Digital acceptance and commitment therapy for adults with chronic pain

Background: Chronic pain is common and usually associated with co-morbid difficulties, which further reduces function and quality of life in those afflicted. Chronic pain also creates a great economic burden on both health-care and society at large. Pharmacological treatment is often not sufficient to solve the chronic pain problem and a combination of pharmacological and behavioral treatment are often needed. Although both CBT and ACT have been found promising to increase function and quality of life in the chronic pain population there is still room for improvement and access to treatment is low. The need for an increased access to treatment could be met by the development of new delivery formats, such as internet- and smartphone delivered treatment.

Aims: The overall objective of the present doctoral thesis was to increase access and reach of evidence-based behavioral treatment for chronic pain by transforming a well proven face-to-face ACT treatment into viable digital formats. Another aim was to gain more knowledge of what predicts treatment results. A successful translation of the treatment would result in accessible, feasible and effective digital treatment that contributes to increased function and quality of life. The primary outcome of the intervention was reduced pain interference but the intervention was also aiming to improve secondary outcomes anxiety, depression, psychological flexibility, valued living, health related quality of life, insomnia and pain intensity.

Methods: Four individual studies have been conducted, where the first (study I) was a randomized controlled trial evaluating the immediate and long-term efficacy of internet delivered ACT (iACT) for chronic pain compared to a waiting list control group. The second study (study II) documented the methodological process of transforming iACT in to a clinical trial ready treatment intervention feasible with smartphone and tablet (ACTsmart). Study II also reports on alpha and beta testing with end users. Subsequently, the immediate and prolonged preliminary efficacy of ACTsmart was evaluated in a non-randomized pilot trial (study III) where participants underwent 8 weeks of treatment and were repeatedly assessed on outcome measures. In study IV data from study I and III as well as data from a pilot that preceded study I was pooled and analyzed to examine potential predictors of treatment outcome in digitally delivered behavioral treatment for adult chronic pain patients.

Results: In study I, significant improvements in favor of the active treatment, iACT, were seen for the primary outcome pain interference as well as for a majority of the secondary outcomes. Between-group effect sizes were large for pain interference (d = 0.99), psychological flexibility (d = 1.00) and pain intensity (d = 1.20). All improvements were maintained at 1-year follow-up. In study II, the alpha and beta testing of ACTsmart resulted in further optimization of the treatment. Following optimization, the treatment was accessible for patients regardless of location or physical functioning and considered feasible with regards to usage, acceptability and practicality. This made the treatment a trial ready solution that was “good enough” to undergo efficacy testing. In study III, the preliminary efficacy testing of ACTsmart showed high treatment compliance among the 34 participants as well as significant improvement in all outcomes with large effect sizes for primary outcome pain interference (d = 1.01) as well as secondary outcomes avoidance (d = 1.34) and value obstruction (d = 1.02). Effects were maintained throughout 12 months of follow-up. In study IV, an examination of 30 potential predictor variables in a sample of pooled data from study I, study III and a pilot study that preceded study I, showed that shorter pain duration and higher levels of insomnia pre-treatment predict greater improvement in pain interference at post treatment.

Conclusion: Internet-delivered ACT (iACT) is clinically effective for treating adult patients with chronic pain. The treatment can improve pain interference, pain intensity, mood and sleep up to 1 year following treatment. The treatment is also feasible with regards to usage, acceptability and practicality when delivered via smartphone and tablet and there is preliminary support for the efficacy of smartphone delivered ACT (ACTsmart) when it comes to improving functioning in adult individuals with chronic pain. Examination of potential predictors of treatment effect show that shorter pain duration and higher degree of insomnia severity at baseline predict larger treatment effect of digital Acceptance and Commitment Therapy (desktop and smartphone/tablet).

List of scientific papers

I. Rickardsson, J., Gentili, C., Holmström, L., Zetterqvist, V., Andersson, E., Persson, J., ... & Wicksell, R. K. (2021). Internet‐delivered acceptance and commitment therapy as micro-learning for chronic pain: A randomized controlled trial with 1‐year follow‐up. European Journal of Pain. 25(5), 1012-1030.
https://doi.org/10.1002/ejp.1723

II. Gentili, C., Zetterqvist, V., Rickardsson, J., Holmström, L., Simons, L. E., Wicksell, R. K. (2020). ACTsmart–development and feasibility of digital Acceptance and Commitment Therapy for adults with chronic pain. NPJ Digital Medicine. 3(1), 1–12.
https://doi.org/10.1038/s41746-020-0228-4

III. Gentili, C., Zetterqvist, V., Rickardsson, J., Holmström, L., Simons, L. E., & Wicksell, R. K. (2020). ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain—A Pilot Trial. Pain Medicine.
https://doi.org/10.1093/pm/pnaa360

IV. Gentili, C., Zetterqvist, V., Rickardsson, J., Holmström, L., Ljótsson, B., & Wicksell, RK. Examining predictors of treatment effect in digital Acceptance and Commitment Therapy for chronic pain. [Manuscript]