Mike K. Kemani

Cognitive Behavioral Therapy increases pain-evoked activation of the prefrontal cortex in patients with fibromyalgeia

Summary Treatment with Cognitive Behavioral Therapy leads to clinical improvements in fibromyalgia patients, paired with increased activity and connectivity in the brain’s pain modulatory regions. ABSTRACT Interventions based on Cognitive Behavioral Therapy (CBT) are widely used to treat chronic pain, but the brain mechanisms responsible for these treatment effects are poorly understood. The aim of this study was to validate the relevance of the cortical control theory in response to an exposure‐based form of CBT, Acceptance and Commitment Therapy, in patients with chronic pain. Forty‐three female patients diagnosed with fibromyalgia syndrome were enrolled in a randomized, 12‐week, waiting‐list controlled clinical trial (CBT n = 25; controls n = 18). CBT was administered in groups of six patients during 12 weekly sessions. Functional magnetic resonance imaging (fMRI) during pressure‐evoked pain was assessed before and after treatment or the 12‐week period. Self‐report questionnaires of depression and anxiety were administered pre‐ and posttreatment as well as 3 months following end of treatment. Patients treated with CBT reported larger improvement of fibromyalgia on the Patient Global Impression of Change measure, and improved depression and anxiety symptoms, compared to the waiting‐list controls. However, there were no effects on clinical pain or pain sensitivity measures. An analysis of fMRI scans revealed that CBT led to increased activations in the ventrolateral prefrontal/lateral orbitofrontal cortex; regions associated with executive cognitive control. We suggest that CBT changes the brain’s processing of pain through an altered cerebral loop between pain signals, emotions, and cognitions; leading to increased access to executive regions for reappraisal of pain. Our data thereby support our hypothesis about the activation of a cortical control mechanism in response to CBT treatment in chronic pain.

Acceptance and commitment therapy for fibromyalgia: A randomized controlled trial

Fibromyalgia (FM) is characterized by widespread pain and co‐morbid symptoms such as fatigue and depression. For FM, medical treatments alone appear insufficient. Recent meta‐analyses point to the utility of cognitive behaviour therapy (CBT), but effects are moderate. Within the continuous development of CBT, the empirical support for acceptance and commitment therapy (ACT) has increased rapidly. ACT focuses on improving functioning by increasing the patients ability to act in accordance with personal values also in the presence of pain and distress (i.e., psychological flexibility). However, no study has yet explored the utility of ACT in FM.

A Case Study: Acceptance and Commitment Therapy for Pediatric Sickle Cell Disease

OBJECTIVEnSickle cell disease (SCD) negatively impacts patients functioning and quality of life. Acceptance and Commitment Therapy (ACT) promotes acceptance of difficult sensations, emotions, and thoughts when doing so facilitates living a values-based life. This study describes ACT for improving functioning and quality of life for an adolescent with SCD and his parents.nnnMETHODSnA 16-year old with SCD and his parents attended an eight-session ACT program. Process (adolescent psychological flexibility, parent acceptance) and outcome (adolescent social anxiety, pain, functioning, quality of life; parent distress) measures were conducted prior to and following treatment and at 3-month follow-up.nnnRESULTS AND CONCLUSIONSnImprovements were evident, especially at follow-up. Process measures suggest adolescent psychological flexibility and parent acceptance might explain positive effects. Anecdotal comments support these findings and provide additional evidence that ACT might effectively promote functioning and quality of life in adolescents with chronic diseases.

Efficacy and Cost-effectiveness of Acceptance and Commitment Therapy and Applied Relaxation for Longstanding Pain: A Randomized Controlled Trial.

Background and Objectives:To date, few studies have compared Acceptance and Commitment Therapy (ACT) for longstanding pain with established treatments. Only 1 study has evaluated the cost-effectiveness of ACT. The aim of the current study was to evaluate the efficacy and cost-effectiveness of ACT and applied relaxation (AR) for adults with unspecific, longstanding pain. Materials and Methods:On the basis of the inclusion criteria 60 consecutive patients received 12 weekly group sessions of ACT or AR. Data were collected pretreatment, midtreatment, and posttreatment, as well as at 3- and 6-month follow-up. Growth curve modeling was used to analyze treatment effects on pain disability, pain intensity, health-related quality of life (physical domain), anxiety, depression, and acceptance. Results:Significant improvements were seen across conditions (pretreatment to follow-up assessment) on all outcome measures. Pain disability decreased significantly in ACT relative to AR from preassessment to postassessment. A corresponding decrease in pain disability was seen in AR between postassessment and 6-month follow-up. Pain acceptance increased only in ACT, and this effect was maintained at 6-month follow-up. Approximately 20% of the participants achieved clinically significant change after treatment. Health economic analyses showed that ACT was more cost-effective than AR at post and 3-month follow-up assessment, but not at 6-month follow-up. Discussion:More studies investigating moderators and mediators of change are needed. The present study is one of few that have evaluated the cost-effectiveness of ACT and AR and compared ACT with an established behavioral intervention, and the results provide additional support for behavioral interventions for longstanding pain.

A Clinical Pilot Study of Individual and Group Treatment for Adolescents with Chronic Pain and Their Parents: Effects of Acceptance and Commitment Therapy on Functioning.

