Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – A randomized controlled trial

Although several studies have illustrated the effectiveness of cognitive behavior therapy (CBT) on adult pain patients, there are few randomized controlled trials on children and adolescents. There is particularly a need for studies on pediatric patients who are severely disabled by longstanding pain syndromes. Acceptance and Commitment Therapy, as an extension of traditional CBT, focuses on improving functioning and quality of life by increasing the patient’s ability to act effectively in concordance with personal values also in the presence of pain and distress. Following a pilot study, we sought to evaluate the effectiveness of an ACT-oriented intervention based on exposure and acceptance strategies and to compare this with a multidisciplinary treatment approach including amitriptyline (n = 32). The ACT condition underwent a relatively brief treatment protocol of approximately 10 weekly sessions. Assessments were made before and immediately after treatment, as well as at 3.5 and 6.5 months follow-up. Prolonged treatment in the MDT group complicated comparisons between groups at follow-up assessments. Results showed substantial and sustained improvements for the ACT group. When follow-up assessments were included, ACT performed significantly better than MDT on perceived functional ability in relation to pain, pain intensity and to pain-related discomfort (intent-to-treat analyses). At post-treatment, significant differences in favor of the ACT condition were also seen in fear of re/injury or kinesiophobia, pain interference and in quality of life. Thus, results from the present study support previous findings and suggest the effectiveness of this ACT-oriented intervention for pediatric longstanding pain syndromes.     

The Psychological Inflexibility in Pain Scale (PIPS) – Statistical properties and model fit of an instrument to assess change processes in pain related disability

Recent developments within CBT have emphasized acceptance rather than control of pain and distress in treatments aimed at improving functioning and life quality, but there is still a lack of reliable and valid instruments to assess relevant processes in such interventions. The Psychological Inflexibility in Pain Scale (PIPS) was developed to assess target variables in exposure and acceptance oriented treatments. A preliminary validation study resulted in a two‐factor solution with subscales for avoidance and cognitive fusion related to pain, showing satisfactory psychometric properties. This study sought to evaluate the instrument with 611 participants with whiplash associated disorders. Exploratory and confirmatory factor analyses supported a two‐factor solution with 12 items which showed an acceptable model fit, adequate internal consistencies, and strong relations with criteria variables (e.g. disability and life satisfaction). The construct validity of the instrument was supported by high correlations with subscales from the Chronic Pain Acceptance Questionnaire (CPAQ) and the Tampa Scale of Kinesiophobia (TSK). Notably, hierarchical regression analyses illustrated that PIPS explained more variance than TSK in pain, disability, life satisfaction and depression. Furthermore, PIPS was found to mediate the relationship between e.g. pain and disability, suggesting the usefulness of PIPS as a process measure in treatments of people with chronic pain. Thus, it is argued that this 12‐item version of PIPS may be used to explore the importance of psychological in/flexibility in chronic pain and to analyse processes of change in exposure based interventions, as well as for clinicians in tailoring interventions for patients with chronic debilitating pain.     

Mediators of change in acceptance and commitment therapy for pediatric chronic pain

Even though psychological interventions are well established in the treatment of pediatric chronic pain, there is a clear need for further development, especially with severely disabled patients. However, optimizing effectiveness in psychological treatments for pain requires clarification of the mechanisms of action. Studies addressing change processes are scarce, however, particularly in relation to pediatric chronic pain. Acceptance and Commitment Therapy (ACT), as an extension of traditional cognitive behavior therapy, is essentially aimed at improving functioning by increasing the ability to act effectively in the presence of pain and distress, that is, psychological flexibility. ACT has shown promising results for both adult and pediatric chronic pain. In the present study, the mediators of change in an ACT-oriented treatment for pediatric chronic pain were examined using a bootstrapped cross product of coefficients approach. Pain interference and depression were used as outcome variables. Six different variables relevant to theories underlying ACT and cognitive behavior therapy were included in the analyses as possible mediators of change: pain impairment beliefs, pain reactivity, self-efficacy, kinesiophobia, catastrophizing, and pain intensity. Results illustrated that pain impairment beliefs and pain reactivity were the only variables that significantly mediated the differential effects of treatment on outcomes at follow-up. Also, these 2 mediators were shown to independently predict effects in outcome variables at follow-up while controlling for earlier effects in outcome, but only for the ACT condition. Although tentative, the pattern of results suggests that variables consistent with psychological flexibility mediate the effects of ACT-based interventions to improve functioning in patients with chronic debilitating pain.     

