Exposure and acceptance in patients with chronic debilitating pain : a behavior therapy model to improve functioning and quality of life
Author: Wicksell, Rikard K
Date: 2009-02-06
Location: Nanna Svartz aula, Karolinska Universitetssjukhuset, Solna
Time: 09.00
Department: Institutionen för klinisk neurovetenskap / Department of Clinical Neuroscience
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Thesis (705.2Kb)
Abstract
A large number of patients suffer from reduced functioning and quality of
life due to longstanding pain. The importance of psychological factors is
undisputable and there is today substantial empirical support for
treatments based on cognitive behavior therapy (CBT). Nevertheless,
previous research also illustrates a clear need for improvements. For
example, there is a lack of studies with children and adolescents that
are severely disabled by longstanding pain other than headache. Also, the
process by which CBT is effective is still rather unclear. Recently,
developments within CBT, such as Acceptance and Commitment Therapy (ACT),
suggest an approach that, in contrast to reduction or control of
symptoms, promotes acceptance of negative private experiences like
chronic pain and distress. This type of intervention is aimed at
improving functioning and quality of life by increasing psychological
flexibility, i.e. the ability to act in alignment with personal values
also in the presence of e.g. pain, fear, and negative thoughts. Although
studies exist, there is an urgent need for randomized controlled trials
with chronic pain patients, especially children and adolescents.
The presented studies were conducted within the development of a clinical model to improve functioning and quality of life in children, adolescents, and adults with chronic debilitating pain. The thesis had two general aims. One, to investigate the effectiveness of an intervention based on values-oriented exposure and acceptance (studies 1, 2, and 4 in the present thesis). Two, to develop and psychometrically evaluate a self-report instrument designed to assess psychological flexibility in people with chronic pain (studies 2 and 5).
Initially, an uncontrolled pilot study (study 1) was conducted with adolescents suffering from chronic idiopathic pain (n=16). Following treatment, large and stable reductions were seen in e.g. functional disability, pain intensity, and catastrophizing, with generally large effect sizes.
Study 3 included people with chronic pain and whiplash associated disorders (WAD) (n=22). Exposure and acceptance delivered in addition to treatment as usual (TAU) was compared with a control group receiving only TAU. Following the exposure and acceptance intervention, improvements were seen in all measures but pain intensity, and these effects were retained seven months following the end of treatment. Furthermore, significant differences following treatment, in favor of the exposure and acceptance group, were seen in e.g. pain disability, life satisfaction, fear of movement, and psychological inflexibility, with moderate to large effect sizes.
In study 4, participants were children and adolescents with chronic idiopathic pain (n=32). The effectiveness of exposure and acceptance was evaluated by comparing it with a multidisciplinary treatment approach including amitriptyline (MDT). The exposure and acceptance group showed large and sustained improvements in all measures, including functioning, quality of life, and pain intensity, with mostly large effects sizes. The exposure and acceptance group performed significantly better than the MDT on e.g. perceived functional ability in relation to pain, kinesiophobia, pain intensity and pain related discomfort, with moderate to large effect sizes.
Parallel to the treatment evaluations, two studies were conducted to develop and evaluate an instrument to assess central and discernible components of psychological flexibility, referred to as the Psychological Inflexibility in Pain Scale (PIPS). In the development study (study 2), data was collected from pain clinics and patient organizations (n=203). Based on an original set of 38 items, principal component analyses suggested a two-factor solution with 16 items, showing adequate internal consistency and concurrent criterion validity.
In study 5, participants were recruited from a patient organization for people with WAD (n=611). Exploratory and confirmatory factor analyses resulted in a two-factor solution with 12 items, illustrating good reliability and validity. Only items that were retained in both studies 2 and 5 were included in the final version of the instrument. Furthermore, hierarchical regression analyses illustrated that PIPS explained a significant amount of variance in e.g. pain, work absence, life satisfaction, disability, depression, and kinesiophobia.
In conclusion, despite some methodological limitations, the treatment evaluations indicate the effectiveness of the exposure and acceptance intervention, and suggest that it may be superior to TAU only, as well as to a multidisciplinary program including amitriptyline. Furthermore, data from two measurement development studies suggest that PIPS can be used as a reliable and valid measure to assess key components in psychological inflexibility in people with chronic pain. More studies are needed to confirm these findings; especially larger scale randomized controlled trials.
The presented studies were conducted within the development of a clinical model to improve functioning and quality of life in children, adolescents, and adults with chronic debilitating pain. The thesis had two general aims. One, to investigate the effectiveness of an intervention based on values-oriented exposure and acceptance (studies 1, 2, and 4 in the present thesis). Two, to develop and psychometrically evaluate a self-report instrument designed to assess psychological flexibility in people with chronic pain (studies 2 and 5).
