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Internet-delivered aftercare following multimodal rehabilitation program for chronic pain: a qualitative feasibility study
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Inst, Sweden.ORCID iD: 0000-0003-4753-6745
2018 (English)In: Journal of Pain Research, E-ISSN 1178-7090, Vol. 11, p. 1715-1728Article in journal (Refereed) Published
Abstract [en]

Purpose: Methods for delivering aftercare to help chronic pain patients to continue practice self-management skills after rehabilitation are needed. Internet-delivered cognitive behavioral therapy (ICBT) has the potential to partly fill this gap given its accessibility and emphasis on self-care. Methods for engaging and motivating patients to persist throughout the full length of treatment are needed. The aim of this study was to describe how chronic pain patients work in an ICBT program, through their descriptions of what is important when they initiate behavior change in aftercare and their descriptions of what is important for ongoing practice of self-management skills in aftercare. Patients and methods: Following a multimodal rehabilitation program, 29 chronic pain patients participated in a 20-week-long Internet-delivered aftercare program (ACP) based on acceptance-based cognitive behavioral therapy. Latent content analysis was made on 138 chapters of diary-like texts written by participants in aftercare. Results: Attitudes regarding pain and body changed during ACP, as did attitudes toward self and the future for some participants. How participants practiced self-management skills was influenced by how they expressed motivation behind treatment goals. Whether they practiced acceptance strategies influenced their continuous self-management practice. Defusion techniques seemed to be helpful in the process of goal setting. Mindfulness strategies seemed to be helpful when setbacks occurred. Conclusion: Self-motivating goals are described as important both to initiate and in the ongoing practice of self-management skills. Experiencing a helpful effect of acceptance strategies seems to encourage participants to handle obstacles in new ways and to persist throughout treatment. Research on whether tailored therapist guidance might be helpful in stating self-motivating goals and contribute to ongoing practice of self-management skills is needed.

Place, publisher, year, edition, pages
DOVE MEDICAL PRESS LTD , 2018. Vol. 11, p. 1715-1728
Keywords [en]
Internet-delivered cognitive-behavioral therapy; chronic pain; acceptance and commitment therapy; qualitative analysis; self-management
National Category
Physiotherapy
Identifiers
URN: urn:nbn:se:liu:diva-151536DOI: 10.2147/JPR.S157939ISI: 000443450600002PubMedID: 30233229OAI: oai:DiVA.org:liu-151536DiVA, id: diva2:1250555
Note

Funding Agencies|County Council of Ostergotland (forsknings-ALF); AFA insurance

Available from: 2018-09-24 Created: 2018-09-24 Last updated: 2024-01-17
In thesis
1. Internet-Delivered Acceptance and Commitment Therapy for Chronic Pain: Feasibility, patients’ experiences and implementation process
Open this publication in new window or tab >>Internet-Delivered Acceptance and Commitment Therapy for Chronic Pain: Feasibility, patients’ experiences and implementation process
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Chronic pain represents a major burden for individuals and society. Internet-delivered psychological interventions are evidence-based treatments that enable patients to access qualified care at a time and place convenient for them. Internet-delivered Acceptance and commitment therapy (IACT) has shown promising treatment effects for chronic pain patients on pain-related outcomes such as disability, pain intensity, and interference, and on psychological outcomes such as catastrophizing, fear-avoidance and acceptance. Interdisciplinary pain rehabilitation programs (IPRP) are multimodal interventions given by synchronized teams of health care professionals from different disciplines. With moderate treatment effects on many outcomes, IPRP is the best evidence treatment for chronic pain to date.   

IACT may add to IPRP’s effectiveness by providing individual psychological treatment via the internet. However, IACT has not yet been implemented in routine care in a larger scale. In this thesis, the aim was to study if IACT may be acceptable for chronic pain patients and if it is feasible and effective as an addition to IPRP. Three methodological approaches were used: qualitative analysis, implementation science and a controlled trial of effectiveness in a clinical context.   

