Victoria L. Mason, Beth Mathias, and Suzanne M. Skevington
This study examines an area of disability ‘adjustment’ that is becoming increasingly important in to therapists and others interested in what helps someone develop readiness to adopt self management rather than an ongoing search for a ‘cure’.
Acceptance refers to ‘a willingness to have pain without feeling the need to control or eliminate it’, and is associated with ‘acknowledging that one has pain, giving up unproductive attempts to control pain, acting as if pain does not necessarily imply disability, and being able to commit one’s efforts towards living a satisfying life, despite pain.’ (McCracken, 1998; McCracken, Spertus, Janeck, et al. 1999; McCracken & Vowles, 2006)
Over the last 10 years or so, there has been a growing use of patient-centred measures of outcome for measuring the impact of programmes for chronic pain, including the WHOQOL, which is an instrument developed by the World Health Organisation covering 25 dimensions of life including pain and discomfort. This study was intended to explore the relationship between a more pain-specific addition to the WHOQOL tool and a measure of pain acceptance previously developed by McCracken and colleagues, and to identify the clinical implications of the findings.
The Short-form Pain Acceptance Questionnaire or SFPAQ is a psychometrically robust questionnaire that has been used to measure the degree of acceptance that people with chronic pain have towards their pain. The original CPAQ total score is associated with standardized measures of emotional distress and daily function. It contains items such as ‘‘My life is going well, even though I have chronic pain’’ and ‘‘It’s not necessary for me to control my pain in order to handle my life well.’’ The SFPAQ uses 20 of the original 34 items, obtained by factor analysis, and has superior psychometric properties to the original version. The two factor structure of the SFPAQ measures ‘activity engagement’ or the willingness to pursue activities despite pain, and ‘pain willingness’ which is a measure of the recognition that avoidance and control are unworkable ways to adapt to a life with pain.
The authors point out that reliability results obtained from pain samples using the WHOQOL pointed to a need for developing a specific module of extra items that would elaborate the QoL, and that could be added to the WHOQOL core instrument when used by chronic pain patients. This would enable a more detailed account of pain and discomfort related to QoL to be explored by people with pain within the framework proposed by theWHOQOL group.
Pragmatically, an ‘opportunistic, purposive sample of patients with diagnosis of CLBP’ was recruited from two outpatient pain clinics at local General Hospitals: an epidural clinic (Salisbury) and a pain management clinic (Bath). Exclusion criteria for the study were minimal and consisted of psychiatric conditions and conditions where fatigue is a major factor. Of 162 patients invited to participate, 86 took part (response rate 53%). This is quite a low response rate, but given that they were sent a letter and asked to complete a questionnaire and post back or hand it in at the appointment, probably quite reasonable. Unfortunately no details of the nonresponders were able to be collected.
The respondent group appear very similar to those referred to any tertiary pain management centre – more women than men, the majority were married, ranging in age from 17 years to 92 years (mean 54.3 years), not in paid work, considering themselves to be unwell, with pain being ‘discomforting’ and ‘continuous’. Lower back and spine pain was the most frequent pain site (90.7%), with the legs (70.9%) and pelvis (25.6%) the next more common pain site.
Results? Glad you asked! Unsurprisingly, acceptance is strongly and positively associated with QoL. Strongest associations were found for the SF-CPAQ (r=0.582, P<0.001) and the subscales of pain willingness (r=0.493, P<0.001), and activities engagement (r=0.455, P<0.001). Higher QoL scores were also associated with lower pain intensity.
“To summarize, engagement in activity is an important predictor of psychologic, independence, and environmental QoL, in addition to pain-related facets assessed by the PDM. Willingness to recognize that avoidance and control may be unworkable explain, in part, physical and environmental QoL and pain-related facets (PDM). Overall, acceptance contributed significantly
to explain QoL relating to level of independence, the environment, and PDM facets, but less so for other domains, particularly social relationships and spirituality, which did not appear to be explained by either present pain level or acceptance. Present pain level seems to be
an important predictor of the physical, social, and painrelated dimensions of QoL. Although R2 change values indicate that present pain level also contributed significantly to explain levels of independence, the effect of pain level decreases when acceptance is included in the model,
indicating shared variance here”.
What does this mean for you and me as clinicians?
Methodological criticisms aside (cross-sectional studies, convenience samples, small number of participants and low response rates) this study demonstrates that people who accept their pain seem to have a greater quality of life (or perhaps that people with better quality of life achieve greater acceptance?). Because pain intensity has an important influence on QoL, it suggests that pain reduction strategies should continue to be pursued at least until the well-established ones relevant to the specific condition have been tried. However, at some point, it seems important to stop continuing with pain reduction and move towards pain management, and most of this should be self management rather than relying on others (or external locus of control) to do so. This is because, despite pain intensity having an influence, it’s influence was weaker than acceptance and QoL.
This study demonstrates the utility and psychometric robustness of both the WHOQOL-Pain and the SF-CPAQ in a clinical sample. Both of these measures can be employed within pain management programmes to monitor individual progress and to look at how patients from different diagnostic groups change during treatment. The authors also suggest they can be used ‘to benefit chronic pain research, clinical trials, clinical governance, and audit’. (Mason, Mathias & Skevington, 2008).
As I noted above, this study can’t answer whether QoL is influenced by acceptance, or whether acceptance is influenced by QoL. This will require further study – and this sort of study will also help identify whether acceptance-based interventions improve QoL, as well as which aspects of pain acceptance (activity engagement or pain willingness) are most influential.
My one concern with this study is this:
- it’s already difficult to get some biomedical practitioners to consider anything other than pain intensity (reported often immediately after a procedure!), or to refer to cognitive behavioural pain management,
- that to introduce another measure (however theoretically sound or patient-centred) on another dimension (that is new and relatively difficult to implement) is going to be fraught with difficulty.
I haven’t yet really come to grips with how to present acceptance or contextual cognitive behavioural therapy to patients. I need to learn more about this – so expect some more posts as I get my head around the concepts!!
McCracken LM. (1998). Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain. 74, pp21–27.
McCracken LM, Spertus IL, Janeck AS, et al(1999). Behavioural dimensions to adjustment in persons with chronic pain: pain-related anxiety and acceptance. Pain. 80, pp283–289.
McCracken LM, Vowles KE. 2006. Acceptance of chronic pain. Current Pain Headache Reports. 10, pp90–94.
Skevington SM, Carse MS, Williams AC de C. (2001). Validation of the WHOQOL-100: pain management improves quality of life in chronic pain patients. Clinical Journal of Pain. 17, pp264–275
Mason, V.L., Mathias, B., Skevington, S.M. (2008). Accepting Low Back Pain: Is It Related to a Good Quality of Life?. Clinical Journal of Pain, 24(1), 22-29. DOI: 10.1097/AJP.0b013e318156d94f