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Internet-Delivered Acceptance and Commitment Therapy Added to Multimodal Pain Rehabilitation: A Cluster Randomized Controlled Trial
Linköpings universitet, Institutionen för hälsa, medicin och vård, Avdelningen för prevention, rehabilitering och nära vård. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Sinnescentrum, Smärt och rehabiliteringscentrum.
Linköpings universitet, Institutionen för hälsa, medicin och vård, Avdelningen för prevention, rehabilitering och nära vård. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Sinnescentrum, Smärt och rehabiliteringscentrum.ORCID-id: 0000-0002-4316-1264
Linköpings universitet, Institutionen för hälsa, medicin och vård, Avdelningen för prevention, rehabilitering och nära vård. Linköpings universitet, Medicinska fakulteten.
Linköpings universitet, Institutionen för hälsa, medicin och vård, Avdelningen för prevention, rehabilitering och nära vård. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Sinnescentrum, Smärt och rehabiliteringscentrum.
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2021 (engelsk)Inngår i: Journal of Clinical Medicine, E-ISSN 2077-0383, Vol. 10, nr 24, artikkel-id 5872Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Internet-delivered interventions hold the possibility to make pain rehabilitation more accessible and adaptable by providing qualified individualized psychological care to chronic pain patients in their homes. Acceptance and commitment therapy (ACT) has shown promising results on psychological functioning and pain acceptance. Internet-delivered ACT (IACT) added to multimodal pain rehabilitation program (MMRP) in primary care has, so far, not shown better results than MMRP alone. The aim of this cluster randomized controlled study was to investigate the effects of adding IACT during and after MMRP in specialist care on psychological outcomes. In total, 122 patients who enrolled in a specialist pain clinic were cluster randomized groupwise to either MMRP (n = 12 groups) or to MMRP with added IACT (n = 12 groups). The IACT addition included 6 weeks of treatment during MMRP and 11 weeks of aftercare following MMRP. Online and paper-and-pencil self-report measures of pain acceptance, psychological inflexibility, self-efficacy, and psychosocial consequences of pain, were collected at four occasions: prior to and post MMRP, post aftercare intervention and at 1 year follow-up. Dropout was extensive with 25% dropping out at post treatment, an additional 35% at post aftercare, and 29% at 1 year follow-up. Medium treatment between-group effects were found on pain acceptance in favor of the group who received IACT added to MMRP, at post treatment and at post aftercare. Large effects were seen on psychological inflexibility and self-efficacy at post aftercare. A medium effect size was seen on affective distress at post aftercare. Moreover, a medium effect on self-efficacy was found at 1 year follow-up. The results indicate that IACT added during MMRP may enhance the treatment effects on pain-related psychological outcomes. Results also suggest that IACT as aftercare may strengthen the long-term effect of MMRP. However, adding a second pain treatment, IACT, to an already extensive pain treatment, MMRP, could be perceived as too comprehensive and might hence influence completion negatively. Further research on adverse events and negative effects could be helpful to improve adherence. Next step of implementation trials could focus on adding IACT before MMRP to improve psychological functioning and after MMRP to prolong its effect.

sted, utgiver, år, opplag, sider
MDPI , 2021. Vol. 10, nr 24, artikkel-id 5872
Emneord [en]
chronic pain; internet-delivered acceptance and commitment therapy (IACT); multimodal pain rehabilitation program (MMRP); aftercare; implementation; internet-delivered cognitive behavioral therapy (ICBT); booster intervention; combined treatment
HSV kategori
Identifikatorer
URN: urn:nbn:se:liu:diva-182224DOI: 10.3390/jcm10245872ISI: 000737821800001PubMedID: 34945167OAI: oai:DiVA.org:liu-182224DiVA, id: diva2:1626787
Merknad

Funding Agencies|REHSAM; Swedish Social Insurance Agency; Ministry of Health and Social Affairs; Swedish Association of Local Authorities and Regions; Vardal Foundation [99368-2009/RS10]; Lions Ostergotland Sweden [2020-01334]; City Council of OEstergoetland, Sweden [LIO-938308, SC-2019-00155-39]

Tilgjengelig fra: 2022-01-12 Laget: 2022-01-12 Sist oppdatert: 2023-04-11
Inngår i avhandling
1. Internet-Delivered Acceptance and Commitment Therapy for Chronic Pain: Feasibility, patients’ experiences and implementation process
Åpne denne publikasjonen i ny fane eller vindu >>Internet-Delivered Acceptance and Commitment Therapy for Chronic Pain: Feasibility, patients’ experiences and implementation process
2023 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
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.   

sted, utgiver, år, opplag, sider
Linköping: Linköping University Electronic Press, 2023. s. 76
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1836
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-193047 (URN)10.3384/9789180750288 (DOI)9789180750271 (ISBN)9789180750288 (ISBN)
Disputas
2023-05-12, Berzeliussalen, Building 463, Campus US, Linköping, 09:00 (svensk)
Opponent
Veileder
Tilgjengelig fra: 2023-04-11 Laget: 2023-04-11 Sist oppdatert: 2023-04-11bibliografisk kontrollert

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