Abstract
Background
Chronic low back pain (cLBP) typically involves behavior patterns in the development and maintenance of symptoms. Acceptance and Commitment Therapy (ACT) is an evidence-based treatment for chronic pain shown to improve pain-related depression, anxiety, and sleep, as well as pain catastrophizing, pain interference, and levels of reported pain. It has been proven effective when delivered in person or online, but an online therapist-enhanced ACT has not been tested to treat cLBP. This approach may have care delivery advantages while maintaining patient engagement with treatment.
Objective
Describe the design and implementation of the therapist-supported, online model of ACT that was evaluated in the Biomarking for Evaluating Spine Treatments (BEST) Trial.
Methods
The BEST Trial is a sequential, multiple assignment randomized trial of 4 treatment modalities (exercise and manual therapy; duloxetine; enhanced self-management of pain; and ACT) to inform a precision medicine approach to the treatment of cLBP. The ACT intervention was delivered over the internet via a custom, web-based software platform. The program had three primary components: (1) interactive online sessions consisting of video, audio and self-assessment; (2) therapist sessions via video visits; and (3) ongoing therapist support outside the video visits through a messaging system.
Discussion
The ACT intervention addresses the need for mental health care integrated with chronic low back pain treatment. The online ACT treatment program with enhanced therapist support was designed to overcome barriers to multimodal care of CLBP and improve a range of treatment outcomes.
ClinicalTrial.gov ID
Registration
The BEST Trial is registered in ClinicalTrials.gov (NCT05396014): https://clinicaltrials.gov/study/NCT05396014.
Keywords: Acceptance and Commitment Therapy, chronic pain, telehealth
Introduction
Chronic low back pain (cLBP) is common, affecting 39% of adults living in the United States,1 up to 25% of the population globally, and is the number 1 cause of disability in the world.2 When low back pain becomes chronic (lasting for at least three months and occurring on a daily basis), it is a complex disorder with dynamic interactions between musculoskeletal, neurological, psychological, and social systems in the development and maintenance of symptoms. Unfortunately, individual treatments are often only partially effective at improving symptoms, complicating clinical management and negatively impacting mood and functioning.
The Biomarkers for Evaluating Spine Treatments (BEST) Trial is a sequential, multiple assignment randomized trial designed to inform a precision medicine approach to the treatment of cLBP by estimating the optimal treatment or combination of treatments based on patient features and response to the initial treatment.3,4 The trial evaluated four treatments (exercise and manual therapy; duloxetine; enhanced self-care; and Acceptance and Commitment Therapy [ACT]) to determine optimal treatment choice based on an individual’s phenotypic markers and response to treatment. Each of these interventions are distinct classes of treatment shown to improve a range of cLBP outcomes with moderate effect sizes, demonstrated in randomized controlled trials. ACT was selected as the psychological intervention based on the strength of literature support as an evidence-based treatment recommended for use in the setting of chronic pain management and its potential for improving difficult to treat subgroups with pain, such as older or less well-educated patients.3,5–7 A diverse group of stakeholders (eg, payors, patients, federal partners) were consulted during trial protocol development to provide input on a design that would improve the care provided to patients experiencing cLBP.
ACT is a process-oriented therapy aimed at increasing psychological flexibility as the direct treatment target. It is a form of cognitive behavioral therapy that emphasizes behavior change and adopts a highly individual functional and contextual approach. With links to existential psychotherapy historically and conceptually, ACT emphasizes the importance of each patient’s individual meanings of illness and transforming suffering through patients reframing perceptions of their illness experience. Psychological flexibility is a key therapeutic mechanism and can be described as being open to experience whether comfortable or uncomfortable, in contact with the present moment when it is needed to achieve goals and based on what the situation affords, and engaged with positive patterns of behavior in the service of chosen values. Six core processes, focused on increasing these qualities of openness, awareness, and engagement, are employed during treatment to enhance psychological flexibility.8 In the setting of chronic pain management, an ACT approach helps individuals learn how to more effectively experience and interact with unwanted and persistent pain, and the associated aversive feelings and emotions, in the existential pursuit of a life with meaning and purpose.