Initially, an uncontrolled pilot study (study 1) was conducted with adolescents suffering from chronic idiopathic pain (n=16). Following treatment, large and stable reductions were seen in e.g. functional disability, pain intensity, and catastrophizing, with generally large effect sizes.
Study 3 included people with chronic pain and whiplash associated disorders (WAD) (n=22). Exposure and acceptance delivered in addition to treatment as usual (TAU) was compared with a control group receiving only TAU. Following the exposure and acceptance intervention, improvements were seen in all measures but pain intensity, and these effects were retained seven months following the end of treatment. Furthermore, significant differences following treatment, in favor of the exposure and acceptance group, were seen in e.g. pain disability, life satisfaction, fear of movement, and psychological inflexibility, with moderate to large effect sizes.
In study 4, participants were children and adolescents with chronic idiopathic pain (n=32). The effectiveness of exposure and acceptance was evaluated by comparing it with a multidisciplinary treatment approach including amitriptyline (MDT). The exposure and acceptance group showed large and sustained improvements in all measures, including functioning, quality of life, and pain intensity, with mostly large effects sizes. The exposure and acceptance group performed significantly better than the MDT on e.g. perceived functional ability in relation to pain, kinesiophobia, pain intensity and pain related discomfort, with moderate to large effect sizes.
Parallel to the treatment evaluations, two studies were conducted to develop and evaluate an instrument to assess central and discernible components of psychological flexibility, referred to as the Psychological Inflexibility in Pain Scale (PIPS). In the development study (study 2), data was collected from pain clinics and patient organizations (n=203). Based on an original set of 38 items, principal component analyses suggested a two-factor solution with 16 items, showing adequate internal consistency and concurrent criterion validity.
In study 5, participants were recruited from a patient organization for people with WAD (n=611). Exploratory and confirmatory factor analyses resulted in a two-factor solution with 12 items, illustrating good reliability and validity. Only items that were retained in both studies 2 and 5 were included in the final version of the instrument. Furthermore, hierarchical regression analyses illustrated that PIPS explained a significant amount of variance in e.g. pain, work absence, life satisfaction, disability, depression, and kinesiophobia.
In conclusion, despite some methodological limitations, the treatment evaluations indicate the effectiveness of the exposure and acceptance intervention, and suggest that it may be superior to TAU only, as well as to a multidisciplinary program including amitriptyline. Furthermore, data from two measurement development studies suggest that PIPS can be used as a reliable and valid measure to assess key components in psychological inflexibility in people with chronic pain. More studies are needed to confirm these findings; especially larger scale randomized controlled trials.
List of papers:
I. Wicksell RK, Melin L, Olsson GL (2007). "Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain - a pilot study." Eur J Pain 11(3): 267-74. Epub 2006 Apr 17
Pubmed
II. Wicksell RK, Renöfält J, Olsson GL, Bond FW, Melin L (2008). "Avoidance and cognitive fusion--central components in pain related disability? Development and preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS)." Eur J Pain 12(4): 491-500. Epub 2007 Sep 20
Pubmed
III. Wicksell RK, Ahlqvist J, Bring A, Melin L, Olsson GL (2008). "Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial." Cogn Behav Ther 37(3): 169-82
Pubmed
IV. Wicksell RK, Melin L, Lekander M, Olsson GL (2007). "Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain - A randomized controlled trial." Pain Dec 22: Epub ahead of print
Pubmed
V. Wicksell RK, Lekander M, Sorjonen K, Olsson GL (2009). "The Psychological Inflexibility in Pain Scale (PIPS) validation and confirmatory factor analysis of an instrument to assess avoidance and cognitive fusion in longstanding pain." (Submitted)
I. Wicksell RK, Melin L, Olsson GL (2007). "Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain - a pilot study." Eur J Pain 11(3): 267-74. Epub 2006 Apr 17
Pubmed
II. Wicksell RK, Renöfält J, Olsson GL, Bond FW, Melin L (2008). "Avoidance and cognitive fusion--central components in pain related disability? Development and preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS)." Eur J Pain 12(4): 491-500. Epub 2007 Sep 20
Pubmed
III. Wicksell RK, Ahlqvist J, Bring A, Melin L, Olsson GL (2008). "Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial." Cogn Behav Ther 37(3): 169-82
Pubmed
IV. Wicksell RK, Melin L, Lekander M, Olsson GL (2007). "Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain - A randomized controlled trial." Pain Dec 22: Epub ahead of print
Pubmed
V. Wicksell RK, Lekander M, Sorjonen K, Olsson GL (2009). "The Psychological Inflexibility in Pain Scale (PIPS) validation and confirmatory factor analysis of an instrument to assess avoidance and cognitive fusion in longstanding pain." (Submitted)
Issue date: 2009-01-16
Rights:
Publication year: 2009
ISBN: 978-91-7409-312-4
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