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Acceptance for persons suffering from pain: Evaluation of acceptance-based interventions for adults with chronic pain and children with cancer experiencing acute pain
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Barnonkologiska forskargruppen)
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

It is increasingly clear that pain and emotions are closely interconnected. Pain does not only cause psychological distress, but psychological distress also amplifies pain through neurological mechanisms. Treatment of both chronic and acute pain would benefit from acknowledging the psychological mechanisms of pain neurophysiology. Psychological acceptance predicts increased pain tolerance and decreased pain intensity and discomfort in experimentally induced pain and improved physical and psychosocial functioning for persons with chronic pain.

The overall aim of this thesis was to evaluate acceptance-based interventions for persons suffering from pain.

In Study I the effect of a manualised ACT-based self-help intervention for adults with chronic pain was evaluated in an RCT (n=90). The results showed improvements in satisfaction with life, physical functioning and pain intensity for the ACT group. Both the ACT and the control group improved regarding depression and anxiety. In Study II the mediating effect of acceptance for treatment change was evaluated, using data from Study I (n=64). The results showed indirect effects of treatment via acceptance for physical functioning but not for satisfaction with life. In Studies III and IV, instruments to measure psychological flexibility in relation to pain were developed for children with cancer, and their parents respectively, using factor analysis. The results showed that a two-factor solution for the child scale (n=61) and a three-factor solution for the parent scale (n=243), best represented the data. In Study V, an acceptance-based intervention was preliminarily evaluated in a single-subject study (n=5) for children reporting pain during cancer treatment. The intervention consisted of an approximately 15-minute long pain exposure exercise. All participants reported reduced discomfort of pain, and three of the participants reported reduced pain intensity.

The results suggest that a manualised ACT-based self-help intervention is a valuable addition to the treatment repertoire for persons with chronic pain and that acceptance may mediate the effect of treatment on physical functioning. Furthermore, instruments to measure acceptance in the context of acute pain in children with cancer are now available, although further validation is needed. Lastly, the results indicate that an acceptance-based intervention may help children undergoing cancer treatment to cope with pain.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. , 64 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1340
Keyword [en]
acute pain, chronic pain, acceptance, psychological flexibility, acceptance and commitment therapy, children and adolescents, cancer
National Category
Applied Psychology Other Medical Sciences not elsewhere specified
Research subject
Psychology
Identifiers
URN: urn:nbn:se:uu:diva-322401ISBN: 978-91-513-0001-6 (print)OAI: oai:DiVA.org:uu-322401DiVA: diva2:1097268
Public defence
2017-09-08, Sal IX, Gamla universitetshuset, Biskopsgatan 3, 753 10 Uppsala, Uppsala, 09:00 (English)
Opponent
Supervisors
Funder
Swedish Childhood Cancer Foundation, FTJH11/002 och PR2013/0058Swedish Cancer Society, CAN2013/749
Available from: 2017-08-18 Created: 2017-05-22 Last updated: 2017-09-08
List of papers
1. A Comparative Study of 2 Manual-based Self-Help Interventions, Acceptance and Commitment Therapy and Applied Relaxation, for Persons With Chronic Pain
Open this publication in new window or tab >>A Comparative Study of 2 Manual-based Self-Help Interventions, Acceptance and Commitment Therapy and Applied Relaxation, for Persons With Chronic Pain
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2011 (English)In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 27, no 8, 716-723 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this study was to compare 2 self-help-based interventions; a coping-oriented approach, applied relaxation (AR) and an acceptance-oriented approach, acceptance and commitment therapy (ACT), for persons with chronic pain. Method: This study is a randomized control trial (N = 90) with a mixed between-within participants design with repeated measures. Interventions in both conditions comprised an initial face-to-face session, a 7-week manual-based self-help intervention including weekly therapist telephone support and a concluding face-to-face session. Outcome measures included satisfaction with life, depression, anxiety, acceptance of chronic pain, level of function, and pain intensity. Effects were measured at preintervention and postintervention and at 6 and 12 months after the end of intervention. Results: The results show that the ACT condition increased their level of acceptance significantly compared with the AR condition. There was also a marginally significant interaction effect regarding satisfaction with life in which the ACT condition had improved in comparison to the AR condition. Further, the ACT condition reported a higher level of function and decreased pain intensity compared with the AR condition. Both conditions improved significantly regarding depression and anxiety. Conclusions: A manual-based self-help intervention with weekly therapist support in an ACT format adds value to the treatment repertoire for persons suffering with chronic pain.