Previous studies have examined various psychological mechanisms of action of ACT.9 Pain acceptance and values-based activities have emerged as particularly effective components of the treatment,10,11 especially in women.12 Pain acceptance can be described as willingness to experience pain without trying to control or change it, as well as engaging in activities despite having pain. Rather than maintaining focus on pain and controlling pain, ACT seeks to help patients expand their awareness, change their relationship with pain, and engage in values-guided activities that are consistent with purpose and meaning. This approach differs from cognitive behavioral therapy (CBT) which has traditionally focused on increasing self-efficacy and control over pain. Research has found, somewhat surprisingly, that efforts to control pain can paradoxically increase one’s distress, and increase the impact of pain, perhaps as one becomes increasingly focused on the pain experience to the exclusion of other interests.13,14 ACT may have additional benefits over CBT in that patients report higher satisfaction with treatment and have lower dropout rates in clinical studies.15,16
Several recent meta-analyses show that, in general, there are moderate effects favoring ACT over control conditions on outcomes including measures of daily functioning at posttreatment and at follow-up.6,17,18 Similarly, moderate effects were noted in secondary outcomes including improved anxiety, depression, psychological flexibility, and pain intensity. Similar findings of medium-to-small effects across outcomes have also been found comparing online-delivered ACT to control treatments.19 Important limitations were also identified in these meta-analyses including very small number of studies comparing ACT with an active treatment, potentially biased measurement, as well as the heterogeneity of the intervention format, the dose of treatment, and the specific pain population being treated. Delivery of ACT can take a variety of forms including face-to-face or online (internet-delivered) modalities, as well as hybrid models that combine face-to-face sessions with digital tools. The degree of therapist support also can vary considerably from unguided programs to exclusive therapist sessions without a self-directed component.20
Our purpose is to describe the design and implementation of an online model of ACT with enhanced therapist support for cLBP in the context of a complex multi-arm trial, the BEST Trial, designed to support a personalized or “precision medicine” approach to this condition.4,7 This ACT program, ACT for PAIN, builds off previously tested versions.21–23 It was further refined, for example, by enhancing the therapist support component with the addition of video visits, to address limitations identified in previous studies (such as improving completion rates) while maintaining effectiveness, accessibility to patients and providers, and potential for scalability.
Methods
Treatment program overview
ACT for PAIN is a pain-focused treatment program designed for the BEST Trial is delivered online via a custom, web-based software platform. It is based on the content and design previously studied in general chronic pain,22 painful diabetic neuropathy,21 vulvodynia,24 and HIV-related pain.23 The treatment has 3 primary components: (1) interactive online sessions consisting of video, audio, and self-assessment; (2) therapist sessions via video visits; and (3) ongoing therapist support outside the video visits. Treatment methods were experiential, including mindfulness exercises, other flexibility skills training, metaphor, and building of patterns of values-based action, addressing the 6 core therapeutic processes for ACT (Figure 1).25
Figure 1.
Six core therapeutic processes for acceptance and commitment therapy.25
Participants randomized to ACT for PAIN take part in a total of 12 sessions over the course of a 12-week treatment period (Figure 2). The 12 sessions included 4 video visits with a therapist and 8 therapist-supported online sessions. At the time of treatment assignment, participants were oriented to the treatment by study staff and given a treatment manual. The manual provided an overview of the treatment program, description of the 6 therapeutic processes or “skills-building opportunities” (Figure 1), and instructions for using the online software. At the study visit, site staff reviewed the manual with participants, assisted them with accessing the website for online treatment, and scheduled 4 video visits with the therapist. Participants were encouraged to watch an introductory video provided via the website prior to their first video visit with the therapist. For the trial, video visits were scheduled within 10 weeks of randomization to accommodate subsequent study visits and second-stage randomization. Site staff were encouraged to schedule the first therapist video visit no later than 2 weeks from the date of randomization.
Figure 2.
Overview of the ACT for PAIN online treatment program with enhanced therapist support.
Online content
The online sessions delivered ACT content that focused on helping participants develop skills in psychological flexibility, including its 6 facets of acceptance, cognitive defusion, present-focused attention, self-as-context, values-based action, and committed action. The online sessions were delivered according to a schedule, with the first session beginning on the Monday following completion of the first video visit with the therapist. Thereafter, they followed a schedule of 1 or 2 each week for a total of 7 weeks (Figure 1). Sessions were completed in sequential order and could not be completed in advance of the program schedule. Participants progressed subsequent sessions only after the previous session has been completed or the therapist had manually skipped a session. The recommended schedule was flexible, however, such that participants could complete the sessions any time during the week they became available, or could delay completion of sessions if needed, provided the full treatment occurred within a 12-week period. This structure incorporated flexibility and sought to increase acceptability to the participant and reflect the pragmatic nature of treatment in practice.