Pediatric chronic pain is common and can result in substantial long-term disability. Previous studies on acceptance and commitment therapy (ACT) have shown promising results in improving functioning in affected children, but more research is still urgently needed. In the current clinical pilot study, we evaluated an ACT-based interdisciplinary outpatient intervention (14 sessions), including a parent support program (four sessions). Adolescents were referred to the clinic if they experienced disabling chronic pain. They were then randomized, along with their parents, to receive group (n = 12) or individual (n = 18) treatment. Adolescent pain interference, pain reactivity, depression, functional disability, pain intensity and psychological flexibility, along with parent anxiety, depression, pain reactivity and psychological flexibility were assessed using self-reported questionnaires. There were no significant differences in outcomes between individual and group treatment. Analyses illustrated significant (p < 0.01) improvements (medium to large effects) in pain interference, depression, pain reactivity and psychological flexibility post-treatment. Additionally, analyses showed significant (p < 0.01) improvements (large effects) in parent pain reactivity and psychological flexibility post-treatment. On all significant outcomes, clinically-significant changes were observed for 21%–63% of the adolescents across the different outcome measures and in 54%–76% of the parents. These results support previous findings and thus warrant the need for larger, randomized clinical trials evaluating the relative utility of individual and group treatment and the effects of parental interventions.

Low-grade inflammation may moderate the effect of behavioral treatment for chronic pain in adults

The purpose of the present pilot study was to explore the moderating role of basal inflammation on the effects of behavioral pain treatment in 41 patients with long-standing pain. Baseline pro-inflammatory status moderated behavioral treatment outcomes: higher pre-treatment levels of Tumor Necrosis Factor (TNF)-α and Interleukin (IL)-6 were related to less improvement in pain intensity, psychological inflexibility and in mental health-related quality of life. The treatment outcomes improved in the subgroup that had low levels of pro-inflammatory cytokines at baseline, while the subjects with higher pro-inflammatory status did not. Altogether, results indicate that low-grade inflammation may influence the behavioral treatment outcomes and provide a possible explanation of the heterogeneity in treatment response.

Evaluating the Statistical Properties of the Pain Interference Index in Children and Adolescents with Chronic Pain.

&NA; The high prevalence of chronic debilitating pain in pediatric populations calls for more knowledge regarding the impact of pain on functioning or pain interference. This in turn requires valid and reliable instruments to adequately assess the impact of pain on functioning. Also, adequate measures of pain interference are important in evaluations of behavioral interventions aimed at improving functioning. Objective: The objectives of this study were to evaluate the statistical properties of the Pain Interference Index (PII), including the factor structure, internal consistency, and concurrent criteria validity of the instrument. Method: Data were collected from a consecutive sample of children and adolescents referred to a tertiary pain clinic due to chronic pain (n = 163). A principal component analysis was used to investigate the latent factor structure of items. The internal consistency was assessed by Cronbachs alpha. A set of hierarchical regression analyses was conducted to evaluate the ability of instruments to predict levels of depression and functional disability. Results: Analyses indicated the adequacy of a 1-factor solution with a total of 6 items. The intercorrelation between items and the scales reliability was satisfactory. Furthermore, bivariate correlations and hierarchical regression analyses illustrate the concurrent criteria validity of the instrument. Conclusion: Results support the use of PII as an adequate instrument to assess pain interference in children and adolescents with chronic pain.

Processes of change in Acceptance and Commitment Therapy and Applied Relaxation for long-standing pain

The utility of cognitive behavioural (CB) interventions for chronic pain has been supported in numerous studies. This includes Acceptance and Commitment Therapy (ACT), which has gained increased empirical support. Previous research suggests that improvements in pain catastrophizing and psychological inflexibility are related to improvements in treatment outcome in this type of treatment. Although a few studies have evaluated processes of change in CB‐interventions, there is a particular need for mediation analyses that use multiple assessments to model change in mediators and outcome over time, and that incorporate the specified timeline between mediator and outcome in the data analytic model.

The Parent Psychological Flexibility Questionnaire (PPFQ): Item Reduction and Validation in a Clinical Sample of Swedish Parents of Children with Chronic Pain

In pediatric chronic pain, research indicates a positive relation between parental psychological flexibility (i.e., the parent’s willingness to experience distress related to the child’s pain in the service of valued behavior) and level of functioning in the child. This points to the utility of targeting parental psychological flexibility in pediatric chronic pain. The Parent Psychological Flexibility Questionnaire (PPFQ) is currently the only instrument developed for this purpose, and two previous studies have indicated its reliability and validity. The current study sought to validate the Swedish version of the 17-item PPFQ (PPFQ-17) in a sample of parents (n = 263) of children with chronic pain. Factor structure and internal reliability were evaluated by means of principal component analysis (PCA) and Cronbach’s alpha. Concurrent criterion validity was examined by hierarchical multiple regression analyses with parental anxiety and depression as outcomes. The PCA supported a three-factor solution with 10 items explaining 69.5% of the total variance. Cronbach’s alpha (0.86) indicated good internal consistency. The 10-item PPFQ (PPFQ-10) further explained a significant amount of variance in anxiety (29%), and depression (35.6%), confirming concurrent validity. In conclusion, results support the reliability and validity of the PPFQ-10, and suggest its usefulness in assessing psychological flexibility in parents of children with chronic pain.

A validation of the pain interference index in adults with long-standing pain.

Chronic pain is a major health problem and more knowledge is needed regarding the interference of pain on behaviors in different life domains. Clinically useful and statistically sound pain interference measures are highly important. Studies on youths have shown that the Pain Interference Index (PII) is a reliable and valid instrument that is sensitive to change following behavioral treatment. This measure may also have utility for adults, but no study has so far evaluated the statistical properties of the PII for long‐standing pain in adults.