The effectiveness of a rehabilitation programme for Chinese cancer survivors: A pilot study

Cancer survivors have experienced high stress which impairs psychological functioning and decreases quality of life (QOL). This study aims to assess the mediating effect of self‐efficacy on mood disturbance and QOL, and determine the effectiveness of a 12 week rehabilitation programme to improve self‐efficacy as well as improve mood disturbance and QOL in Chinese cancer survivors. A total of 47 cancer patients were randomly assigned into the experimental (n = 24) and control (n = 23) groups. The participants in the experimental group received cancer‐related education, progressive muscle relaxation and emotional support. Self‐reported questionnaires, including General Self‐efficacy Scale (GSES), Profile of Mood States Scale–Short Form (POMS‐SF) and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ‐C30) were collected in pre‐ and post‐intervention. Findings from this study indicated that self‐efficacy was a complete mediator between mood disturbance and QOL, and the 12 week rehabilitation programme had a positive effect on self‐efficacy, mood disturbance and QOL for Chinese cancer survivors.     

Cognitive‐Behavioural Therapy for Command Hallucinations and Intellectual Disability: A Case Study

Background There is a paucity of literature detailing cognitive‐behavioural therapy (CBT) for psychosis in people with intellectual disability. Of the available literature, only two case studies involve people with command hallucinations and these do not address specific issues of intervention indicated in the wider literature for this type of presentation. Methods The present paper reports a case study documenting the successful application of CBT targeting the treatment of command hallucinations for mild intellectual disability. Results A range of measures (including positive and negative syndrome scale, beliefs about voices questionnaire and psychotic symptom rating scale for auditory hallucinations) collected at pre‐ and post‐intervention indicates successful reduction in positive symptoms, with 3‐ and 6‐month follow‐up data indicating maintenance of improvements. Critically, positive clinical changes in core beliefs regarding the power of the hallucinatory voice are also observed. Conclusions Cognitive‐behavioural therapy for command hallucinations can be successfully adapted and applied to people with a mild disability.     

Functional Outcomes in Patients with Chronic Nonmalignant Pain on Long‐Term Opioid Therapy

? Abstract Objectives: Although long‐term opioid therapy for chronic nonmalignant pain (CNMP) is widely accepted, it is controversial as to whether long‐term benefits outweigh detrimental side effects. This study examines the effect of long‐term opioid therapy on quality of life in terms of both physical and mental health in patients with CNMP. Methods: We retrospectively studied a cohort of patients with CNMP. With informed consent, data were collected prior to and at 6–36 months after the institution of opioid therapy in 67 patients with CNMP. The Short Form 36 (SF‐36) health survey was used to compare self‐reported measures of health‐related quality of life in nine subscales. Visual analog scale (VAS) for pain intensity scores, disability status, and ability to return to work were also assessed. The pre‐ and post‐therapy parameters were compared. Results: The average scores of self‐reported quality of life improved significantly in eight out of the nine parameters in the SF‐36 after at least 6 months of opioid therapy. The increase in reported scores was statistically significant for physical functioning, physical role, bodily pain, general health, validity, social functioning, emotional role, and mental health. No significant changes were observed in reported health transition, VAS pain scores, disability status, or return to work. Conclusions: We conclude that judicious use of opioid therapy may lead to improvement in perceived quality of life and certain aspects of functional capacity and daily activities in a highly selected group of patients with CNMP who have not responded to other therapeutic modalities for over 6 months. ?     

Do quality of life,anxiety, depression and acceptance improve after interdisciplinary pain rehabilitation? A multicentre matched control study of acceptance and commitment therapy-based versus cognitive–behavioural therapy-based programmes

