Lennart Melin

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

ABSTRACT 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 accuracy of remembering chronic pain

Abstract Twelve chronic pain patients were employed in an investigation of the accuracy of memory for chronic pain. Subjects first made pain ratings before entering a treatment program. At dismissal 3–11 weeks later they were asked to remember how much pain they had had at baseline. Results show that patients remembered having significantly more pain than they actually rated during the baseline period. Caution is therefore warranted when using post‐hoc pain measures with chronic pain patients.

Evaluation of Acceptance and Commitment Therapy for Drug Refractory Epilepsy: A Randomized Controlled Trial in South Africa—A Pilot Study

Summary:  Purpose: Psychological interventions in the treatment of epilepsy have been developed and evaluated for many years but the amount of research has hardly made an impact on how epilepsy is treated. The purpose of this study was to develop and evaluate a psychological treatment program consisting of acceptance and commitment therapy (ACT) together with some behavioral seizure control technology shown to be successful in earlier research.

A cognitive-behavioral return-to-work program: effects on pain patients with a history of long-term versus short-term sick leave.

&NA; A cognitive–behavioral return‐to‐work focused program was evaluated in a randomized controlled design, and the effects were compared between two groups of women with musculoskeletal pain. One group of patients (n=36) had a history of long‐term sick leave (>12 months) at the start of the program and the other (n=36) had a history of short‐term sick leave (2–6 months). The outpatient treatment program, conducted by a psychologist, included 12 sessions with the primary aim to help the patients return‐to‐work. The treatment first included teaching of coping strategies such as applied relaxation, stress management, graded activity training and pacing. Thereafter the patients were taught how to manage difficulties at their return‐to‐work and how to generalize coping strategies to different risk factors at their work places. The control condition received treatment‐as‐usual. The results showed that the cognitive–behavioral return‐to‐work program was more effective than the treatment‐as‐usual control condition in reducing the number of days on sick leave for patients on short‐term sick leave, but not for patients on long‐term sick leave. The treatment program also helped the patients on short‐term sick leave to increase their ability to control and decrease pain and to increase their general activity level compared to the control condition. These results underscore the need for an early return‐to‐work focused rehabilitation to prevent long‐term sick leave and disability.

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 patients 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 and yoga for drug-refractory epilepsy: a randomized controlled trial.

OBJECTIVE There is a need for controlled outcome studies on behavioral treatment of epilepsy. The purpose of this study was to evaluate Acceptance and Commitment Therapy (ACT) and yoga in the treatment of epilepsy. METHODS The design consisted of a randomized controlled trial with repeated measures (N=18). All participants had an EEG-verified epilepsy diagnosis with drug-refractory seizures. Participants were randomized into one of two groups: ACT or yoga. Therapeutic effects were measured using seizure index (frequency x duration) and quality of life (Satisfaction with Life Scale, WHOQOL-BREF). The treatment protocols consisted of 12 hours of professional therapy distributed in two individual sessions, two group sessions during a 5-week period, and booster sessions at 6 and 12 months posttreatment. Seizure index was continuously assessed during the 3-month baseline and 12-month follow-up. Quality of life was measured after treatment and at the 6-month and 1-year follow-ups. RESULTS The results indicate that both ACT and yoga significantly reduce seizure index and increase quality of life over time. ACT reduced seizure index significantly more as compared with yoga. Participants in both the ACT and yoga groups improved their quality of life significantly as measured by one of two quality-of-life instruments. The ACT group increased their quality of life significantly as compared with the yoga group as measured by the WHOQOL-BREF, and the yoga group increased their quality of life significantly as compared with the ACT group as measured by the SWLS. CONCLUSIONS The results of this study suggest that complementary treatments, such as ACT and yoga, decrease seizure index and increase quality of life.

Predictors of tinnitus discomfort, adaptation and subjective loudness

In a nation-wide investigation, covering all the hearing centres in Sweden, a study was made of adaptation processes, subjective discomfort from tinnitus, subjective loudness of tinnitus and psychological complaints in 3372 subjects by means of a questionnaire. The most important predictors of discomfort from and adaptation to tinnitus were found to be the controllability and the degree of maskability by external sounds, i.e. the subjects coping abilities or internal-external locus of control. Increased control and masking effects from the environment imply a decrease in discomfort and better adaptation. The most important predictor of worsened subjective loudness of tinnitus was the duration of the tinnitus. That is, subjects who had had tinnitus for a longer time perceived the loudness as more intense. The psychosomatic factors which most strongly predicted increased discomfort from and decreased tolerance to tinnitus were depression and insomnia. These findings have theoretical and practical implications for the management and treatment of tinnitus.

Chronic headaches in adolescents: Treatment in a school setting with relaxation training as compared with information-contact and self-registration

An experimental study was conducted on 33 adolescent students with various types of chronic headaches (tension and combined tension and migraine headaches), all treated in a school setting. After a 4-week baseline period during which the subjects rated their headache activity, they were randomly assigned to a 9-session relaxation training programme or to an information-contact condition, both contrasted with an untreated self-registration group. Relaxation therapy alone led to significant improvement in headache activity, particularly in reduction of the frequency of complaints which still was significantly reduced at a 6-month follow-up evaluation. The effects obtained in the information-contact condition were comparable to those in the self-registration group, both achieving only minor improvements after treatment or at the follow-up assessment. The majority of students in the relaxation treatment, however, was much improved, attaining more than 50% reduction in headache activity. The findings in the present study are consistent with results from similar treatment outcome studies, reported on adult populations with chronic headaches, and demonstrate that relaxation training programmes can be of substantial help in a school setting.

Development of cognitive functions in children with rolandic epilepsy

An initial investigation of cognitive functions in 32 children, aged 7 to 15 years, with rolandic epilepsy (RE), using an extensive test battery, was followed 2.5 to 3 years later by a second assessment of 26 of these children, using the same technique. The initial investigation reported cognitive deficits in memory and learning of auditory-verbal material together with executive functions compared with controls. At the second assessment, the ability for immediate memory, memory and learning of visuospatial as well as auditory-verbal material and delayed recall was the same in the RE group as in the control group. On one of the tests measuring executive functions, Verbal Fluency, the RE group scored significantly lower than controls. With respect to reading and writing ability, the children with RE had some difficulty with word comprehension. Nonverbal reasoning was the same in the two groups, as was general IQ. In conclusion, the children with RE did not present any major cognitive difficulties when a mean of approximately 5 years had passed since onset of the typical syndrome, and at a time when most of them were seizure-free. Maturational factors apparently are of importance to the course of RE.

Avoidance and cognitive fusion--central components in pain related disability? Development and preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS).

Acceptance of pain and other associated negative private experiences has received increasing attention in recent years. This approach is in stark contrast to the traditional approach of reducing or controlling symptoms of pain. The empirical support for treatments emphasizing exposure and acceptance, such as Acceptance and Commitment Therapy, is growing. However, to date, few instruments exist to assess the core processes in these types of treatments. This study describes the development and preliminary validation of the Psychological Inflexibility in Pain Scale. Principal components analysis (PCA) suggests a 2‐factor solution with a total of 16 items measuring avoidance of pain and cognitive fusion with pain. Results also indicate adequate reliability and validity for the scale. Implications of these findings for clinical assessment, as well as for research on pain related disability, are discussed along with suggestions for further research in this area.