The online sessions consisted of video and audio segments intermixed with text prompts and self-assessments. At the beginning of each session, participants were asked to rate how often over the past 2 days, on a scale of 0 (never) to 10 (always): (1) they had responded with openness to thoughts and feelings rather than struggling with them; (2) been aware and focused on the present rather than dwelling in the past or worried about the future; and (3) behaved in a way guided by their goals and values rather than by experiences they want to avoid. Video segments guided patients through the session and featured a therapist who delivered the skills training elements, as summarized in Table 1. Audio content featured stand-alone exercises such as “Your 80th Birthday,” “Passengers on the Bus,” and “Tracking Your Thoughts in Time.” Self-assessments were interspersed throughout the session and probed for reactions to the exercises, including thoughts or feelings, and asked patients to reflect on their ongoing skills practice. Responses were recorded on online forms and were available for both patients and therapists to review after sessions were complete. At the close of each session, patients completed a Behavioral Commitment Worksheet. This exercise asked participants to commit to practicing a specific behavior for the upcoming week, describe why it is important to them, anticipate barriers and strategize how to overcome them, and prepare ways to keep their commitment. The 8 sessions varied in content length, ranging from 16 to 40 minutes, with additional time for self-assessment. Individual sessions could be completed all at once or could be paused and re-started at a later time. Once complete, an automated message and copy of submitted responses was sent to the therapist.
Table 1.
Content of online sessions.
| Session | Title | Session content | Experiential exercises |
|---|---|---|---|
| 1 | Shift your focus and What will you do? | Introduction: Living with Pain, Shifting focus |
|
| 2 | Drop the struggle and ACT with openness | Openness (acceptance) |
|
| 3 | ACT with openness to thoughts | Openness: More on Opening Up, Including Thoughts (cognitive defusion) |
|
| 4 | Clarify your values, define your goals, and ACT | Engagement: Choosing your Values and Goals (values-based action) |
|
| 5 | Focus on the present moment and take action | Awareness: Focusing on the Present Moment (contact with the present) |
|
| 6 | Build further engagement and incorporate barriers | Engagement: Engaged—Committed to Your Goals (committed action and goal setting) |
|
| 7 | Commit, ACT, and see the observer self | Awareness: Self as Observer (self-as-context/observer) | Observer |
| 8 | Build wider patterns of success | Engagement: Building Wider Patterns of Success (integration of skills sets) |
|
In addition to the 8 online sessions there were 8 supplemental sessions consisting primarily of audio content (Table 2). Therapists could augment the core content with these supplemental sessions depending on the patient’s progress and needs; for example, if it was clear the participant would benefit from additional practice on a particular skill. Supplemental sessions were not available to patients until they were assigned by therapists via the platform.
Table 2.
Content of eight supplemental online sessions.
| Supplemental online sessions |
|---|
|
Enhanced therapist support
The primary purpose of therapist support was to tailor treatment to the patient, support skills building, and maintain engagement. Where the online content was structured and content-focused, the therapist time was process-focused and allowed for tailored application of ACT (eg, by referring supplemental sessions, covering specific content as part of the video visits, and reviewing patient self-assessments and commitment goals). Online communications and video visits provided personalized support and accountability for participants to engage in treatment and practice skills.
Therapists provided support and coaching through the four video visits as well as an online messaging system. Video visits were 60 minutes in duration and conducted via HIPAA compliant videoconference (or audio-only if video was unavailable). The first visit focused on establishing rapport, discussing goals of treatment, and reviewing the online protocol and platform. The therapists conducted a brief assessment of life context and primary problems and oriented toward patient goals for treatment. Skills based learning was introduced, and a brief mindfulness exercise was practiced with therapist guidance. During subsequent visits, participants were asked to share their experience of skills practice and mastery, provide examples of skills use at home, and describe barriers they encounter (Table 3). Therapists provided guidance for patient practice, personalizing application of skills and reminding them of underlying goals they had identified along the way. In advance of each session, therapists reviewed diary data and session content via the online platform. After each session, therapists completed a Fidelity Checklist to record the therapeutic processes used in each session. At the final session, therapists helped patients reflect on the changes patients had made that had the biggest impact on their life and what skills they will continue to maintain.