ObjectiveInterdisciplinary pain rehabilitation (IPR) usually employs a cognitive–behavioural therapeutic (CBT) approach. However, there is growing support for chronic pain treatments based on acceptance and commitment therapy (ACT). Most studies of ACT and CBT for chronic pain have evaluated their effects after psychological interventions, not after IPR. We compared the results of an ACT-based IPR programme with two CBT-based IPR programmes.MethodsWe used a retrospective multicentre pretest–posttest design with matched patient groups at three centres. Data were collected from the Swedish Quality Registry for Pain Rehabilitation before and after IPR participation. Participants completed the EQ-5D health-related quality of life questionnaire, the Chronic Pain Acceptance Questionnaire, (CPAQ) and the Hospital Anxiety and Depression Scale (HADS). Analyses were performed to compare the effects of the different interventions.ResultsNeither EQ-5D nor HADS depression scores were affected by the psychological approach used. The score changes on both CPAQ subscales (activity engagement and pain willingness) indicated significant improvements between admission and discharge at all centres.ConclusionsThese findings indicate the effectiveness of using psychological approaches to manage chronic pain. Both CBT and ACT had a beneficial effect on most of the assessed health-related parameters.     

Attention management as a treatment for chronic pain

Attention management is often included in cognitive‐behavioural treatments (CBT). The aim of this study was to evaluate the effects of attention management strategies in the treatment for chronic pain. The present pilot study consisted of six weekly 90‐min treatment sessions and was based on a CBT attention management manual describing techniques such as attention diversion, imagery and mindfulness exercises. The intended outcomes were reduction in pain‐related anxiety and hypervigilance to pain and decrease in pain impact of everyday life, measured by self‐report. Information was collected at baseline, pre‐treatment, post‐treatment, and at 3 and 6 months follow‐up. The results at the end of treatment, and at 3‐month follow‐up, show significant reductions in pain‐related anxiety, hypervigilance and interference of pain (effect sizes 0.40–0.90). Reduction in pain‐related interference and anxiety remained at the 6‐month follow‐up. The results indicate that attention control skills can be a useful method to reduce anxiety in the short term. Clinical implications of the results are discussed.     

A Trial of a Brief Group-Based Form of Acceptance and Commitment Therapy (ACT) for Chronic Pain in General Practice: Pilot Outcome and Process Results

Acceptance and commitment therapy (ACT) is a developing approach for chronic pain. The current study was designed to pilot test a brief, widely inclusive, local access format of ACT in a UK primary care setting. Seventy-three participants (68.5% women) were randomized to either ACT or treatment as usual (TAU). Many of the participants were aged 65 years or older (27.6%), were diagnosed with fibromyalgia (30.2%) and depression (40.3%), and had longstanding pain (median = 10 years). Standard clinical outcome measures included disability, depression, physical functioning, emotional functioning, and rated improvement. Process measures included pain-related and general psychological acceptance. The recruitment target was met within 6 months, and 72.9% of those allocated to ACT completed treatment. Immediately post treatment, relative to TAU, participants in ACT demonstrated lower depression and higher ratings of overall improvement. At a 3-month follow-up, again relative to TAU, those in ACT demonstrated lower disability, less depression, and significantly higher pain acceptance; d = .58, .59, and .64, respectively. Analyses based on intention-to-treat and on treatment “completers,” perhaps predictably, revealed more sobering and more encouraging results, respectively. A larger trial of ACT delivered in primary care, in the format employed here, appears feasible with some recommended adjustments in the methods used here (Trial registration: ISRCTN49827391).     

Influence of specific muscle training on pain,activity limitation and kinesiophobia in women with back pain post‐partum — A ‘Single‐subject research design’

Background and Purpose . Many women suffer from back pain and experience activity limitation post‐partum. To our knowledge the physiological factors and physiotherapy related to back pain post‐partum have received limited evaluation and the effectiveness of specific physiotherapeutic approaches to exercise should be tested. In addition, there has been limited research on kinesiophobia in women with back pain post‐partum. The purpose of the current study was to test the influence of specific trunk muscle training on pain, activity limitation and kinesiophobia in 10 subjects with back pain post‐partum. Method . The treatment consisted of specific deep muscle training of the transversus abdominus and multifidus muscles. Pain was rated based on the visual analogue scale (VAS) and pain drawings. Activity limitation was recorded using the Disability Rating Index. Kinesiophobia was evaluated using the Swedish version of the Tampa Scale for Kinesiophobia. An A–B–A single‐subject research design was used and a number of measurements were obtained during each phase. The analysis consisted of a visual inspection and a two standard deviation band test (2‐SD). Results . The visual analysis showed a trend towards reduced pain and activity limitation for all 10 subjects. The 2‐SD test showed mixed results among all subjects. In addition, all subjects reported kinesiophobia before and after treatment. Conclusions . Individual specific deep muscle training of the transversus abdominus and multifidus muscles reduced pain and activity limitation in women with back pain post‐partum. Further research is needed to determine more precisely how kinesiophobia affects women with back pain post‐partum. Copyright © 2007 John Wiley & Sons, Ltd.     

