The purpose of pain management is, in the end, of no earthly use if it doesn’t change a person’s quality of life. It’s fine to maybe reduce pain intensity (remembering that most pain reduction approaches seem to reduce pain by around 10 – 40%), and it’s great to improve function – but unless the person feels their life is better, I’m guessing these outcomes won’t be sustained.
Over this week I’ve been looking at acceptance, with an eye to the ACT (Acceptance and Commitment Therapy) approach to helping people have a life despite encountering negative events. One important aspect of coping with chronic pain is coming to terms with the fact that pain persists and it seems that no part of life is left unaffected. It also seems that evidence is accumulating to support the idea that acceptance of pain is related to both emotional wellbeing as well as readiness to begin to do valued activities again.
This study is another from the Bath University stable, this time from a PhD study carried out by Dr Victoria Mason and supported by Beth Mathias and Dr Suzanne Skevington. Mason’s PhD was around developing a chronic pain component/module to the World Health Organisation’s Quality of Life measure, the WHOQOL, and this study was a part of the larger programme.
Quality of life is one of those terms that I’ve never really taken to – it’s always felt quite nebulous. The WHO definition of quality of life is ‘‘‘an individual’s perception of their position in life, in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.’’ Hmmm, suitably broad, so reasonably difficult to measure, I would have thought! Nevertheless, there are many different measures of quality of life, and the WHOQOL is probably the one most widely used internationally. It covers 25 dimensions or facets of life, and includes a section on pain – but as Mason and colleagues point out, although the original module has validity, its reliability wasn’t quite to the same standard and hence the desire to develop a chronic pain module specifically for people with chronic pain.
How did they do the study?
Patients attending two pain treatment facilities in Bath and Salisbury were recruited ‘opportunistically’ and ‘purposively’. This isn’t clearly described in the study, which is a shame because I wasn’t able to identify the basis for the ‘purposive’ sampling. However, 86 participants agreed to be part of the study, 15 from the epidural clinic and the remainder from the chronic pain centre.
Participants completed the WHOQOL-pain which is a 100-item instrument covering 6 domains; physical, psychologic, level of independence, environment, social relationship and spirituality, religion and personal beliefs. In addition, the PDM (Pain and discomfort module) was added to this and consists of 4 PDM facets that address pain relief, anger and frustration, vulnerability/ fear and worry, and uncertainty.
Participants also completed the Chronic Pain Acceptance Questionnaire, which is a 34-item inventory designed to measure acceptance of pain. This has been analysed as having a two-factor structure: pain willingness and activity engagement.
Who were the participants?
The demographics of the participants suggest they were mainly middle-aged (average age 52, but ranging from 17 – 92!); over 60% were married; 64% not working; and believed they were not well and ‘currently ill’.
Pain was identified as ‘discomforting’ and ‘continuous’ and located mainly in the lower back and spine.
What were the results?
The 4 measures of acceptance were strongly and positively associated with general QoL, suggesting that high acceptance is related to a good QoL.
Low present pain level was also related to a good QoL and health.
Fifteen of the 29 WHOQOL-Pain facets were strongly and positively associated with acceptance across all measures: pain and discomfort, energy and fatigue, positive feelings, mobility, activities of daily living (ADL),dependence on medication, working capacity, personal relationships, opportunities for acquiring new information and skills, participation and opportunities for recreation/leisure, pain relief, anger and frustration, vulnerability fear and worry, uncertainty and overall QoL.
4 facets were only weakly associated with acceptance namely practical social support, spirituality, body image, and sleep and rest.
Activity engagement was most strongly associated with working capacity and mobility and pain willingness with anger and frustration and uncertainty.
What does this mean?
Mason conducts multiple regressions to look at the factors that predict various aspects of QoL. She makes the point that ‘engagement in activity is an important predictor of psychologic, independence, and environmental QoL, in addition to pain-related facets assessed by the PDM.‘ This is probably of little surprise to occupational therapists in particular, because a fundamental tenet of occupational therapy is that ‘doing’ is good for health.
The authors also make the point that ‘willingness to recognize that avoidance and control may be unworkable explain, in part, physical and environmental QoL and pain-related facets (PDM). ‘ So part of the process of moving from resisting and fighting against the experience of chronic pain is identifying that this actually doesn’t change anything – in fact it only adds to distress and despair.
One thing we can do for people who have chronic pain is help them look at how ‘workable’ their current coping strategies are. This doesn’t have to be brutal, and I find I draw on motivational interviewing to do this – helping someone firstly identify what is working in their current coping strategy (because there is always something helpful in that strategy even if it’s only short term), then helping them identify the not so good things about that strategy – often delayed consequences that become evident after the immediate positive effects have worn off. This makes it quite difficult for people to recognise because we’re so good at remembering short term effects and failing to see longer term ones.
The finding that acceptance was associated with good QoL in terms of being mobile, ability to perform ADL, the capacity to work, and experiencing more certainty suggests that there are practical aspects to helping people work towards accepting their pain. It seems from this study at least, that there is an association between acceptance and being less disabled. This is somewhat at odds with the finding from the study I discussed yesterday, which found that there was less effect on physical function, and the impact was primarily on emotional function.
Where this study, and the others on acceptance leaves me is that I think I need to review the ACT model in more detail, so I can understand more of the concepts behind the therapeutic strategies. I do find it hard to unpack the linguistic aspects of ACT, the ‘cognitive defusion’ part seems less confusing as does the actions and values – but relational frame theory is just plain hard work.
If I put that aside, and recognise that often we describe ourselves in terms of what we think we are ‘hard-working’, ‘perfectionist’, ‘loser’, and that these are actually only labels that sit on top of ‘who’ we are, I think it makes it a bit easier to understand. By learning to see that these labels are just that: labels, I can see them for simply noise in the system and I can decide/choose to do things differently. It’s that ‘choosing to do’ aspect of acceptance that makes the greatest impact for me – actions speak louder, don’t they?
Mason VL, Mathias B, & Skevington SM (2008). Accepting low back pain: is it related to a good quality of life? The Clinical journal of pain, 24 (1), 22-9 PMID: 18180632