Acceptance and Commitment Therapy for Chronic Pain Shows Benefit
Patients with chronic pain are subject to 2 cycles, noted the presenters: a physical and a psychological vicious circle.
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In a presentation given at the annual PAINWeek conference, held in Las Vegas, Nevada, September 4 to 8, Heather Poupore King, PhD, from the Division of Pain Management at Stanford University School of Medicine, and Corinne Cooley, DPT, from the Pain Management Center at Stanford Health Care, both in Redwood City, California, presented results from a preliminary study examining the effects of an acceptance and commitment therapy in individuals with chronic pain.
Patients with chronic pain are subject to 2 cycles, noted the presenters: a “physical vicious circle,” in which pain leads to activity avoidance, itself resulting in progressive deconditioning, which leads to pain with reduced activity, and further deconditioning, itself feeding back into activity avoidance; and a “psychological vicious circle,” in which symptoms such as anxiety, anger, or fear, which are commonly associated with chronic pain, lead to impoverished mood and depression, resulting in an enhanced perception of pain, itself feeding back into a state of impaired mood.
The 6-week program that the researchers have implemented at Stanford relies on evidence-based studies indicating the efficacy of multi- and interdisciplinary approaches to the management of chronic pain. This program includes 6 components: acceptance and commitment therapy; pain neuroscience education; value-based weekly goal-setting (30 minutes) combined with mindfulness/meditation (30-minute session); individualized exercise program designed by a physical therapist, based on activity goals set by the patient (1 hour-long); aerobic-graded exercise program; and yoga-based group movement program led by a physical therapist, during which awareness is brought to one’s breath and emotions during movement.
The goal of the acceptance and commitment therapy program is for patients to accept their difficulties while acknowledging their barriers (namely, avoidance and “cognitive fusion”) in an effort to shift from an awareness of the content of the pain experience to an awareness of the context of the pain experience. With this therapy, investigators seek to help patients reach a state of psychological flexibility vs inflexibility, in which, for example, cognitive fusion is replaced with “defusion,” experiential avoidance is replaced with acceptance, and a lack of direction is replaced with a set of values. Patients are encouraged to take small steps toward the values they have set for themselves.
In this preliminary study, results from 18 individuals (mean age, 56.5 years; chronic pain duration, 1-18 years) with chronic low back pain (radicular or nonradicular) who had previously been enrolled in a physical therapy program and completed this 6-week program, were presented. The study’s primary outcomes were disability and acceptance, assessed with the Roland Morris Disability and Chronic Pain Acceptance questionnaires, respectively. Secondary outcomes were pain measurements (assessed using the 0-10 numeric pain rating scale); evaluation of catastrophizing, using the Pain Catastrophizing Scale; and objective measures of physical activity, with testing of walking, lifting, and balancing abilities.
Acceptance was found to increase in individuals enrolled in the program, from a score of 48 on the questionnaire at baseline to a score of 73.7 at the end of the therapy (at 6 weeks), an improvement that was maintained at the 3-month follow-up (score, 72.8). Disability was also improved by the program in this small cohort, as indicated by a reduction in the disability score from baseline (12.7 points) to the end of the treatment (7.3 points at 6 weeks), a score that was further improved at the 3-month follow-up (5.2 points). Pain levels were also found to be improved by the program.
A correlation was established between higher acceptance scores and lower disability (n=18; P =.05), as well as with reduced catastrophizing (n=13; P =.01). Higher pain intensity was also found to correlate with higher pain catastrophizing (n=13; P =.05).
Patients enrolled in this initial study provided positive feedback, emphasizing the importance of adding a psychological component to the physical therapy program.
Poupore-King H, Cooley C. The carrot vs the stick: Interdisciplinary values based treatment for chronic pain. Presentation BHV-01. Presented at: PAINWeek 2018; September 4-8, 2018; Las Vegas, NV.
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