Table 3.
Content and goals for therapist sessions delivered via video visit and supplemental online session content.
| Therapist session goals |
|---|
| Session 1 |
|
|
|
|
|
|
| Sessions 2–4 |
|
|
|
|
|
|
| Session 4 |
|
|
Coaching support was also provided to patients via the online messaging system. Therapists send individualized written messages following completed online session as well as on an as-needed basis over the course of treatment. Written feedback aimed to reinforce session information and to build and reinforce psychological flexibility. Therapists assessed patient’s level of engagement and skill building from session responses, including participant text inputs sent to the therapists, allowing for the intervention and discussion to be tailored to their individual needs and skill level. The therapist offered modifications for practice, helped overcome barriers between sessions, offered clarifications, positively reinforced efforts and provided support, as would occur in video visits. This additional mode of interaction allowed patients greater flexibility for completing modules between therapist video visits. Motivation enhancing interactions were delivered through messaging platforms when a patient faced a barrier or setback in progress, further encouraging flexible, active engagement. Reminders and scheduling changes were addressed via the platform and messages were sent to prompt participants who had disengaged from treatment.
Delivery and implementation
Qualified therapists for the BEST trial were psychologists with previous training in chronic pain management and experience delivering ACT. Therapists underwent additional training and certification prior to initiating treatment. Training consisted of a 2-hour ACT seminar, participation in a live 2-hour training with the central ACT provider, review of study materials and a treatment manual, and a video tutorial and demonstration of the online platform.
A custom, web-based software application was designed to deliver the treatment content to patients, facilitate therapist-patient coaching interactions, and support therapists in managing their patients. Patients used the online platform to access online sessions, ACT for PAIN resources and informational videos, self-assessments, and video visit schedules and links. Therapists utilized a dashboard that displayed completion status of the online sessions, date of upcoming visit, referrals to supplemental content, and indicators of unread messages for each of their patients. Patient profiles provided a graphic of participant ratings of openness, awareness, and values-based behavior over time as well as access to all session content. Therapists completed the fidelity checklist for each visit online. Patients and therapists had access to a messaging system to send and receive messages.
Automatic notifications were distributed to patients and therapists. Patients received notifications according to their preferred mode (SMS or email) when online sessions became available to them. They also received reminders when online sessions were overdue. Therapists and patients received reminders of upcoming video visits 2 days prior to and the day of each visit.
Fidelity monitoring
Fidelity to protocol was monitored and supported throughout the study. Therapists participated in one hour of monthly group supervision co-led by a study team member (S.B.) and the central ACT provider (L.M.). These meetings were designed to prevent drift and provide a forum for discussing protocol questions and challenges that arose with delivery of the treatment program. In addition, challenging cases were discussed, similar to peer supervision process in clinical practice. Therapists completed a fidelity checklist after each visit (Supplementary Material). Visits were recorded and a subset were reviewed for fidelity under the direction of study investigators (L.M., S.B., A.W.) using the ACT-Fidelity Measure (FM) tool. The ACT-FM assesses the degree of ACT consistent and ACT inconsistent behavior in 4 domains: Therapist stance, open response style, aware response style and engaged response style.26 Participant engagement was measured throughout the 12-week treatment period and included attendance at therapist visits, completion of online sessions, and utilization of the online messaging system.
Patient engagement
Data from the 203 participants assigned to ACT in Stage 1 randomization were used to summarize engagement with the therapist visits and online sessions. On average, participants completed 3.2 therapist visits (SD 1.2) and 5.7 (2.8) online sessions. The median numbers of therapist visits and online sessions completed were 4 and 7, respectively. Eighty percent of participants completed 3 or more therapist visits, and 63% of participants completed 6 or more online sessions. Adherence to ACT, defined as completion of at least half of the therapist visits and half of the online sessions, was 74%.
