Guided internet-delivered acceptance and commitment therapy for chronic pain patients: A randomized controlled trial

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Highlights

  • Internet-delivered acceptance and commitment therapy for chronic pain is investigated.

  • Chronic pain patients are randomized to a treatment or to a control group.

  • Internet-delivered ACT shows some promise as a treatment option for chronic pain.

  • The findings are important as it add to the literature on ACT and chronic pain.

  • Results add to the field examining cost-effective interventions for chronic pain.

Abstract

Acceptance and commitment therapy (ACT) interventions for persons with chronic pain have recently received empirical support. ACT focuses on reducing the disabling influences of pain through targeting ineffective control strategies and teaches people to stay in contact with unpleasant emotions, sensations, and thoughts. The aim of the present study was to investigate the effect of a guided internet-delivered ACT intervention for persons with chronic pain. A total of 76 patients with chronic pain were included in the study and randomized to either treatment for 7 weeks or to a control group that participated in a moderated online discussion forum. Intent-to-treat analyses showed significant increases regarding activity engagement and pain willingness. Measurements were provided with the primary outcome variable Chronic Pain Acceptance Questionnaire which was in favour of the treatment group. Reductions were found on other measures of pain-related distress, anxiety and depressive symptoms. A six month follow-up showed maintenance of improvements. We conclude that an acceptance based internet-delivered treatment can be effective for persons with chronic pain.

Introduction

For many individuals chronic pain has adverse consequences on daily activity, employment, relationships, and emotional functioning (Breivik, Collett, Ventafridda, Cohen & Gallcher, 2006). Several studies have investigated the prevalence of chronic pain among adults. Results show that 15–20 percent of adults experience chronic pain. Considering all sources of expenditures, chronic pain has a large financial impact on society (Breivik et al., 2006).

Chronic pain is a demoralizing situation that compromises all aspects of the person's life, including disability and emotional distress. Psychological research has identified the central role of cognitive, behavioural and emotional factors contributing to the perpetuation of chronic pain (Kerns, Sellinger, & Goodin, 2011). Cognitive-behavioural therapy (CBT) delivered in a multidisciplinary setting has been shown in several controlled studies to be effective in the treatment of chronic pain (e.g. Hoffman, Papas, Chatkoff, & Kerns, 2007; Morley, Eccleston, & Williams, 1999). A common factor for the psychologically oriented interventions for chronic pain is that the focus is on the consequences that pain has on one's life, rather than on pain intensity, as a way of directly addressing adaptive behavioural change (Kerns et al., 2011).

In the so called third generation of cognitive behavioural treatments, e.g. acceptance and commitment therapy (ACT), function is emphasized in contrast to form. Behaviour is analysed from a functional perspective, i.e. the aim is to understand why a particular behaviour is maintained rather than describing what kind of behaviour a person performs. In order to understand how influence can affect the function of behaviour it is important to alter the social/verbal context through identification of basic processes that are common across settings (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes, Strosahl, & Wilson, 1999). From this perspective, chronic pain can be viewed as an experiential avoidance disorder. Experiential avoidance has been defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences, which often creates suffering in the long-run (McCracken, Vowles, & Eccleston, 2004; Vowles & McCracken, 2010). Studies have shown that experiential avoidance is associated with higher pain intensity, pain-related anxiety, depression and physical and psychosocial disability (Feldner et al., 2006; McCracken, 1998; McCracken & Vowles, 2006). These results suggest that acceptance of pain and a willingness to abandon the struggle to avoid or reduce pain, will enable the individual to be more present in the moment. Mindfulness exercises, have its roots in Asian religious traditions, help the individual to fully experience the phenomenon in the present moment without the influence of verbal content (Fletcher & Hayes, 2005). Being present in the moment will help the individual distancing from pain-related thoughts and acting in accordance with chosen values (McCracken, 1998; McCracken & Eccleston, 2003; McCracken & Vowles, 2006; McCracken et al., 2004; Wetherell et al., 2011).

A systematic review showed that acceptance based therapies could be an alternative to CBT although the researchers stated that more controlled studies are needed (Veehof, Oskam, Schreurs & Bohlmeijer, 2011). The review included seven ACT-studies and fifteen mindfulness-based stress reduction (MBSR) programs. In addition, ACT has been listed as an empirically supported treatment for chronic pain and depression (APA, 2006/2011).

There are many obstacles for persons with chronic pain to seek or receive adequate help such as, financial barriers, reluctance to seek treatment, and paucity of clinicians trained in CBT (including evidence-based multidisciplinary treatment options) (Jamison, Gintener, Rogers, & Fairchild, 2002). The use of internet as a delivery format for CBT interventions could be a way to overcome many of these barriers. Internet-delivered cognitive behaviour therapy (ICBT) has proved effective for various conditions both in the physical and mental health domains (Andersson et al., 2008; Barak, Hen, Boniel-Nissim, & Shapira, 2008; Cuijpers, van Straten, & Andersson, 2008). Some of the advantages with internet-based treatments are: reducing therapist time and waiting lists, allowing patients to work in their own pace, no need for scheduling with a therapist, availability to a greater number of patients and cost-effectiveness (Cuijpers et al., 2008).

