Digging Deeper

We have looked at the scientific evidence for this treatment published in international medical journals. Below are some questions and answers that will help you better understand the evidence for ACT.

1. What is meant by “evidence” in medical and psychological journals?

When journals discuss “evidence,” they are referring to information that has been collected by researchers and clinicians to support or refute a topic or point of interest. Good quality evidence is most often collected by randomised control trials (RCTs) or systematic reviews.

2. What are randomised control trial (RCT)?

A RCT is a study where people participating in clinical research are randomly allocated to different groups. One group is given an intervention (treatment), while other groups might be given a different intervention or no intervention at all. Comparisons can then be made between the outcomes of each group to see how effective a treatment is.

RCTs are the “gold standard” in research because study conditions are highly controlled and monitored. This means researchers can ensure they are measuring the impact of the intervention and not something else that might influence outcomes.

3. And what about systematic reviews?

A systematic review involves collecting information from multiple studies to answer a specific question. It is “systematic” because the researchers clearly describe how they searched and selected the research in their review. This allows other researchers to replicate the review. By collating the findings of multiple studies, all the available evidence that is relevant to a particular question can be found in one place.

4. So, how does ACT fit into RCTs and systematic reviews?

There are RCTs that test how effective and safe ACT is with different groups of people, including those with chronic pain. There are also systematic reviews of these RCTs. The findings from these RCTs and systematic reviews form part of the evidence we have for ACT.

5. Tell me then – what evidence is there for ACT and chronic pain management?

Several studies provide evidence that ACT is effective for the management of chronic pain:

• One systematic review found that ACT can help improve physical functioning and reduce the distress caused by pain. This means you are more physically active.[1]
• Another systematic review found that ACT can have a considerable positive impact on pain acceptance and this led to a positive impact on daily functioning. Again showing higher levels of physical activity can be achieved.[2]
• In a third systematic review,  it was shown that ACT led to improvements in pain intensity, disability, depression, and quality of life were seen with ACT.[3]  Even greater improvements were shown in when looking at anxiety and pain interference. Further, when following up with participants between 2 to 6 months after ACT, considerable improvements in depression and quality of life and major reductions in pain interference were found. In the same review, ACT was more effective for pain management than applied relaxation (mind-body exercises) or expressive writing (writing about stressful or traumatic experiences). So overall showing mental well-being and physical acitivity improved and that ACT is superior to similar compatible programmes.

 

    6. How exactly does ACT help with chronic pain?

Research suggests three key-ways in which ACT can help with chronic pain:

• ACT increases psychological flexibility. In other words, it increases your ability to be in the present moment more fully. This give you time to make a conscious decision about whether certain behaviours related to your pain are in line with your end goals. If these behaviours are in line with your end goals, you can choose to continue with them. If they aren’t, then you can choose to change them. So you decide what You do – You are NOT being dictated to by your pain all the time!

 

• ACT increases pain-related acceptance. Instead of avoiding pain, you allow it to enter your awareness without attempting to change it. You become more able to be at ease and live with your pain better.

 

• ACT increases values-based action. This means that you become more aware of your personal values and commit to living according to those values despite any struggles you may be having with pain. So living a life that is more about being true to you. Recognising yourself once again. A valued life!

Research also suggests that the benefits of ACT for pain management can be explained by its neurological underpinnings.

7. What do you mean by neurobiological underpinnings?

When we talk about the neurobiological underpinnings of ACT, we are referring to what happens in the brain during ACT. Studies have shown that ACT can change the way the brain processes pain.[4]^,[5] For example, one study involving women with fibromyalgia (chronic pain in the bones and muscles) found that ACT led to increases in thought control, enabling the women to reappraise their pain and look at it differently leading to their pain having less impact. In essence, ACT has been shown in effect to rewire your brain and how it processes pain leading to a better quality of life.

8. Do we know anything about who ACT helps?

There is some evidence that older adults and those who are in distress might respond well to ACT.[6]^,[7] Evidence also suggests that social and demographic characteristics don’t appear to impact its effectiveness.[8] This is good news! It means that a wide range of people can benefit from the practice.

9. I have heard of CBT (cognitive behavioural therapy) – how does ACT compare?

CBT has for chronic pain has been around a long time compared to ACT and there are more studies to evaluate how effective it is.

You can think of CBT as a much earlier version of ACT. CBT focuses on challenging thoughts and behaviours rather than noticing and accepting them. There is a detailed article by Dr Lydia Rodney looking at the CBT vs ACT.

It is interesting to note, however, that more people tend to drop out of RCTs testing CBT than those testing ACT. One study found the dropout rate to be 15.8% for ACT and 25.3% for CBT.[9] More people seem to complete ACT programs compared to those going on a CBT program.