Discussion
The online, therapist-supported ACT for PAIN treatment program designed for the BEST Trial has the potential to transform care for patients with chronic pain, expanding its reach and improving access to under-served patient populations. Barriers to treatment include limited availability of specially trained providers who have knowledge and experience in ACT, lack of transportation, cost concerns, long waiting lists or the disabling effects of pain itself.27 Efforts to address treatment delivery barriers include providing treatment in group settings and internet-delivered approaches. While potentially more efficient, group therapy has the added burden of coordinating schedules and having adequate space or facilities for this type of treatment. It is also quite difficult to personalize treatment within a group setting. As a result, and coupled with more accessible technology, there has been a growing interest in developing and examining completely remotely delivered treatments. Internet delivery may be particularly well suited for individuals with transportation limitations or who reside in areas with limited access to qualified providers. Patients with chronic pain, in particular, may face mobility limitations and high-quality internet-delivered treatment options are needed to enhance access. Finally, expanding the reach of this potentially more cost-effective therapy (given the smaller number of therapist sessions relative to other programs) to more diverse population with respect to socioeconomic status is an important consideration given that prevalence of chronic pain is higher in more disadvantaged populations.28
There are many variations of treatments designed for remote delivery, including therapist administered sessions via telehealth, therapist supported protocols via text, email or phone call, and unguided internet interventions.19,21,22,29–31 Taken together, these variations have generally been found to be effective and add a potentially cost-effective treatment that is more accessible.32,33 A systematic review of online treatments for chronic pain found internet interventions to have small to moderate effects, comparable to in-person interventions.34 In a head-to-head comparison between in-person and virtual ACT for chronic pain, online treatment was found to be noninferior to in-person treatment.31 However, these studies identified problems with attrition in online variations, sometimes as high as 71%,35 and patients who fall behind experience poorer outcomes.36
Studies have begun to examine the relationship of therapist guidance in online treatment with drop-out rates and content completion. Improved outcomes and higher rates of session completion have been reported in guided internet-based ACT treatment compared to unguided treatment.37,38 Without guidance and ongoing motivation, it can be easy for participants to disengage. Completion and follow-up rates have also been found to be higher in older and unemployed populations.22,31 In a recent pilot study examining a therapist-guided smart-phone ACT intervention, participants with chronic pain reported improvement in pain interference as well as in secondary outcome measures of insomnia, values, and quality of life.39 The researchers discuss possible explanations for the high completion rate in this study (90%) including design of the study, therapists’ level of training in both ACT and chronic pain, as well as the “microinteractions” possible with smartphone delivered treatment (eg, text messages, notifications) that are possibly better suited for participants with chronic pain. These features mirror core aspects of ACT for PAIN. Our results from participants assigned to ACT in the first stage of the BEST Trial support high levels of engagement in the treatment program. In this growing body of research, treatment completion and engagement appear to be enhanced with therapist-guided involvement which may also improve patient engagement. Optimal level of therapist guidance associated with the most effective outcomes while reducing barriers to treatment is unclear.
The design of ACT for PAIN offers built-in flexibility and treatment personalization, which is limited in other evidence-based interventions. Efficiency in delivery is achieved with background and education on ACT covered by online sessions thus freeing the therapist to spend more focused time on process and patient-centered care during therapist sessions. Care can be personalized based on skill level, life events, and personal goals. Further adaptations to this treatment program may make the number of therapists visits modifiable from potentially no visits, relying solely on the online therapist-support as originally designed22 or more than four video visit sessions as needed. Internet delivery may also leverage ongoing initiatives (eg, PSYPAC) to expand provider availability by allowing US providers to treat patients across state lines, thereby easing constraints of limited supply of providers in certain regions of the country. Finally, the online content and the manualized nature of the video visits suggest that practitioners without experience with ACT can be trained by a health/pain psychologist to deliver the intervention, thereby expanding the workforce of providers with competency for delivering ACT.
In many ways, online delivery of ACT is poised for scalability, meeting the increasing needs for ACT and significant accessibility challenges many people experience with in-person delivery. For instance, the software is designed for installation behind IT firewalls in healthcare systems, and we are currently pursuing this at the University of Pittsburgh Medical Center. Future work will consider a cloud computing version to further enhance accessibility nationwide and worldwide. The clinical and research implications of online platforms for ACT for chronic pain are profound. From improving access and potentially reducing costs to contributing to novel research on mechanisms and therapeutic effectiveness, these platforms hold significant promise. Future analyses of the BEST trial will inform as to which participants are most likely to benefit from ACT.
