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]