Domains of Chronic Low Back Pain and Assessing Treatment Effectiveness: A Clinical Perspective

Nonspecific chronic low back pain (CLBP) is a common clinical condition that has impacts at both the individual and societal level. Pain intensity is a primary outcome used in clinical practice to quantify the severity of CLBP and the efficacy of its treatment; however, pain is a subjective experience that is impacted by a multitude of factors. Moreover, differences in effect sizes for pain intensity are not observed between common conservative treatments, such as spinal manipulative therapy, cognitive behavioral therapy, acupuncture, and exercise training. As pain science evolves, the biopsychosocial model is gaining interest in its application for CLBP management. The aim of this article is to discuss our current scientific understanding of pain and present why additional factors should be considered in conservative CLBP management. In addition to pain intensity, we recommend that clinicians should consider assessing the multidimensional nature of CLBP by including physical (disability, muscular strength and endurance, performance in activities of daily living, and body composition), psychological (kinesiophobia, fear‐avoidance, pain catastrophizing, pain self‐efficacy, depression, anxiety, and sleep quality), social (social functioning and work absenteeism), and health‐related quality‐of‐life measures, depending on what is deemed relevant for each individual. This review also provides practical recommendations to clinicians for the assessment of outcomes beyond pain intensity, including information on how large a change must be for it to be considered “real” in an individual patient. This information can guide treatment selection when working with an individual with CLBP.     

Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain - a pilot study.

For chronic pain of unclear origin (idiopathic), pharmacological therapy is often insufficient. Psychological treatment strategies have been developed and evaluated for adults with chronic pain. However, few such studies are seen with youths, and to date there is limited empirical evidence regarding the effectiveness of psychological treatment for generalized musculoskeletal pain syndromes in adolescents. Acceptance and commitment therapy (ACT) is a development of cognitive behaviour therapy emphasizing exposure and acceptance. In this pilot study, 14 adolescents referred to the pain treatment service due to chronic debilitating pain were treated using an ACT-based approach. It was hypothesized that avoidance of pain and related stimuli was central to the disability seen among these patients, and that exposure and acceptance strategies could increase functioning and decrease pain. In contrast to emphasizing reductions in pain and distress, the treatment objective was to improve functioning by increasing the patient's ability to act in line with personal values in the presence of negative thoughts, emotions or bodily sensations. Following treatment, and retained at 3- and 6-month follow-up, improvements in functional ability, school attendance, catastrophizing and pain (i.e., intensity and interference) were seen. The outcome of this pilot study indicates that exposure and acceptance can been useful in the rehabilitation of adolescents with chronic debilitating pain. Randomized controlled studies are needed to empirically evaluate the effectiveness of this approach.     

Prevalence,severity, and chronicity of pain and general health‐related quality of life in patients with localized prostate cancer

Aims: To analyze the prevalence and the severity spectrum of pain and its relationships to health‐related quality of life and the bio‐psycho‐social consequences of pain among patients scheduled for radical prostatectomy. Methods: Urological inpatients completed an epidemiological pain questionnaire extensively exploring pre‐operative acute and chronic pains in 21 body regions. The severity of pain was determined using von Korff's Pain Grading (CPGQ). Pain chronicity was estimated employing the Mainz Pain Staging System (MPSS). Anxiety and depressive symptoms were identified with the HADS and the Habitual Well‐Being Questionnaire (FW‐7). Health‐related quality of life was measured using the SF‐12. Comorbidities and comorbidity‐related interferences with daily activities were ascertained with the Weighted Illness Checklist (WICL). Results: Eighty of 115 patients (69.6%) reported about pain during the last 3 months pre‐operatively. 28.7% of the pain patients had pain related to urological disease. Severe dysfunctional pain was identified by pain Grades 3 and 4 of the CPGQ in 20% and 13.8%, respectively. Advanced pain chronicity characterized by pain Stages II and III of the MPSS was present in 38.8% and 11.3%. Patients with localized prostate cancer without pain complaints had significantly better health‐related quality of life and habitual well‐being and lower anxiety and depression scores and fewer comorbidities. Patients with cancer‐related and non‐cancer pain did not differ in pain chronicity, pain severity, pain intensities, anxiety, comorbidities and physical health (SF12‐PCS). Conclusions: The high prevalence of severe and chronic pain in cancer patients before scheduled radical prostatectomy – combined with considerable disability effects and markedly reduced quality of life necessitate a short routine screening‐analysis of the severity spectrum of pain and psychopathology. Patient self‐rated pain chronicity staging and psychological distress analysis will allow a disorder severity‐guided treatment and the prevention of suffering and additional new chronic post‐surgical pain.     