Keyword
chronic pain, manual-based, self-help, acceptance and commitment therapy, acceptance, satisfaction with life
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-159223 (URN)10.1097/AJP.0b013e318219a933 (DOI)000294709700009 ()
Available from: 2011-09-27 Created: 2011-09-26 Last updated: 2017-08-15Bibliographically approved
2. Acceptance as a Mediator for Change in Acceptance and Commitment Therapy for Persons with Chronic Pain?
Open this publication in new window or tab >>Acceptance as a Mediator for Change in Acceptance and Commitment Therapy for Persons with Chronic Pain?
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2016 (English)In: International Journal of Behavioral Medicine, ISSN 1070-5503, E-ISSN 1532-7558, Vol. 23, no 1, 21-29 p.Article in journal (Refereed) Published
Abstract [en]

Background Cognitive behavior therapy (CBT) is considered effective for chronic pain, but little is known about active treatment components. Although acceptance correlates with better health outcomes in chronic pain patients, no study has examined its mediating effect in an experimental design. Purpose The aim of the present study is to investigate acceptance as a mediator in acceptance and commitment therapy (ACT), a third wave CBT intervention, for chronic pain. Method A bootstrapped cross product of coefficients approach was used on data from a previously published RCT evaluating ACT for chronic pain. To address the specificity of acceptance as a mediator, anxiety and depression were also tested as mediators. Outcome variables were satisfaction with life and physical functioning. Two change scores, preassessment to 6-month follow-up (n=53) and pre-assessment to 12-month follow-up (n=32), were used. Results Acceptance was found to mediate the effect of treatment on change in physical functioning from pre-assessment to follow-up at 6 months. Further, a trend was shown from pre-assessment to follow-up at 12 months. No indirect effect of treatment via acceptance was found for change in satisfaction with life. Conclusion This study adds to a small but growing body of research using mediation analysis to investigate mediating factors in the treatment of chronic pain. In summary, the results suggest that acceptance may have a mediating effect on change in physical functioning in ACT for persons with chronic pain. However, given the small sample size of the study, these findings need to be replicated.

Keyword
Acceptance, Acceptance and commitment therapy, Chronic pain, Mediation analysis, Physical functioning, Satisfaction with life
National Category
Medical and Health Sciences Applied Psychology
Identifiers
urn:nbn:se:uu:diva-256448 (URN)10.1007/s12529-015-9494-y (DOI)000370243400003 ()26041582 (PubMedID)
Available from: 2015-06-23 Created: 2015-06-23 Last updated: 2017-08-15Bibliographically approved
3. Parents’ relationship to pain during children's cancer treatment – a preliminary validation of the Pain Flexibility Scale for Parents
Open this publication in new window or tab >>Parents’ relationship to pain during children's cancer treatment – a preliminary validation of the Pain Flexibility Scale for Parents
2017 (English)In: Journal of Pain Research, ISSN 1178-7090, E-ISSN 1178-7090, Vol. 10, 507-514 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Pain is one of the most frequent and burdensome symptoms for children with cancer. Psychological acceptance has been shown to be beneficial in chronic pain. Acceptance-based interventions for experimentally induced pain have been shown to predict increased pain tolerance and decreased pain intensity. An acceptance-based pilot study for children with cancer experiencing pain has shown promising results. Further, parental acceptance has been shown to predict decreased child distress. To date, no instruments measuring acceptance in the context of acute pain in children are available. The aim of this study was to develop and evaluate an instrument to measure acceptance in parents of children experiencing pain during cancer treatment. Methods: A test version of the Pain Flexibility Scale for Parents (PFS-P) was sent to parents of all children undergoing cancer treatment in Sweden at the time of the study. Exploratory factor analysis (n=243) examined numerous solutions. Internal consistency, test-retest reliability and convergent validity were calculated. Results: A three-factor Promax solution best represented the data. The subscales were pain resistance, valued action and pain fusion. Internal consistency was good (alpha=0.81-0.93), and the total scale and the subscales demonstrated temporal stability (r=0.76-0.87) and good convergent validity (-0.40 to -0.84). Discussion: The PFS-P measuring acceptance in parents of children experiencing pain during cancer treatment is now available, enabling evaluation of acceptance in the context of acute pain in children. The scale shows good psychometric properties but needs further validation.

