Barriers and Facilitators of Evidence-Based Psychotherapies for Chronic Pain in Adults: A Systematic Review

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n = 28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs individual therapy and telehealth or asynchronous digital approaches.PerspectiveThis systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain.RegistrationPROSPERO number CRD42021252038     

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.     

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.     

Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash

Cognitive behavior therapy (CBT) has made important contributions to chronic pain management, but the process by which it is effective is not clear. Recently, strong arguments have been raised concerning the need for theory driven research to e.g. identify mechanisms of change in CBT and enhance the effectiveness of this type of treatment. However, the number of studies addressing these issues is still relatively scarce. Furthermore, the arrival of varieties of CBT with seemingly different process targets increases the need for such information. The present study explored the processes of change in a previously reported successful randomized controlled trial evaluating the effectiveness of an exposure‐based form of behavioral and cognitive therapy, Acceptance and Commitment Therapy (ACT), on improvement in pain‐related disability and life satisfaction for patients suffering from whiplash‐associated disorder (WAD). Several process variables relevant to theories underlying traditional CBT were included: pain, distress, kinesiophobia, self‐efficacy, and the process primarily targeted by ACT: psychological inflexibility. Mediation analyses were performed using a non‐parametric cross‐product of the coefficients approach. Results illustrated that pain intensity, anxiety, depression, kinesiophobia, and self‐efficacy did not have significant mediating effects on the dependent variables. In contrast, significant indirect effects were seen for psychological inflexibility on pain‐related disability (pre‐ to post‐change scores) and life satisfaction (pre‐ to post; pre‐ to 4‐month follow‐up change scores). Although tentative, these results support the mediating role of psychological inflexibility in ACT‐oriented interventions aimed at improving functioning and life satisfaction in people with chronic pain.     

Therapeutic modalities in the management of nonspecific neck pain

This article has surveyed several therapeutic modalities, including physical modalities, thermal modalities, electrical modalities, exercise therapy, behavioral therapy, education, and laser therapy. Of these, exercise, mobilization, and manipulation have the greatest support in the literature, whereas thermal treatments (including therapeutic ultrasound), and electrical therapies (including TENS) have little evidence of effectiveness and no evidence for more than a transient benefit. There is a need for well-controlled studies of educational programs and behavioral interventions specifically for patients with chronic neck pain, particularly because these interventions are often employed as part of a multimodal treatment program. Low-power laser treatment and magnetic therapy require some well-controlled studies before they can be recommended to neck pain patients or discarded as worthless interventions. Cervical traction and soft collars seem to be generally ineffective for nonspecific neck pain.     

Cognitive and behavioral interventions for the management of chronic neuropathic pain in adults – A systematic review

Background: Chronic neuropathic pain is often associated with conditions such as depression and anxiety and strongly affects daily functioning and overall quality of life. It is argued, therefore, that psychosocial interventions should be added to traditional biomedical interventions. This systematic review evaluates the effectiveness of cognitive and behavioral interventions for the management of chronic neuropathic pain. Methods: Electronic databases were searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was assessed with the Health Technology Assessment‐Disease Management instrument. Furthermore, an explorative meta‐analysis of four selected studies was performed. Results: Fourteen studies were assessed: three randomized controlled trials, three controlled before–after studies, seven uncontrolled before–after studies and one time series analysis. The findings of the meta‐analysis were not consistent with a significant effect on pain intensity. Only one study had good methodological quality; it showed some significant effects of the interventions, but only in female participants. Other studies of limited methodological quality did report positive effects on pain and quality of life. Conclusions: This is the first systematic review that has evaluated the effectiveness of cognitive and behavioral techniques for the management of chronic neuropathic pain. Given the limited methodological quality, no informative conclusions can be drawn with respect to the study objective. However, this review does provide insight into the difficulties of this specific area, the need for a clear and widely accepted definition of neuropathic pain and the need for standardized multidimensional measurement instruments.     

接纳与承诺疗法用于干预终末期癌痛患者的效果

目的 探讨接纳与承诺疗法(ACT)用于干预终末期癌痛患者的效果.方法 选取2018年1月至2019年1月在江苏省肿瘤医院进行终末期癌痛护理的100例患者,随机分为对照组与研究组,每组50例.两组患者入院后均行常规镇痛治疗与常规终末期癌痛护理,研究组另给予以接纳与承诺疗法为核心的心理灵活性护理.通过对比两组患者的生活质量...     