Despite its many advantages, there are notable limitations to online delivery modalities. Low digital literacy, discomfort with technology, lack of access to necessary devices, and limited internet access may reduce reach for certain individuals or patient engagement.40 Further, there is a need to directly compare efficacy of ACT across modes of delivery as well as with respect to the degree of therapist involvement and support. Future work should identify patient phenotypes that are more likely to drop out or that engage better with self-directed versus therapist-supported components or in-person versus online modes. This information will aid in further personalizing ACT treatment with respect to the delivery mode and degree of therapist involvement to the needs of individual patients. Because of its built-in flexibility, the ACT for PAIN platform can be adapted for testing these features in future clinical trials to determine, for example, the optimal level of therapist support or what patient phenotypes are most likely to benefit from ACT for PAIN. Further, the platform is being integrated into the electronic medical record system for use in routine clinical care across multiple practices within a large health system, as noted. Further dissemination and implementation can scale this platform to other practices, particularly those that serve hard-to-reach patients in rural or under-resourced areas. Evaluation of cost-effectiveness, provider and patient acceptability of treatment, and patient outcomes in these real-world settings will further inform future implementation.
Supplementary Material
Acknowledgments
The Back Pain Consortium (BACPAC) Research Program is administered by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).
Contributor Information
Sara Jones Berkeley, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States.
Sharlene Wedin, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, United States.
Seema M Patidar, Department of Anesthesiology, UNC School of Medicine, Chapel Hill, NC 27514, United States.
Skye O Margolies, Department of Anesthesiology, UNC School of Medicine, Chapel Hill, NC 27514, United States.
Amy M Goetzinger, Department of Anesthesiology, UNC School of Medicine, Chapel Hill, NC 27514, United States.
Matthew C Mauck, Department of Anesthesiology, UNC School of Medicine, Chapel Hill, NC 27514, United States.
Ajay D Wasan, Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, United States.
Lance M McCracken, Psychology Department, Uppsala University, Uppsala 751 42, Sweden.
Author contributions
SJB, MM, ADW and LMM contributed to the conceptualization of the project. SJB, ADW, and LMM contributed to the methodology. SJB contributed to the software and project administration. All authors contributed to the investigation. SJB, SW, SMP, and SOM produced the original draft and subsequent review and editing; AG, MM, ADW, and LMM also contributed to manuscript review and editing. SJB and LMM contributed to visualization and ADW and LMM contributed to supervision. Finally, MM and ADW contributed to funding acquisition.
Supplementary material
Supplementary material is available at Pain Medicine online.
Funding
This research was supported by the National Institutes of Health through the NIH HEAL Initiative under award number 1U24AR076730. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or its NIH HEAL Initiative.
Conflicts of interest: All authors report no disclosures or conflicts of interest.
References
- 1. Lucas JW, Connor EM, Bose J. Back, lower limb, and upper limb pain among U.S. adults, 2019. NCHS Data Brief. 2021;(415):1-8. [PubMed] [Google Scholar]
- 2. GBDLBP Collaborators. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(6):e316-e329. 10.1016/S2665-9913(23)00098-X [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Mauck MC, Aylward AF, Barton CE, et al. Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach. Pain Rep. 2022;7(5):e1019. 10.1097/PR9.0000000000001019 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Mauck MC, Lotz J, Psioda MA, et al. The Back Pain Consortium (BACPAC) research program: structure, research priorities, and methods. Pain Med. 2023;24(suppl 1):S3-S12. 10.1093/pm/pnac202 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. NICE Guideline. Chronic Pain (Primary and Secondary) in over 16s: Assessment of All Chronic Pain and Management of Chronic Primary Pain (NG193). National Institute for Health and Care Excellence; 2021. [PubMed] [Google Scholar]
