Download 2. Is pain acceptance a good indicator for differential response to

Is pain acceptance a good indicator for
differential response to various
rehabilitation packages?
Linn Wifstrand1, David Gillanders2, Graciela Rovner1,3
1Institute
3Rehabilitation
2Psychology
of Neuroscience and Physiology at
Sahlgrenska Academy, University of Gothenburg
Rehabilitation Medicine, SWEDEN
Medicine, Dept of Clinical
Sciences Karolinska Institutet, Danderyd
University Hospital Stockholm, SWEDEN
School,
University of Edinburgh
Scotland, UK
CBT encourages patients to develop
Multi-Professional
Rehabilitation for
Chronic Pain
ACT focuses on function rather than
on controlling thoughts, emotions or
symptoms. The goal of rehabilitation is
to help patients live a meaningful life
despite their pain. Focusing on their
values, the program improved their
willingness to experience pain (or
negative thoughts or emotions) while
choosing to live a vital life.
coping strategies to avoid external
stressors and teaches patients
’adaptive’ skills through exposure,
education, relaxation and cognitive
restructuring. The idea is that the
patients need to control thoughts and
emotions to modify ’maladaptive’ pain
behaviors.
There is strong evidence for the
effectiveness of behavioral-based
rehabilitation programs for patients
with chronic pain, both those based
on Acceptance & Commitment
Therapy (ACT) and those on
Cognitive Behavioral Therapy (CBT)
What is not known is which group of patients benefit best of these rehabilitation programs
Aim: to investigate the patients’ differential response to various rehabilitation packages
Pain Rehabilitation
Clinic, Danderyd
Hospital
Clustering patients in groups
according to their pain acceptance
Previous research has suggested that
clustering patients according to their pain
acceptance can predict treatment outcome.
Study
population
N=391
Self-report
Questionnaires
Study Design
& Statistics
Rehabilitation
program
ACT
T-test/X2 group differences
CBT
n= 272
1
n= 119
SF-36 Medical Outcome Study
CPAQ
Short Form 36
HAD
Scales Subscales
Anxiety
Depression
Physical Function
Role Physical
Bodily Pain
General Health
Vitality
Social Function
Role Emotional
Mental Health
Physical Comp. Sum.
Mental Comp. Sum.
Activity Engagement
Pain Willingness
MPI Pain Severity
EQ-5D Index
T-test outcome differences
High AE
High PW
High AE
Low PW
Low AE
Low PW
4
Pre-rehab T-test
Post-rehab
n= 53 outcome
3
ANOVA total cluster differences
PAIN WILLIGNESS (PW)
2
4 CLUSTERS
ACTIVITY ENGAGEMENT (AE)
Higher in
High in
The patients were Middle
• QoL
• QoL
• Mental Function
•
Physical
Function
grouped in four
• Physical
• Mental Function
Function
• Social Function
• Social Function
clusters by
• Pain
Lower in
High High
• Pain
performing
AE AE
hierarchical cluster
analysis on their
Low High
pain acceptance
PW PW
scores from the
Low Low
CPAQ two
AE AE
subscales:
Low High
PW: Pain
Middle low in
Lower in
• QoL
PW
PW
Willingness is the •• QoL
• Mental Function
Mental Function
• Physical
• Physical Function
amount of pain
Function
• Social Function
• Social Function
Higher in
• Pain
the patient is
• Pain
willing to
experience while participating in important actitivites.
AE: Activity Engagement is the degree to which the
patient continues with daily life despite the presence of
pain.
4
Pre-rehab T-test
Post-rehab
n= 57 outcome
4
Pre-rehab T-test
Post-rehab
n= 70 outcome
4
Low AE
High PW
Pre-rehab T-test
Post-rehab
n= 92 outcome
2
4
Pre-rehab T-test
Post-rehab
n= 33 outcome
4
Pre-rehab T-test
Post-rehab
n= 34 outcome
4
Pre-rehab T-test
Post-rehab
n= 18 outcome
TSK
4
Pre-rehab T-test
Post-rehab
n= 34 outcome
5
Mixed between-within subjects ANOVA outcome differences depending on rehabilitation type
In 2 between ACT and CBT and in 5 between all clusters
Research questions
• Main findings
1 ACT & CBT groups:
Differences at base-line?
2 ACT & CBT groups:
Differential responses?
• Both groups improved in quality of life, pain, mental and physical
function. The ACT group improved in more areas and greately in
physical function
3 Clusters:
Differences at base-line?
• Distinct differences were found among clusters in all aspects
• The greatest difference was between the ’high’ and the ’low’
cluster, where the ’low’ reported feeling worse in all aspects
4 Clusters:
Differential responses?
• Clusters that underwent ACT rehabilitation improved in more
areas than those that underwent CBT
• Both the ’high’ and ’low’ clusters improved more after ACT
rehabilitation regarding their physical function
• This difference was the largest for the ’low’ cluster
Physical Mental Social
Funct. Funct. Funct.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
QoL: Qualtiy of Life
HAD: Hospital Anxiety and Depression Scale
CPAQ-8: Chronic Pain Acceptance Questionnaire, 8 items
MPI: Multidimensional Pain Inventory
EQ-5D: European Quality of Life- 5 Dimentions
TSK: Tampa Scale for Kinesiophobia
Conclusions
• ACT group: widespread pain, 89.3% women, low in quality of life
and all functional levels and high in pain levels
• CBT group: neck and/or back pain, 60.5% women and better in all
aspects
5 Is ACT or CBT more
effective?
Kinesiophobia
QoL Pain
• The ACT group benefited across more domains than
the CBT group
• Distinct differences were found regarding improvement of
physical function between ACT and CBT groups
• Acceptance-based clusters are effective as indicators for:
• Quality of life and functional differences among patients
at base-line
• Differential responses to rehabilitation
Take home message
Behavioral medicine targets ’verbs’.
’To accept pain’ is a verb, a behavior: something
we always can do better and improve.
Pain symptoms are not behaviors.
To assess and group patients according to their
pain acceptance helps us understand what they
need and to better predict their outcome.
Med. Stud. Linn Wifstrand
[email protected]
Dr. David Gillanders
[email protected]
Dr. Graciela Rovner
[email protected]