癌症病人心理一致感干预措施及其效果的系统评价

目的:系统评价癌症病人心理一致感干预措施及其效果。方法:计算机检索中国生物医学文献数据库(CBM)、中国知网(CNKI)、维普、万方、PubMed、the Cochrane Library、Web of Science、EBSCO等数据库中评价癌症病人心理一致感干预研究的随机对照试验,检索时限均为建库至2020年5月31日。由2名研究者独立进行文献筛选、质量评价以及资料提取,采用定性方法汇总纳入文献的干预措施及其效果。结果:最终纳入9项随机对照试验,涉及1090例病人。纳入文献的质量等级均为B级。干预措施中认知行为疗法3篇,正念减压疗法2篇,音乐疗法结合放松训练1篇,志愿者团队健康教育法1篇,基于平台的支持教育计划1篇,家属同步阶段性认知疗法1篇。7项研究结果显示,干预措施可提高病人心理一致感水平。结论:现有证据表明采取认知行为疗法、正念减压疗法、志愿者团队健康教育法、家属同步阶段性认知疗法均能提高癌症病人的心理一致感水平。     

正念训练改善残疾人情绪和心理接受效果的系统综述北大核心CSCD

目的系统评价正念训练改善残疾人情绪和心理接受的效果。方法检索2010年1月1日至2020年11月31日Web of Science、EBSCO、APA PsycInfo、Psychology and Behavioral Sciences Collection、Medline、CNKI、Wanfang数据库关于正念训练与残疾人心理康复的研究。筛选文献,进行质量评定并提取文献资料,对正念训练改善残疾人情绪和心理接受的效果进行综述。结果共纳入15项研究,涉及64个独立效应量,1065例被试。主要涉及精神残疾、智力残疾、肢体残疾和言语残疾。常用的正念训练方案是正念认知行为疗法、正念减压疗法、正念太极拳和正念瑜伽等。正念训练对残疾人的效果主要表现为缓解焦虑/抑郁,提高对于消极体验的接受性等。结论正念训练可以辅助改善残疾人的负性情绪,提高残疾人心理接受水平,进而促进身心健康,提高生活质量。     

Moderators of Mindfulness Meditation,Cognitive Therapy,and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain: A Test of the Limit,Activate, and Enhance Model

This study examined psychosocial pain treatment moderation in a secondary analysis of a trial that compared cognitive therapy (CT), mindfulness-meditation (MM), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP). The Limit, Activate, and Enhance (LA&E) model of moderation provided a framework for testing a priori hypotheses. Adult participants (N = 69) with CLBP completed a pretreatment assessment of hypothesized moderators: pain catastrophizing, brain state as assessed by electroencephalogram, mindful observing, and nonreactivity. Outcomes were pain interference, characteristic pain intensity, physical function, and depression, assessed at pre- and post-treatment. Moderation analyses found significant interaction effects, specifically: 1) higher and lower baseline pain catastrophizing was associated with greater improvement in pain intensity in MM and MBCT, respectively; 2) higher baseline theta power was associated with greater improvement in depression in MBCT and interfered with response to CT; 3) lower baseline nonreactivity was associated with greater improvement in physical function in MM while higher nonreactivity was associated with greater improvement in MBCT. The findings support the possibility that different patients are more or less likely to benefit from various treatments. Theory-driven moderation research has the capacity to inform the development of patient-treatment matching algorithms to optimize outcome.PerspectiveThis study presents preliminary findings from theory-driven tests of the moderators of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain. The results of such analyses may inform the understanding of for whom various evidence-based psychosocial pain treatments may engender the most meaningful benefits.     

接纳与承诺疗法对乳腺癌患者干预效果的Meta分析

目的 系统评价接纳与承诺疗法对乳腺癌患者的干预效果。方法 计算机检索Cochrane Library、Web of Science、PubMed、Embase、CINAHL、PsycInfo、中国知网、万方数据库、维普数据库、中国生物医学文献数据库中关于接纳与承诺疗法对乳腺癌患者干预效果的随机对照实验,检索时限为建库至2021年8月。由2名研究者根据纳入和排除标准对文献进行筛选、提取资料和方法学质量评价,运用Revman 5.4软件进行Meta分析。 结果 共纳入13篇随机对照研究,共1 061例患者。Meta分析结果显示,与常规护理相比,接纳与承诺疗法可减少乳腺癌患者的抑郁情绪[SMD=-1.15,95%CI（-1.48,-0.82）,P<0.001]、焦虑水平[SMD=-1.28,95%CI（-1.53,-1.04）,P<0.001],提升心理灵活性[MD=-12.26,95%CI（-15.02, -9.51）,P<0.001]及创伤后成长水平[MD=-12.48,95%CI（-13.55,-11.40）,P<0.001],增加患者疾病感知益处[MD=-8.77,95%CI（-10.79,-6.75）,P<0.001]。 结论 接纳与承诺疗法能够缓解乳腺癌患者的抑郁及焦虑情绪,提高心理灵活性及创伤后成长水平,增强疾病感知益处,对乳腺癌患者心理状态的改善起到积极作用。     