Effectiveness of group acceptance and commitment therapy for fibromyalgia: A 6-month randomized controlled trial (EFFIGACT study)

In the last decade, there has been burgeoning interest in the effectiveness of third-generation psychological therapies for managing fibromyalgia (FM) symptoms. The present study examined the effectiveness of acceptance and commitment therapy (ACT) on functional status as well as the role of pain acceptance as a mediator of treatment outcomes in FM patients. A total of 156 patients with FM were enrolled at primary health care centers in Zaragoza, Spain. The patients were randomly assigned to a group-based form of ACT (GACT), recommended pharmacological treatment (RPT; pregabalin + duloxetine), or wait list (WL). The primary end point was functional status (measured with the Fibromyalgia Impact Questionnaire, FIQ). Secondary end points included pain catastrophizing, pain acceptance, pain, anxiety, depression, and health-related quality of life. The differences between groups were calculated by linear mixed-effects (intention-to-treat approach) and mediational models through path analyses. Overall, GACT was statistically superior to both RPT and WL immediately after treatment, and improvements were maintained at 6 months with medium effect sizes in most cases. Immediately after treatment, the number needed to treat for 20% improvement compared to RPT was 2 (95% confidence interval 1.2–2.0), for 50% improvement 46, and for achieving a status of no worse than mild impaired function (FIQ total score <39) also 46. Unexpectedly, 4 of the 5 tested path analyses did not show a mediation effect. Changes in pain acceptance only mediated the relationship between study condition and health-related quality of life. These findings are discussed in relation to previous psychological research on FM treatment.     

Is adherence to pain self‐management strategies associated with improved pain,depression and disability in those with disabling chronic pain?

There is generally good evidence that pain management interventions that include self‐management strategies can substantially reduce disability and improve psychological well‐being in patients with chronic pain. Reductions in unhelpful responses, especially catastrophising and fear‐avoidance beliefs, have been established as key contributors to these gains. In contrast, there is surprisingly little evidence that adherence to self‐management strategies contributes to achieving these outcomes. Difficulties in defining and measuring the use of pain self‐management strategies have been obstacles for this research. Using a pragmatic way of assessing the practice of specific strategies this study investigated their ability to account for changes in pain, disability and depressive symptoms after a 3‐week cognitive‐behavioural pain management program. The post‐treatment outcomes on these dimensions were found to be statistically and, for many, clinically significant. Consistent with previous research, reductions in catastrophising and fear‐avoidance beliefs, and increased pain self‐efficacy beliefs, were also associated with these gains. But the key new finding was that there was a clear gradient between adherence to specific self‐management strategies and reductions in pain, disability and depressive symptoms. Furthermore, adherence to the self‐management strategies was predictive of better outcomes even after controlling for the moderating effects of initial catastrophising, fear‐avoidance and pain self‐efficacy beliefs.     

Acceptance and Commitment Therapy for Chronic Pain: Evidence of Mediation and Clinically Significant Change Following an Abbreviated Interdisciplinary Program of Rehabilitation