Place, publisher, year, edition, pages
Dovepress, 2017
Keyword
acute pain, children, parents, acceptance, psychological flexibility, factor analysis
National Category
Psychology Neurology
Identifiers
urn:nbn:se:uu:diva-316716 (URN)10.2147/JPR.S127019 (DOI)000396320600001 ()
Funder
Swedish Childhood Cancer Foundation, PR2013-0058Swedish Cancer Society, CAN2013/749
Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2017-08-15Bibliographically approved
4. Children’s and adolescents’ relationship to pain during cancer treatment: a preliminary validation of the Pain Flexibility Scale for Children
Open this publication in new window or tab >>Children’s and adolescents’ relationship to pain during cancer treatment: a preliminary validation of the Pain Flexibility Scale for Children
2017 (English)In: Journal of Pain Research, ISSN 1178-7090, E-ISSN 1178-7090, Vol. 10, 1171-1178 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Children with cancer often suffer from pain. Pain is associated with psychological distress, which may amplify the pain experience. In chronic pain, it has been shown that psychological acceptance is helpful for both adults and children. For experimentally induced pain, interventions fostering psychological acceptance have been shown to predict increases in pain tolerance and reductions in pain intensity and discomfort of pain. A single subject study aiming to nurture psychological acceptance for children with cancer experiencing pain has shown promising results. No instruments measuring psychological acceptance in acute pain are yet available. The aim of the current study was to develop and preliminarily evaluate an instrument to measure psychological acceptance in children experiencing pain during cancer treatment.

Methods: A test version of the Pain Flexibility Scale for Children was sent to all children aged 7–18 years undergoing cancer treatment in Sweden at the time of the study. Exploratory factor analysis was used. Internal consistency, test–retest reliability, and convergent validity were examined.

Results: Sixty-one children participated in the study. A two-factor solution with Promax rotation was found to best represent the data. Internal consistency was good to excellent (a =0.87–0.91). The total scale and the subscales demonstrated temporal stability (Intraclass correlation coefficient =0.56–0.61) and satisfactory convergent validity (r=−0.27 to −0.68).

Discussion: The Pain Flexibility Scale for Children measuring psychological acceptance in children with cancer experiencing pain is now available for use. This enables the evaluation of acceptance as a mediator for treatment change in the context of acute pain in children with cancer, which in turn is a step forward in the development of psychological treatments to help children cope with the pain during these difficult circumstances. The scale shows good psychometric properties but needs further validation, particularly considering the small sample size.

Place, publisher, year, edition, pages
Dove Medical Press, 2017
Keyword
Acute pain, children, acceptance, psychological flexibility, factor analysis, Akut smärta, barn och ungdomar, acceptans, psykologisk flexibilitet, faktoranalys
National Category
Applied Psychology Medical and Health Sciences
Research subject
Psychology
Identifiers
urn:nbn:se:uu:diva-322391 (URN)10.2147/JPR.S137871 (DOI)000401610300001 ()
Funder
Swedish Childhood Cancer Foundation, FTJH11/002 och PR2013/0058Swedish Cancer Society, CAN2013/749
Available from: 2017-05-22 Created: 2017-05-22 Last updated: 2017-08-15Bibliographically approved
5. An acceptance-based intervention for children and adolescents with cancer experiencing pain – a single subject study
Open this publication in new window or tab >>An acceptance-based intervention for children and adolescents with cancer experiencing pain – a single subject study
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Children and adolescents with cancer report pain as one of their most recurrent and troublesome symptoms throughout the cancer trajectory. Pain evokes psychological distress, which in turn, has an amplifying effect on the pain experience. Acceptance-based interventions for experimentally induced acute pain predict increased pain tolerance, decreased pain intensity and decreased discomfort of pain. The aim of this study was to preliminarily evaluate an acceptance-based intervention for children and adolescents with cancer experiencing acute pain, with regards to feasibility and effect on pain intensity and discomfort of pain.

Methods: The study is a single subject study with an AB design with a non-concurrent multiple baseline. Children and adolescents aged 4-18 years undergoing cancer treatment at the Children’s University Hospital, Uppsala, Sweden, reporting sustained acute pain were offered participation. Pain intensity and discomfort of pain were measured during baseline and at post intervention. The intervention consisted of a pain exposure exercise lasting approximately 15 minutes.

Results: Five children participated in the study. All participants completed the intervention and reported that it had helped them to cope with the pain in the moment. All participants reported decreased discomfort of pain at post measurement, three of whom also reported decreased pain intensity.

Discussion: The results suggest that an acceptance-based intervention may help children and adolescents with cancer to cope with the pain that is often associated with cancer treatment in spite of pharmacological pain management. The results are tentative but promising and warrant further investigation.  

Keyword
Acute pain, children, cancer, acceptance, pain intensity, discomfort of pain
National Category
Applied Psychology Other Medical Sciences not elsewhere specified
Research subject
Psychology
Identifiers
urn:nbn:se:uu:diva-322400 (URN)
Funder
Swedish Childhood Cancer Foundation, FTJH11/002 och PR2013/0058Swedish Cancer Society, CAN2013/749
Available from: 2017-05-22 Created: 2017-05-22 Last updated: 2017-08-15Bibliographically approved

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