- 6. Lai L, Liu Y, McCracken LM, Li Y, Ren Z. The efficacy of acceptance and commitment therapy for chronic pain: a three-level meta-analysis and a trial sequential analysis of randomized controlled trials. Behav Res Ther. 2023;165:104308. 10.1016/j.brat.2023.104308 [DOI] [PubMed] [Google Scholar]
- 7. Greco CM, Wasan AD, Schneider MJ, et al. Biobehavioral Assessments in BACPAC: Recommendations, Rationale, and Methods. Pain Med. 2023;24(suppl 1):S61-S70. 10.1093/pm/pnac175 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Hayes SC, Strosahl K, Wilson KG. Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. 2nd ed. Guilford Press; 2012: xvi, 304 p. [Google Scholar]
- 9. McCracken LM. Psychological flexibility, chronic pain, and health. Annu Rev Psychol. 2024;75:601-624. 10.1146/annurev-psych-020223-124335 [DOI] [PubMed] [Google Scholar]
- 10. Akerblom S, Perrin S, Rivano Fischer M, McCracken LM. The mediating role of acceptance in multidisciplinary cognitive-behavioral therapy for chronic pain. J Pain. 2015;16(7):606-615. 10.1016/j.jpain.2015.03.007 [DOI] [PubMed] [Google Scholar]
- 11. Vowles KE, McCracken LM. Acceptance and values-based action in chronic pain: a study of treatment effectiveness and process. J Consult Clin Psychol. 2008;76(3):397-407. 10.1037/0022-006X.76.3.397 [DOI] [PubMed] [Google Scholar]
- 12. Pester B, Crouch T, Christon L, et al. Gender differences in multidisciplinary pain rehabilitation: the mediating role of pain acceptance. J Con Beh Sci. 2022;23:117-124. 10.1016/j.jcbs.2022.01.002 [DOI] [Google Scholar]
- 13. McCracken LM, Vowles KE, Eccleston C. Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase. Behav Res Ther. 2005;43(10):1335-1346. 10.1016/j.brat.2004.10.003 [DOI] [PubMed] [Google Scholar]
- 14. Vowles KE, McCracken LM. Comparing the role of psychological flexibility and traditional pain management coping strategies in chronic pain treatment outcomes. Behav Res Ther. 2010;48(2):141-146. 10.1016/j.brat.2009.09.011 [DOI] [PubMed] [Google Scholar]
- 15. Ong CW, Lee EB, Twohig MP. A meta-analysis of dropout rates in acceptance and commitment therapy. Behav Res Ther. 2018;104:14-33. 10.1016/j.brat.2018.02.004 [DOI] [PubMed] [Google Scholar]
- 16. Wetherell JL, Afari N, Rutledge T, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain. 2011;152(9):2098-2107. 10.1016/j.pain.2011.05.016 [DOI] [PubMed] [Google Scholar]
- 17. Hughes LS, Clark J, Colclough JA, Dale E, McMillan D. Acceptance and Commitment Therapy (ACT) for chronic pain: a systematic review and meta-analyses. Clin J Pain. 2017;33(6):552-568. 10.1097/AJP.0000000000000425 [DOI] [PubMed] [Google Scholar]
- 18. Ma TW, Yuen AS, Yang Z. The efficacy of acceptance and commitment therapy for chronic pain: a systematic review and meta-analysis. Clin J Pain. 2023;39(3):147-157. 10.1097/AJP.0000000000001096 [DOI] [PubMed] [Google Scholar]
- 19. Trindade IA, Guiomar R, Carvalho SA, et al. Efficacy of online-based acceptance and commitment therapy for chronic pain: a systematic review and meta-analysis. J Pain. 2021;22(11):1328-1342. 10.1016/j.jpain.2021.04.003 [DOI] [PubMed] [Google Scholar]
- 20. French K, Golijani-Moghaddam N, Schroder T. What is the evidence for the efficacy of self-help acceptance and commitment therapy? A systematic review and meta-analysis. J Context Behav Sci. 2017;6(4):360-374. 10.1016/j.jcbs.2017.08.002 [DOI] [Google Scholar]
- 21. Kioskli K, Scott W, Winkley K, Godfrey E, McCracken LM. Online acceptance and commitment therapy for people with painful diabetic neuropathy in the United Kingdom: a single-arm feasibility trial. Pain Med. 2020;21(11):2777-2788. 10.1093/pm/pnaa110 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Scott W, Chilcot J, Guildford B, Daly-Eichenhardt A, McCracken LM. Feasibility randomized-controlled trial of online Acceptance and Commitment Therapy for patients with complex chronic pain in the United Kingdom. Eur J Pain. 2018;22:1473-1484. 10.1002/ejp.1236 [DOI] [PubMed] [Google Scholar]
- 23. Scott W, Guildford BJ, Badenoch J, et al. Feasibility randomized-controlled trial of online acceptance and commitment therapy for painful peripheral neuropathy in people living with HIV: the OPEN study. Eur J Pain. 2021;25(7):1493-1507. 10.1002/ejp.1762 [DOI] [PubMed] [Google Scholar]
