changes in people’s performance and their relationship to events. ACT can affect sleep quality by providing techniques to enhance the flexibility of patients’ thoughts, yet maintaining mindfullness. Therefore, for the first time, a systematic review on the effects of ACT on sleep quality has been conducted.

Methods

This systematic review was performed to determine the effect of ACT on insomnia and sleep quality. To collect articles, the PubMed, Web of Science (WOS), Cochrane library, Embase, Scopus, Science Direct, ProQuest, Mag Iran, Irandoc, and Google Scholar databases were searched, without a lower time-limit, and until April 2020.

Results

Related articles were derived from 9 research repositories, with no lower time-limit and until April 2020. After assessing 1409 collected studies, 278 repetitive studies were excluded. Moreover, following the primary and secondary evaluations of the remaining articles, 1112 other studies were removed, and finally a total of 19 intervention studies were included in the systematic review process. Within the remaining articles, a sample of 1577 people had been assessed for insomnia and sleep quality.

Conclusion

The results of this study indicate that ACT has a significant effect on primary and comorbid insomnia and sleep quality, and therefore, it can be used as an appropriate treatment method to control and improve insomnia.

"Bearing the Pain": The Experience of Aging African Americans With Osteoarthritis Pain

Studies document that osteoarthritis-related joint pain is more severe in African American older adults, but research on the personal experience of osteoarthritis pain self-management in this population is limited. Using a qualitative descriptive design, our objective was to extend our understanding of the experience of life with osteoarthritis pain. Eighteen African Americans (50 years and older) were recruited from Louisiana to participate in a single semi-structured, in-depth interview. A conventional content analysis revealed that “Bearing the pain” characterized how older African Americans dealt with osteoarthritis. Bearing the pain comprised three actions: adjusting to pain, sharing pain with others, and trusting God as healer. We discovered that a metapersonal experience subsumes the complex biopsychosocial-cultural patterns and the intricate interaction of self, others, and God in living with and managing osteoarthritis pain. Study findings have implications for application of more inclusive self-management frameworks and interventions.

The Phenomenon of Treatment Dropout, Reasons and Moderators in Acceptance and Commitment Therapy and Other Active Treatments: A Meta-Analytic Review

Treatment dropout is one of the most crucial issues that a therapist has to face on a daily basis. The negative effects of premature termination impact the client who is usually found to demonstrate poorer treatment outcomes. This meta-analysis reviewed and systematically examined dropout effects of Acceptance and Commitment Therapy (ACT) as compared to other active treatments. The goals of this study were to compare treatment dropout rates and dropout reasons, examine the influence of demographic variables and identify possible therapy moderators associated with dropout.

The current meta-analysis reviewed 76 studies of ACT reporting dropout rates for various psychological and health-related conditions.

Across reviewed studies (N = 76), the overall weighted mean dropout rate was 17.95% (ACT = 17.35% vs. comparison conditions = 18.62%). Type of disorder, recruitment setting and therapists’ experience level were significant moderators of dropout. The most frequently reported reasons for dropout from ACT were lost contact, personal and transportation difficulties, whereas for comparative treatments they were lost contact, therapy factors and time demands.

Given that most moderators of influence are not amenable to direct changes by clinicians, mediation variables should also be explored. Overall, results suggest that ACT appears to present some benefits in dropout rates for specific disorders, settings and therapists.

There was no difference in dropout rate between ACT and control conditions (17.35% vs.18.62%). Significant moderators were client disorder, therapists’ experience level and recruitment and setting.

Comparison condition frequently reported therapy related dropout factors, suggesting that ACT may be a more acceptable option.

Osteoarthritis year in review 2018: rehabilitation and outcomes

OBJECTIVE

Conduct a systematic review of systematic reviews and randomised controlled trials (RCTs) from the past year evaluating rehabilitation for people with osteoarthritis, and provide narrative synthesis of findings focused on core recommended treatments for osteoarthritis (exercise, education, biomechanical interventions, weight loss).

DESIGN

A comprehensive search strategy was used to search PubMed, EMBASE and Cochrane databases (16^th May 2017 to 22^nd March 2018). Search terms included 'osteoarthritis', 'rehabilitation', 'systematic review', and 'randomised controlled trial'. Inclusion criteria were: (1) RCT, or systematic review of randomised clinical trials (RCTs); (2) human participants with osteoarthritis (any joint); (3) evaluation of rehabilitation intervention; and (4) at least one patient-reported measure. Methodological quality was evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR) tool (systematic reviews) and PEDro rating scale (RCTs). Narrative synthesis mapped findings to core recommendations from existing osteoarthritis clinical guidelines.

RESULTS

From 1994 records, 13 systematic reviews and 36 RCTs were included. 73% of these evaluated knee osteoarthritis (36 studies). The remaining studies evaluated hand osteoarthritis (6 studies), hip, hip/knee and general osteoarthritis (each 2 studies), and neck osteoarthritis (1 study). Exercise was the most common intervention evaluated (31%). Updated recommendations for exercise prescription and preliminary guidance for psychological interventions are provided.