More UK based pain clinics are utilising ACT in their approach to pain management programs as it seems to be more effective based on experience of practitioners.

10. Is there any evidence ACT for pain can work online?

Yes,  several studies have shown that ACT  can be helpful for chronic pain suffer through an online program- which is one of the reasons for setting this program up[10] [11].

11. What does evidence of cost-effectiveness mean?

Cost-effectiveness is a way of weighing the costs of treatment against the health benefits to patients. It also helps determine if a certain treatment is more cost-effective than another treatment.

There isn’t a lot of studies looking at the the cost-effectiveness of ACT for chronic pain. One study[12] suggests that ACT is more cost-effective than applied relaxation and another study[13] found it to be more cost-effective than pain medications.

10. This all sounds great, but what does it mean for me?

There is evidence from both patient reports and neurological findings that support the use of ACT for the management of chronic pain. Some research even shows it to be better than pain medication!

It can help you gain greater awareness of your personal values and how pain-related behaviours might be getting in the way of living according to those values. With this knowledge, you will have greater control over the decisions you make and how you live your life despite your pain.

Overall, the evidence suggests and it is our belief that your pain will have less of an interfering impact on your daily life and it will lift your mood. Your physical and mental well-being improves!

 

[1] Hann, K. and McCracken, L. (2014). A systematic review of randomized controlled trials of acceptance and commitment therapy for adults with chronic pain: outcome domains, design quality, and efficacy, Journal of Contextual Behavioural Science. 2014;3(4):217–227.

[2] Hughes, L., Clark, J., Colclough, J. and Mcmillan, D. (2017). Acceptance and commitment therapy (ACT) for chronic pain: a systematic review and meta-analyses, Clinical Journal of Pain 2017;33:552–568.

[3] Veehof, M., Trompetter, H., Bohlmeijer, E. and Schreurs, K. (2016). Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review, Cognitive Behavior Therapy. 2016; 45(1):5-31.

[4] Jensen, K., Kosek, E., Wicksell, R., Kemani, M., Olsson, G., Merle, J., Kadetoff. D. and Ingvar, M. (2012). Cognitive Behavioral Therapy increases pain-evoked activation of the prefrontal cortex in patients with fibromyalgia, Pain. 2012 Jul; 153(7):1495-503.

[5] Smallwood, R., Potter, J. and Robin, D. (2016). Neurophysiological mechanisms in acceptance and commitment therapy in opioid-addicted patients with chronic pain, Psychiatry Research Neuroimaging. 2016 Apr 30; 250():12-4.

[6] Wetherell, J.L. et al. (2016). Age moderates response to acceptance and commitment therapy vs. cognitive behavioral therapy for chronic pain. Int J Geriatr Psychiatry. 2016;31(3):302–308.

[7]Davis, M.C. et al. (2015). Mindfulness and cognitive–behavioral interventions for chronic pain: differential effects on daily pain reactivity and stress reactivity. J Consult Clin Psychol. 2015;83(1):24–35.

[8] McCracken, L. and Gutiérrez-Martínez, O. (2011). Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy, Behavioural Research Therapy. 2011 Apr; 49(4):267-74.

[9] Ong, C., Lee, E. and Twohig, M. (2018). A meta-analysis of dropout rates in acceptance and commitment therapy, Behaviour Research Therapy. 2018 May; 104():14-33.

[10] Fledderus, M., Schreurs, K. M., Bohlmeijer, E. T., & Vollenbroek-Hutten, M. M. (2015). Development and pilot evaluation of an online relapse-prevention program based on acceptance and commitment therapy for chronic pain patients. JMIR human factors, 2(1), e1.

[11] Simister, H. D., Tkachuk, G. A., Shay, B. L., Vincent, N., Pear, J. J., & Skrabek, R. Q. (2018). Randomized controlled trial of online acceptance and commitment therapy for fibromyalgia. The Journal of Pain, 19(7), 741-753.

[12] Kemani, M., Olsson, G., Lekander, M., Hesser, H., Andersson, E. and Wicksell, R. (2015). Efficacy and Cost-effectiveness of Acceptance and Commitment Therapy and Applied Relaxation for Longstanding Pain: A Randomized Controlled Trial, Clinical Journal of Pain. 2015 Nov; 31(11):1004-16.

[13] Luciano, J., D’Amico, F., Feliu-Soler, A., McCracken, L., Aguado, J., Peñarrubia-María, M., Knapp, M., Serrano-Blanco, A. and García-Campayo, J. (2017). Cost-Utility of Group Acceptance and Commitment Therapy for Fibromyalgia Versus Recommended Drugs: An Economic Analysis Alongside a 6-Month Randomized Controlled Trial Conducted in Spain (EFFIGACT Study), Journal of Pain. 2017 Jul; 18(7):868-880.