接纳承诺疗法在中老年带状疱疹后神经痛患者中的应用效果

目的探讨对中老年带状疱疹后神经痛患者实施接纳承诺疗法干预的效果。方法采用便利抽样方法,选取2019年1—6月在山西省太原市某三级甲等医院疼痛科就诊的带状疱疹后神经痛中老年患者70例作为研究对象,根据随机数字表将其分为观察组与对照组,每组各35例。对照组沿用常规心理护理干预,观察组患者实施接纳承诺疗法干预。分别采用中文版简易慢性疼痛接受问卷(CPAQ-8)、简化Mc Gill疼痛问卷(SF-MPQ)和医院焦虑抑郁量表(HADS)在患者干预前后进行问卷调查,评估疼痛接纳程度、疼痛程度以及焦虑、抑郁程度。结果干预前,两组患者的CPAQ-8、SF-MPQ和HADS得分差异均无统计学意义(P>0.05)。干预后,观察组患者CPAQ-8得分高于对照组,SF-MPQ、HADS得分低于对照组,两组比较差异有统计学意义(P<0.05)。结论接纳承诺疗法可有效提升中老年带状疱疹后神经痛患者对疼痛的接纳程度,减轻疼痛程度,使疼痛带来的焦虑、抑郁情绪得到改善,值得临床推广使用。     

The Chronic Pain Acceptance Questionnaire (CPAQ)-further validation including a confirmatory factor analysis and a comparison with the Tampa Scale of Kinesiophobia

Acceptance of pain and distress has lately appeared as an important factor in determining peoples’ ability to restore functioning in the presence of chronic pain. Although treatments based on cognitive behaviour therapy are beginning to incorporate acceptance strategies, there is still a lack of reliable and valid instruments to assess relevant processes in such interventions. The Chronic Pain Acceptance Questionnaire (CPAQ) was originally constructed as part of the development of an acceptance oriented treatment approach for pain patients. A revised 20-item version of the instrument with two subscales has shown adequate reliability and validity. In the present study, a Swedish translation of CPAQ was evaluated with 611 participants reporting chronic pain and symptoms of whiplash associated disorders. This study sought to further assess the psychometric properties of the instrument and to investigate its relation to another important measure of pain adjustment, the Tampa Scale of Kinesiophobia. Due to low intercorrelations with other items, item 16 was excluded. Exploratory and confirmatory factor analyses supported the previously suggested two-factor solution. Furthermore, the internal consistencies were good for the subscales (activities engagement and pain willingness) as well as the total scale. Hierarchical regression analyses illustrated strong relations with criteria variables (e.g. disability and life satisfaction). In general, the activities engagement subscale contributed more than pain willingness to the prediction of criteria variables. Furthermore, results illustrated that CPAQ explained more variance than the Tampa Scale of Kinesiophobia in pain intensity, disability, life satisfaction, and depression.     

Personal Values and Pain Tolerance: Does a Values Intervention Add to Acceptance?

Previous research suggests that acceptance is a promising alternative to distraction and control techniques in successfully coping with pain. Acceptance interventions based upon Acceptance and Commitment Therapy (ACT) have been shown to lead to greater tolerance of acute pain as well as increased adjustment and less disability among individuals with chronic pain. However, in these previous intervention studies, the ACT component of values has either not been included or not specifically evaluated. The current study compares the effects of an ACT-based acceptance intervention with and without the values component among individuals completing the cold-pressor task. Results indicate that inclusion of the values component (n = 34) of ACT leads to significantly greater pain tolerance than acceptance alone (n = 30). Consistent with previous research, both conditions were associated with greater pain tolerance than control (n = 35). Despite the difference in tolerance, pain threshold did not differ, and participants in the control condition provided lower ratings of pain severity. The findings from this study support the important role of values and values clarification in acceptance-based interventions such as ACT, and provide direction for clinicians working with individuals with chronic pain conditions.PerspectiveThis article evaluates the additive effect of including a personalized-values exercise in an acceptance-based treatment for pain. Results indicate that values interventions make a significant contribution and improvement to acceptance interventions, which may be of interest to clinicians who provide psychological treatment to individuals with chronic pain.     

Chronic low back pain: Progress in therapy

Low back pain is a common complaint in the primary care setting. Although most patients with acute low back pain will improve with conservative treatment, back pain often recurs, and a subset of patients will progress to chronic and sometimes disabling symptoms. A variety of treatments have been used for chronic low back pain; the best evidence supports intensive rehabilitation programs that include tailored exercise therapy in conjunction with cognitive behavioral interventions and education. The benefit of medications, including nonsteroidal anti-inflammatory drugs, analgesics, and possibly antidepressants or muscle relaxants, must be weighed against potential adverse effects. There is insufficient evidence regarding the effectiveness of many of the available therapies for chronic low back pain, and well-designed, randomized controlled trials are needed to clarify the role of these treatments.     

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.     

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.     

The role of psychosocial factors in temporomandibular disorders

The temporomandibular disorders (TMDs) comprise a constellation of symptoms affecting the joints and muscles involved in jaw movement. Patients complain of orofacial pain, limited jaw opening, and clicking or popping sounds. Although pain is generally the defining characteristic of TMD, patients often report marked degrees of stress and interference in daily life. This article reviews recent studies on epidemiology, sex differences, pediatric TMD, classification systems, comparisons to other chronic pain disorders of uncertain etiology, psychological assessment, depression, central modulation and hypervigilance, sleep disturbances, stress, and the management of TMD by conservative physical interventions and cognitive behavioral therapy. Both the assessment and the management of TMD requires a multidisciplinary perspective with strong emphasis on psychosocial variables.