There is an emerging body of evidence regarding interdisciplinary acceptance and commitment therapy in the rehabilitative treatment of chronic pain. This study evaluated the reliability and clinical significance of change following an open trial that was briefer than that examined in previous work. In addition, the possible mediating effect of psychological flexibility, which is theorized to underlie the acceptance and commitment therapy model, was examined. Participants included 117 completers of an interdisciplinary program of rehabilitation for chronic pain. Assessment took place at treatment onset and conclusion, and at a 3-month follow-up when 78 patients (66.7%) provided data. At the 3-month follow-up, 46.2% of patients achieved clinically significant change, and 58.9% achieved reliable change, in at least 1 key measure of functioning (depression, pain anxiety, and disability). Changes in measures of psychological flexibility significantly mediated changes in disability, depression, pain-related anxiety, number of medical visits, and the number of classes of prescribed analgesics. These results add to the growing body of evidence supporting interdisciplinary acceptance and commitment therapy for chronic pain, particularly with regard to the clinical significance of an abbreviated course of treatment. Further, improvements appear to be mediated by changes in the processes specified within the theoretical model.PerspectiveOutcomes of an abbreviated interdisciplinary treatment for chronic pain based on a particular theoretical model are presented. Analyses indicated that improvements at follow-up mediated change in the theorized treatment process. Clinically significant change was indicated in just under half of participants. These data may be helpful to clinicians and researchers interested in intervention approaches and mechanisms of change.     

Cognitive Behavioral Therapy increases pain-evoked activation of the prefrontal cortex in patients with fibromyalgia

Interventions based on Cognitive Behavioral Therapy (CBT) are widely used to treat chronic pain, but the brain mechanisms responsible for these treatment effects are poorly understood. The aim of this study was to validate the relevance of the cortical control theory in response to an exposure-based form of CBT, Acceptance and Commitment Therapy, in patients with chronic pain. Forty-three female patients diagnosed with fibromyalgia syndrome were enrolled in a randomized, 12-week, waiting-list controlled clinical trial (CBT n=25; controls n=18). CBT was administered in groups of six patients during 12 weekly sessions. Functional magnetic resonance imaging (fMRI) during pressure-evoked pain was assessed before and after treatment or the 12-week period. Self-report questionnaires of depression and anxiety were administered pre- and posttreatment as well as 3 months following end of treatment. Patients treated with CBT reported larger improvement of fibromyalgia on the Patient Global Impression of Change measure, and improved depression and anxiety symptoms, compared to the waiting-list controls. However, there were no effects on clinical pain or pain sensitivity measures. An analysis of fMRI scans revealed that CBT led to increased activations in the ventrolateral prefrontal/lateral orbitofrontal cortex; regions associated with executive cognitive control. We suggest that CBT changes the brain's processing of pain through an altered cerebral loop between pain signals, emotions, and cognitions; leading to increased access to executive regions for reappraisal of pain. Our data thereby support our hypothesis about the activation of a cortical control mechanism in response to CBT treatment in chronic pain.     

Are patient ratings of chronic pain services related to treatment outcome?

Consumer ratings of satisfaction with treatment are rarely used as measures of treatment outcome. This study examined the relationships between service ratings and psychometric outcomes of patients receiving pain-management services in a tertiary teaching hospital. A group of 122 patients who completed a multidisciplinary pain-management program rated their satisfaction with and effectiveness of services received and changes in their pain condition and quality of life (QOL). They also completed pre- and posttreatment measures of pain severity, pain interference, depression, and disability. Pain severity, pain interference, and depression significantly decreased following treatment. The patients' ratings of services were significantly associated with outcome measures. Pre- to posttreatment changes in pain severity and pain interference were associated with treatment satisfaction and effectiveness, improvement in pain condition, and QOL. Pre- to posttreatment change in disability was significantly related to ratings of treatment effectiveness, improvement in pain condition, and quality of life. The findings suggest that pain intensity, pain interference, and disability are important outcome dimensions of pain-management programs.     

Chronic pain acceptance and affective well‐being: A coping perspective

This study examined the relationship between chronic pain acceptance and affective well‐being from a coping perspective. One hundred‐fifty patients from a multidisciplinary pain centre provided self‐report data including measures of pain acceptance, positive and negative affect, and accommodative flexibility. The bivariate and multiple correlation patterns were consistent with the assumption that pain willingness (the attitudinal component of pain acceptance including the recognition of the uncontrollability of pain) primarily reduces negative affect, whereas activity engagement (the behavioural component of pain acceptance including the pursuit of life activities despite pain) additionally produces positive affect. The data furthermore suggested activity engagement as a mediating link between pain willingness and positive affect. Moderation analyses showed that accommodative flexibility (the general readiness to adjust personal goals to situational constraints) facilitates both pain willingness and activity engagement – especially when average pain intensity is high. In sum, the results support the view that chronic pain patients’ well‐being is closely tied to the maintenance of life activities which presupposes an accepting attitude towards pain.