In the field of pain, several internet-based treatments have been developed (Bender, Radhakrishnan, Diorio, Englesakes & Jadad, 2011; Macea, Gajos, Daglia-Calil, & Fregni, 2010). These have mainly concerned CBT and participants have been recruited through newspaper advertisements (Brattberg, 2006; Buhrman, Fältenhag, Ström, & Andersson, 2004; Buhrman, Nilsson-Ihrfelt, Jannert, Ström, & Andersson, 2011; Carpenter, Stoner, Mundt, & Stoelb, 2012; Ruehlman, Karoly, & Enders, 2012). One study showed that a self-help intervention based on ACT for chronic pain was superior to applied relaxation. The participants in that study received one face-to-face session and a self-help manual with reading instructions including a CD with exercises (Thorsell et al., 2011). Even though there have been ACT elements in some of these studies there is no study on internet-based ACT for chronic pain to date in use.

The purpose of the present study was to investigate if a guided internet-based ACT intervention could help chronic pain patients. Participants were recruited from a clinical setting. The active treatment group was compared to a moderated online discussion forum which has been used as an active intervention in previous studies (e.g. Lorig et al., 2002).

Section snippets

Recruitment procedure and inclusion

All participants were recruited from the Pain Center at the Uppsala University hospital in Sweden. The patients had undergone a medical examination but had not received any multidisciplinary rehabilitation. Information about the present study was sent to 273 patients from the patient register. The letter also informed the patients that they would be contacted via telephone and that they could decline participation without being further contacted. The patients were contacted by telephone in

Materials

Measures were obtained pre- and post-intervention and administered via the internet. Self-report questionnaires generally show the same psychometric properties as paper-and-pencil administration (Buchanan, 2003). In order to be able to compare the results with our previous studies several outcome variables were similar to the ones used in our earlier trials (Buhrman et al., 2004, 2011), with the exception of the acceptance measure. Given that the present study focused on ACT, acceptance was

Chronic Pain Acceptance Questionnaire (CPAQ)

After controlling for pretest scores, there were significant effects between groups on the CPAQ- activity engagement scale [F(1,73) = 4.36, p = .04], CPAQ- pain willingness scale [F(1,73) = 6.69, p = .012], and on the total scale on CPAQ [F(1,73) = 6.0, p = .017], all in favour for the treatment group. The corresponding effects sizes were medium to small with Cohen's being d = 0.60 (CI95% = 0.11–1.03), d = 0.49 (CI95% = 0.04–0.94), and d = 0.41 (CI95% = 0.0–0.86) respectively. The six months

Discussion

The present study examined if an internet-based ACT intervention could help chronic pain patients and the findings support this intervention therapy. Results are encouraging considering that participants in the study were recruited from a clinical setting and had average pain duration of 15 years. Moreover, the majority was on sick leave and half of the participants had concurrent psychiatric problems (see Table 1). Improvements were maintained over a 6-month follow-up period.

The choice of

Conflict of interest

No conflicts of interest.

Acknowledgements

We thank the Multidisciplinary Pain Center at Uppsala University hospital for support during the trial. We also thank Alexander Alasjö for web support. Dr Andersson is supported in part by a grant from Linköping University, a grant from Rehsam/Vårdalsstiftelsen, and the Swedish council for working and life research.

References (58)

  • R.A. Fish et al.

    Validation of the chronic pain acceptance questionnaire (CPAQ) in a Internet sample and development and preliminary validation of the CPAQ-8

    Pain

    (2010)
  • S.C. Hayes et al.

    Acceptance and commitment therapy: model, processes and outcomes

    Behaviour Research and Therapy

    (2006)
  • E. Hedman et al.

    Cost-effectiveness of Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: results from a randomized controlled trial

    Behaviour Research and Therapy

    (2011)
  • R.D. Kerns et al.

    The West Haven Yale Multidimensional Pain Inventory (WHYMPI)

    Pain

    (1985)
  • D.D. Macea et al.

    The efficacy of Web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis

    The Journal of Pain

    (2010)
  • L.M. McCracken

    Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain

    Pain

    (1998)
  • L.M. McCracken et al.

    Coping or acceptance: what to do about chronic pain

    Pain

    (2003)
  • L.M. McCracken et al.

    Acceptance of chronic pain: component analysis and a revised assessment method

    Pain

    (2004)
  • L.M. McCracken et al.

    Acceptance based treatment for persons with complex, long-standing chronic pain: a preliminary analysis of treatment outcome in comparison to waiting phase

    Behaviour Research and Therapy

    (2005)
  • S. Morley et al.

    Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache

    Pain

    (1999)
  • A.K. Rosenstiel et al.

    The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment

    Pain

    (1983)
  • L.S. Ruehlman et al.

    A randomized controlled evaluation of an online chronic pain self management program

    Pain

    (2012)
  • M.M. Veehof et al.

    Acceptance-based intervention for the treatment of chronic pain: a systematic review and meta-analysis

    Pain

    (2011)
  • K.E. Vowles et al.

    Comparing the role of psychological flexibility and traditional pain management coping strategies in chronic pain treatment outcomes

    Behaviour Research and Therapy

    (2010)
  • K.E. Vowles et al.

    The chronic pain acceptance questionnaire: confirmatory analysis and identification of patient subgroups

    Pain

    (2008)
  • J.L. Wetherell et al.

    A randomized controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain

    Pain

    (2011)
  • R.K. Wicksell et al.

    Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain: a randomized controlled trial

    Pain

    (2009)
  • R.K. Wicksell et al.

    The chronic pain acceptance questionnaire (CPAQ)-further validation including a confirmatory factor analysis and a comparison with the Tampa Scale of Kinesiophobia

    European Journal of Pain

    (2009)
  • G. Andersson et al.

    Development of a new approach to guided self-help via the internet. The Swedish experience

    Journal of Technology in Human Services

    (2008)
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