CONCLUSION

Level 1 and 2 osteoarthritis rehabilitation literature continues to be dominated by knee osteoarthritis studies. Consistent with current clinical guidelines, exercise should be a core treatment for osteoarthritis, but future studies should ensure that exercise programs follow published dose guidelines. There is a clear need for research on rehabilitation for hip, hand, foot/ankle, shoulder and spine osteoarthritis.

A meta-analysis of dropout rates in acceptance and commitment therapy

Many psychotherapies, including cognitive behavioral therapy and acceptance and commitment therapy (ACT), have been found to be effective interventions for a range of psychological and behavioral health concerns. Another aspect of treatment utility to consider is dropout, as interventions only work if clients are engaged in them. To date, no research has used meta-analytic methods to examine dropout in ACT. Thus, the objectives of the present meta-analysis were to (1) determine the aggregate dropout rate for ACT in randomized controlled trials, (2) compare dropout rates in ACT to those in other psychotherapies, and (3) identify potential moderators of dropout in ACT. Our literature search yielded 68 studies, representing 4,729 participants. The weighted mean dropout rates in ACT exclusive conditions and ACT inclusive conditions (i.e., those that included an ACT intervention) were 15.8% (95% CI: 11.9%, 20.1%) and 16.0% (95% CI: 12.5%, 19.8%), respectively. ACT dropout rates were not significantly different from those of established psychological treatments. In addition, dropout rates did not vary by client characteristics or study methodological quality. However, master's-level clinicians/therapists (weighted mean = 29.9%, CI: 17.6%, 43.8%) were associated with higher dropout than psychologists (weighted mean = 12.4%, 95% CI: 6.7%, 19.4%). More research on manipulable, process variables that influence dropout is needed.

Effect of Land-Based Generic Physical Activity Interventions on Pain, Physical Function, and Physical Performance in Hip and Knee Osteoarthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this study was to evaluate the effects of land-based generic physical activity interventions on pain, physical function, and physical performance in individuals with hip/knee osteoarthritis, when compared with a control group that received no intervention, minimal intervention, or usual care.

METHODS

A systematic search for randomized controlled trials on 11 electronic databases (from their inception up until April 30, 2016) identified 27 relevant articles. According to the compendium of physical activities, interventions were categorized into: recreational activities (tai chi/Baduajin-6 articles), walking (9 articles), and conditioning exercise (12 articles).

RESULTS

Meta-analysis for recreational activity (n = 3) demonstrated significant mean difference (MD) of -9.56 (95% confidence interval [CI], -13.95 to -5.17) for physical function (Western Ontario and McMaster Universities Arthritis Index) at 3 mos from randomization. Pooled estimate for walking intervention was not significant for pain intensity and physical performance but was significant for physical function (n = 2) with a MD of -10.38 (95% CI, -12.27 to -8.48) at 6 mos. Meta-analysis for conditioning exercise was significant for physical function (n = 3) with a MD of -3.74 (95% CI, -5.70 to -1.78) and physical performance (6-minute walk test) with a MD of 42.72 m (95% CI, 27.78, 57.66) at 6 mos. The timed stair-climbing test (n = 2) demonstrated a significant effect at 18 mos with a MD of -0.49 secs (95% CI, -0.75 to -0.23).

CONCLUSION

Very limited evidence to support recreational activity and walking intervention was found for knee osteoarthritis, in the short-term on pain and physical function, respectively.

Understanding knee osteoarthritis from the patients' perspective: a qualitative study

BACKGROUND

No studies of Health Coach Interventions for knee OA sufferers that include patients' perspectives have been published. The study assesses current clinical practice and primary care professionals' advice from the patients' perspective, in order to obtain a participative design for a complex intervention based on coaching psychology. Moreover, wants to analyse the experiences, perceptions, cognitive evaluation, values, emotions, beliefs and coping strategies of patients with knee osteoarthritis, and secondly the impact of these factors in the Self-management of this condition.

METHODS

It is an interpretative qualitative study. The study included patients with diagnosis of knee osteoarthritis (OA) from 4 primary health care centres in Barcelona. A theoretical sampling based on a prior definition of participants' characteristics was carried out. Ten semi-structured interviews with knee OA patients were carried out. A content thematic analysis was performed following a mixed-strategy text codification in Lazarus framework and in emerging codes from the data.

RESULTS

The results are structured in two blocks: Experiences and perceptions of informants and Experiences of knee osteoarthritis according to the Lazarus model. Regarding experiences and perceptions of informants: Some participants reported that the information was mostly provided by health professionals. Informants know which food they should eat to lose weight and the benefits of weight loss. Moreover, participants explained that they like walking but that sometimes it is difficult to put into practice. Regarding experiences of knee osteoarthritis according Lazarus model: Cognitive evaluation is influenced by cognitive distortions such as obligation, guilt, dramatization and catastrophism.

VALUES

Family is the value most associated with wellbeing. Helping others is another recurring value. Emotions: Most participants explain that they feel anxiety, irritability or sadness. Beliefs: To some, physiotherapy helps them feel less pain. However, others explain that it is of no use to them. Participants are aware of the association overweight- pain. Coping strategies: The strategies for coping with emotions aim to reduce psychological distress (anxiety, sadness, anger) and some are more active than others.

CONCLUSIONS

The study highlights that patients with knee osteoarthritis require a person-centered approach that provides them with strategies to overcome the psychological distress caused by this condition.