Table of Contents

Table 1
Assessments Used

1. Medications used

2. Hours resting each day due to pain

3. Appts made with primary care physician in past 6 months

4. Ratings of current pain, usual pain, and lowest pain in last week (these were combined into a composite score)

5. Beck Depression Inventory - measures depression and general emotional distress

6. Pain Anxiety Symptoms Scale - measures pain related anxiety and avoidance

7. Sickness Impact Profile - measures physical and psychosocial disability

8. Chronic Pain Acceptance Questionnaire - Activity Engagement and Pain Willingness subscales were used to measure involvement in daily activities despite pain and willingness to have pain without avoiding it

9. 10 meter timed walk

10. How many times can person stand-sit in an armless chair in 1 minute

Data was collected 4 times: 

1. Initial assessment

2. Pre-treatment

3. Post-treatment

4. 3-month follow-up

September 15, 2005 -- It is human nature to avoid things which are unpleasant.  Unpleasant situations, unpleasant people, unpleasant weather, it doesn't matter; we are programmed to seek out comfort.  This is even more true when it comes to pain. 
     Anyone living with residual pain due Chiari or syringomyelia knows the feeling.  You are asked to go somewhere or do something that you know will cause a great deal of pain and discomfort.  The dread starts to build.  Do you find an excuse, or do you force yourself to go through with it, anxious about how it will affect you?
     Obviously, avoiding pain is not a behavior limited to Chiari patients.  It may, in some cases however, actually be counterproductive.  In the field of pain research, there is a body of thought that one way in which regular, short-lasting pain becomes chronic, is through avoidance.  The avoidance theory states that when people are in pain, and they avoid doing activities because they are anxious or afraid of making things worse, they are in fact making things worse.  The resulting inactivity leads to muscle atrophy, feelings of depression, and more.
     Interestingly, in another realm, some psychologists have begun to develop treatments based on acceptance of things that can't be changed rather than avoidance.  For example, people with obsessive personalities may not be able to control negative thoughts they have, but they may be able to learn to not let the negative thoughts influence their actions.  Such acceptance based treatments have shown promise in helping people with borderline personality disorders and even schizophrenia.
     Dealing with chronic pain may be a similar situation.  It can be difficult to avoid or even control chronic pain.  Trying to control something which can't be controlled can actually make things worse, by increasing anxiety and distress.  As mentioned earlier, trying to avoid activities which increase pain often backfires and can increase disability.
     There is, however, an alternative, namely acceptance.  For example (this is taken from the source article) someone with severe chronic pain when presented with a social invitation may turn it down, think I can't go because I'm in too much pain, and feel anxiety about the whole situation.  Traditional therapy would focus on identifying these thoughts as faulty and reframing them into a more positive light.  An acceptance approach, on the other hand, recognizes that these thoughts happen, the pain will be there, but says, so what.  Go to the party anyway.  Recognize the pain, but don't let it control you.
     A recent study, led by Lance McCracken in the UK, and published in the October, 2005 issue of the journal, Behavior Research and Therapy, highlights the potential of the acceptance based approach to dealing with chronic pain.  McCracken and his colleagues evaluated the effectiveness of an acceptance based treatment program on the quality of life of 108 chronic pain patients.
   The study involved patients in a pain management unit in the UK which were treated between March, 2001 and July, 2002.  To participate in the study, patients had to have had pain for at least 3 months, reported pain related stress and disability, were not eligible for any more tests or procedures, and had no psychiatric conditions which would interfere with the proposed treatment.  One hundred forty two patients started the program, but only 108 participated for the entire treatment time.
     The patient group was 64% women, with about half suffering from low back pain.  Most people had been suffering for a long time, with the average duration over 10 years.  They had seen an average of 6 doctors related to their pain, and most had tried opioids and antidepressants without success.  More than 40% had even had some type of surgical treatment for pain.
     The study was designed to collect data at an initial assessment, just prior to the acceptance treatment, at the end of the acceptance treatment, and 3 months after the program (see Table 1).  The researchers gathered data on pain, the impact of the pain, anxiety, depression, and even two physical tests.  It should be pointed out that two measures were also used to gauge the level of pain acceptance in the patients.
     All the patients were given a fairly intensive, multi-disciplinary, acceptance based treatment.  The program lasted for 3 or 4 weeks depending on the need, and included physical therapists, occupational therapists, nurses, doctors, and clinical psychologists.  The program was five days a week for six hours a day. and was designed to focus on improving function.
     The treatment included exercises designed to activate the whole body, programs to develop healthy habits and provide a meaningful direction in life, and an extensive psychological focus.  The psychological component included reversing habits, being aware of avoidance thoughts, meditation exercises, relaxation techniques, body awareness to improve functioning, and raising awareness of the social effects of pain displays.
     The team found that the acceptance based intervention resulted in a significant improvement across nine measures (see Table 2), including the two physical tests.  Levels of depression dropped dramatically, as did psychosocial disability, and the amount of pain-related rest needed on a daily basis.  Three months later, while the improvement wasn't quite as strong, it was still significant compared to before the treatment.
    Interestingly, the patients also showed a greater level of acceptance (see Table 3) and a willingness to engage in activities despite the pain.  Using statistical methods, the researchers were able to show that there was a relationship between this increase in acceptance and five of the measures:  depression, anxiety, physical and psychosocial disability, and the results of the sit-stand test.
     The authors believe their results strongly demonstrate the potential of acceptance based treatments for several reasons.  The patients in this group had suffered from pain for years and had unsuccessfully tried many different treatments.  In addition, improvement was shown on a wide range of measures.  Finally, the improvements were seen were not just significant in the numbers, but represented a real improvement in the patients' lifestyles.
     While these results do appear promising, the gold standard to evaluate a treatment like this would be a random, controlled trial (RCT) where people are picked at random to either receive the acceptance based treatment, receive a different treatment, or receive no treatment.  The results comparing the different groups would then more definitively demonstrate the value of the acceptance based approach.  It should also be pointed out that the treatment program used in this study was an intensive program involving a variety of professional disciplines.  Outside of the research world, implementing such a program would likely be expensive and out of reach for many patients.
    In the end, one way to think about chronic pain is that a person has two choices.  They can try to control the actual pain through different treatments and by avoiding painful activities; or they can accept the pain, sort of put it in a box inside their head, try not to react to it, and live their life despite the pain. 
    For those in this situation, it is certainly worth thinking about.

--Rick Labuda 

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Key Points

1. It is a common reaction to avoid painful or negative experiences, however with chronic pain this may make things worse

2. Some researchers are now focusing on accepting pain and engaging in activities despite the pain

3. Study looked at using an acceptance based, multi-disciplinary treatment for 108 chronic pain patients

4. There was significant improvement in a number of measures after the treatment and even 3 months later

5. A random, controlled trial is the next step, but researchers believe their results are strong and indicate the value of acceptance based treatement

Table 2
Change In Measures Between Pre and Post Treatment
 

Table 3
Acceptance Measures, Pre and Post Treatment
 

Source: 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 Oct;43(10):1335-46. Epub 2005 Jan 7.

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