- 24. Chisari C, McCracken LM, Cruciani F, Moss-Morris R, Scott W. Acceptance and commitment therapy for women living with vulvodynia: a single-case experimental design study of a treatment delivered online. J Context Behav Sci. 2022;23:15-30. [Google Scholar]
- 25. Feliu-Soler A, Montesinos F, Gutiérrez-Martínez O, Scott W, McCracken LM, Luciano JV. Current status of acceptance and commitment therapy for chronic pain: a narrative review. J Pain Res. 2018;11:2145-2159. 10.2147/JPR.S144631 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. O'Neill L, Latchford G, McCracken LM, Graham CD. The development of the Acceptance and Commitment Therapy Fidelity Measure (ACT-FM): a Delphi study and field test. J Context Behav Sci. 2019;14:111-118. 10.1016/j.jcbs.2019.08.008 [DOI] [Google Scholar]
- 27. Modi HO, Orgera K, Grover A. Exploring Barriers to Mental Health Care in the U.S. American Association of Medical Colleges; 2022. [Google Scholar]
- 28. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. 10.15585/mmwr.mm6736a2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Macea DD, Gajos K, Daglia Calil YA, Fregni F. The efficacy of Web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis. J Pain. 2010;11(10):917-929. 10.1016/j.jpain.2010.06.005 [DOI] [PubMed] [Google Scholar]
- 30. Vugts MAP, Joosen MCW, van der Geer JE, Zedlitz A, Vrijhoef HJM. The effectiveness of various computer-based interventions for patients with chronic pain or functional somatic syndromes: a systematic review and meta-analysis. PLoS One. 2018;13(5):e0196467. 10.1371/journal.pone.0196467 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Herbert MS, Afari N, Liu L, et al. Telehealth versus in-person acceptance and commitment therapy for chronic pain: a randomized noninferiority trial. J Pain. 2017;18(2):200-211. 10.1016/j.jpain.2016.10.014 [DOI] [PubMed] [Google Scholar]
- 32. Rohrbach PJ, Dingemans AE, Evers C, et al. Cost-effectiveness of internet interventions compared with treatment as usual for people with mental disorders: systematic review and meta-analysis of randomized controlled trials. J Med Internet Res. 2023;25:e38204. 10.2196/38204 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Romero-Sanchiz P, Nogueira-Arjona R, Garcia-Ruiz A, et al. Economic evaluation of a guided and unguided internet-based CBT intervention for major depression: results from a multi-center, three-armed randomized controlled trial conducted in primary care. PLoS One. 2017;12(2):e0172741. 10.1371/journal.pone.0172741 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Buhrman M, Gordh T, Andersson G. Internet interventions for chronic pain including headache: a systematic review. Internet Interv. 2016;4:17-34. 10.1016/j.invent.2015.12.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Guiomar R, Trindade IA, Carvalho SA, et al. Usability Study of the iACTwithPain platform: an online acceptance and commitment therapy and compassion-based intervention for chronic pain. Front Psychol. 2022;13:848590. 10.3389/fpsyg.2022.848590 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Gasslander N, Alfonsson S, Jackalin A, et al. Predictors of adherence to an internet-based cognitive behavioral therapy program for individuals with chronic pain and comorbid psychological distress. BMC Psychol. 2021;9(1):156. 10.1186/s40359-021-00663-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Lin J, Paganini S, Sander L, et al. An internet-based intervention for chronic pain. Dtsch Arztebl Int. 2017;114(41):681-688. 10.3238/arztebl.2017.0681 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38. Chew MT, Chan C, Kobayashi S, Cheng HY, Wong TM, Nicholson LL. Online pain management programs for chronic, widespread musculoskeletal conditions: a systematic review with meta-analysis. Pain Pract. 2023;23(6):664-683. 10.1111/papr.13227 [DOI] [PubMed] [Google Scholar]
- 39. Gentili C, Zetterqvist V, Rickardsson J, Holmström L, Simons LE, Wicksell RK. ACTsmart: guided smartphone-delivered acceptance and commitment therapy for chronic pain-a pilot trial. Pain Med. 2021;22(2):315-328. 10.1093/pm/pnaa360 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Tauben DJ, Langford DJ, Sturgeon JA, et al. Optimizing telehealth pain care after COVID-19. Pain. 2020;161(11):2437-2445. 10.1097/j.pain.0000000000002048 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.