Study I showed that an internet-delivered aftercare intervention enabled chronic pain patients to change their perception of their body and pain and their attitude about their future and self. Furthermore, self-motivating goals and acceptance strategies appeared to influence autonomy. The results gave promise to the feasibility of IACT as aftercare following IPRP. Study II showed that chronic pain patients’ experiences of IACT vary, with respect to being in treatment and the consequences of treatment. Specifically, e-therapist feedback and deadlines for homework may have an impact on autonomy and change. Patients’ expectations, motivations, and restraints could explain treatment engagement and experiences. In Study III, IACT added during IPRP enhanced the treatment effects on pain acceptance and affective distress. Furthermore, IACT added as aftercare strengthened the long-term effect of IPRP on psychological flexibility and self-efficacy. However, unsatisfactory completion rates complicated the interpretation of the findings. Study IV showed that implementing IACT in an IPRP setting may be facilitated by contextual alinement and modifications based on patients’ needs. Thorough testing of the application and matching the intervention’s aim with the host’s needs are important not to challenge the process. An implementation framework may ease planning and evaluation of implementation processes.   

In conclusion, IACT could be feasible as an addition to IPRP. IACT can help chronic pain patients self-manage their pain and improve pain acceptance and self-efficacy. However, chronic pain patients’ varying experiences may need to be considered to improve treatment engagement and help patients benefit from treatment. In addition, implementation of IACT in IPRP settings is likely to depend on both flexibility to changing host needs and continuity of known pivotal components in IACT.   

Abstract [sv]

Långvarig smärta medför ett lidande för den drabbade individen och konsekvenser för samhället. Internetbaserade psykologiska behandlingar är evidensbaserade in-satser som ger patienter tillgång till kvalificerad vård vid den tid och på den plats som passar dem. Internetbaserad Acceptance and commitment therapy (IACT) kan påverka smärtintensitet samt hur mycket smärtan hindrar individen. IACT påverkar också psykologiska faktorer som katastrofiering, rädsla/undvikande och smärtacceptans. Multimodala smärtrehabiliteringsprogram (MMR) består av flera behandlingsinsatser som ges parallellt av ett team där vårdpersonal från olika professioner samarbetar. MMR har medelstor påverkan på flera faktorer och är den rekommenderade behandlingen för personer med långvarig smärta.  

IACT skulle kunna vara hjälpsamt för smärtpatienter som komplement till MMR, genom att ge individuell psykologisk behandling via internet. IACT har ännu inte implementerats rutinmässigt i sjukvården. I denna avhandling är syftet att studera om IACT uppskattas av smärtpatienter och om IACT är tillämpbart och effektivt som tillägg till MMR. Tre olika metoder används, nämligen kvalitativ analys, implementeringskunskap och en kontrollerad studie av effektivitet på en smärtrehabiliteringsklinik.   

Studie I visade att internetbaserad eftervård hjälpte smärtpatienter att förändra sin uppfattning om sin kropp och sin smärta samt sin attityd till sin framtid och sig själva. Därtill tycktes patienternas autonomi påverkas av motiverande mål och acceptansstrategier. Resultatet talar för att IACT är tillämpbart som eftervård efter MMR. Studie II visade att smärtpatienters upplevelser av IACT varierar, både avseende att vara i behandling och behandlingens konsekvenser. Kontakten med en terapeut via internet (e-terapeut) och deadlines för hemuppgifter tycktes på-verka patienternas förändring och autonomi. Patienternas förväntningar, motivation och begränsningar kan förklara deras upplevelser och hur de deltar i behandling. Studie III visade att IACT som tillägg kan förbättra den effekt som MMR har på patienters smärtacceptans och hur påverkade de är av känslor. IACT som tillägg efter MMR kan förstärka den långsiktiga effekten av MMRP på psykologisk flexibilitet och self-efficacy. Studie IV visade att implementering av IACT på en smärtrehabiliteringsklinik kan underlättas av likriktning med kontextfaktorer och anpassningar utifrån patienters behov. Noggrann testning av tekniken bakom IACT och att matcha syftet med IACT med klinikens behov är viktigt för att inte försvåra implementeringen. Ett ramverk för implementering kan underlätta såväl planering som utvärdering av processen.   

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2023. p. 76
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1836
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-193047 (URN)10.3384/9789180750288 (DOI)9789180750271 (ISBN)9789180750288 (ISBN)
Public defence
2023-05-12, Berzeliussalen, Building 463, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2023-04-11 Created: 2023-04-11 Last updated: 2023-04-11Bibliographically approved

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