ACT plus exercise, vs exercise alone…

and what a shame there was no ACT alone group…

No secret here, I like ACT (Acceptance and Commitment Therapy) as an approach for living well with chronic pain. I like it for many reasons, but probably the most compelling ones are that the hierarchy between therapist and person living with pain is minimised (we’re both humans finding our way through life) and that it doesn’t require the person to delve into challenging or disputing thoughts – this in turn enhances adherence to the core elements of ACT: living a life aligned with what really matters to this person. People seem to find using ACT more appealing than other forms of therapy for chronic pain.

Anyway, just recently a new study investigating ACT plus an additional exercise component (for eight weeks of physiotherapy supervised exercise, and ACT led by a psychologist), vs a supervised exercise programme only. This recent publication is a 12 month follow-up from the original (Casey et al., 2022).

The design of this study involved participants referred to an outpatient musculoskeletal clinic living with any chronic pain condition. Participants were excluded from the trial if they needed further diagnosis, experienced a major medical or psychiatric diagnosis, had cancer, an ‘unstable’ inflammatory condition, substance misuse, some kind of surgical or interventional procedure in the previous 3 months, were part of another supervised exercise programme or were taking part in psychological or physiotherapy treatment, or had attended a previous multidisciplinary pain programme – or couldn’t exercise because of some contraindication.

The two approaches were: (1) an ACT programme with exercise – 8 weeks of once a week two hours of ACT, then a 1.5 hour of exercise led by a physiotherapist who had not undertaken ACT training; and (2) 8 in-person supervised physiotherapy exercise sessions that followed the same structure as the ACT plus exercise. The same therapist led both groups of participants in the exercise component.

The primary outcome was pain interference as measured by the Brief Pain Inventory at 12 months follow-up, with secondary outcomes of pain intensity (BPI), the Patient Health Questionnaire-9 for depression, and the General Anxiety Disorder-7 to assess anxiety. Patient satisfaction was measured, along with the Patient Global Impression of Change. “Process” oriented measures (designed to measure factors thought to change over time and influence outcome) of pain self efficacy, pain catastrophising and the TSK were also taken, along with two measures from ACT, the Chronic Pain Acceptance Questionnaire and the Committed Action Questionnaire.

There were some intriguing changes to the original protocol including redefining some of the measures from outcomes into process measures, and the exercise intervention wasn’t fidelity tested.

What did they find? Well, a bit underwhelming for a person who likes ACT, to be honest! Both groups showed the same amount of pain interference, though with a slight tendency towards the ACT + exercise group which became significant only at one year. No other differences between the two groups were identified with the exception of slightly reduced pain catastrophising in the ACT + exercise group. Participants were happy with the ACT + exercise programme vs the exercise only, and the same participants reported positive responses to the global impression of change question.

Interestingly, there were more drop-outs from the exercise-only group, and the authors also report that the therapist contact time wasn’t equivalent. With a very low follow-up response rate (slightly higher for the ACT + ex group), again it’s not really possible to definitively know just how effective either approach was. The authors also point out that participants weren’t encouraged to use ACT approaches during the exercise part of the ACT + exercise programme because the physiotherapist wasn’t trained in ACT.

Some unanswered questions for me from this study, which was well-conducted within the confines of funding and patient availability.

One big question for me is why movement practices aren’t routinely part of ACT for chronic pain anyway. Certainly the way I practice, and the way physiotherapists I know who have learned ACT and use it routintely, wouldn’t add a non-ACT-based movement intervention into the mix. Given we know that movement practices are an ideal context for employing ACT methods, I’m curious as to why the principles that have been part of CBT approaches to pain management (ie all the team adopt the same over-arching model, employ the same strategies) weren’t adopted here. It’s during movement practices that sticky thoughts arise, and when leaning in to discomfort with pain and anxiety and sadness is highly relevant. They’re also a great time to work with self-as-context given how relevant self-concept is when setting movement practice challenge intensity. Of course, I’d still argue that movement practices can be decontextualised from daily life, and there is always a need to get out of the clinic and into the real world, however even in a ‘gym’ or ‘exercise class’ setting there are opportunities for physiotherapists (and other movement practitioners) to apply ACT strategies.

That the team members didn’t share skills across the team raises yet again the problem we have with siloed treatment. Interprofessionalism is sorely needed to ensure consistent practice of any kind of approach, whether it’s a physio using ACT to work with sticky thoughts and mindlessness, or it’s a psychologist understanding enough about movement and bodies to reinforce that movement is a good thing. It’s like the interprofessional nature of chronic pain management hasn’t yet gone very far, and I wonder why given how many decades it’s been since this was first proposed (at least since 2005, see McCallin, 2005).

Arguing for exercise (about which we know a reasonable amount) head-to-head with ACT + exercise feels a bit redundant to me. We know movement is a good thing. We know the effect sizes are small on both pain intensity and disability, and we know these are consistent findings for almost any treatment approach for chronic pain. We also know that ACT for chronic pain is slightly better adhered to than other forms of therapy, and that it seems especially helpful for people who avoid and are freaked out (though not so much as to make us use it everywhere). What we don’t know, and this study, along with many others, can’t tell us, is whether it made a big difference to the unique and individual daily lives of participants.

Some other missing information that I’ve commented on before. We don’t know the regular movement practices of participants prior to entering these programmes. We don’t know whether participants maintained their movement practices beyond the end of the eight week programme. We have no idea whether the movement practices were enjoyed by participants although we do know that people attending the ACT + exercise were more satisfied than those just attending exercise. We don’t know anything about their lifestyles before, during or after the study, so we don’t know whether the gym or hydrotherapy were exercise practices they valued. We also don’t know whether they transferred any of the learning from the movement practices into other parts of their lives – step counts do not equal daily life. We don’t know anything about the participants family life, their sense of curiosity and joy, or even whether participants who weren’t working during this study were able to return to work or find work.

If we are going to be serious about helping people with persistent pain live lives they value, isn’t it important to find out what people want to be able to do in their worlds? If we want to know how well a therapy works, shouldn’t we attempt to find out a bit more about the person’s world so that anything we offer can actually be done long-term? Life is more than a series of exercise programmes and psychotherapy – life is full of surprises, awe, devastation, busy periods, slow times, grief, love, births, deaths and other health problems. While designing studies is hard, I wonder if we’ve come to the end of the usefulness of further studies exploring movement/exercise for chronic pain. The studies don’t seem to be adding much – just that movement practices are good for health. We kinda know that. Let’s get far more creative and work out how people can integrate all sorts of movement practices for the entirety of their life, throughout all of their life contexts, in all that they do. And let’s do the same for ‘psychological’ approaches. In fact, can we move from siloed ‘physio, psychology, OT, nursing’ and into ‘pain therapists’ and remove the death grip we seem to have for ‘our unique contribution.’ We have far more in common than not in pain therapies, and there is considerably more power in a united approach than a fragmented one.

Casey, M. B., Smart, K. M., Segurado, R., Hearty, C., Gopal, H., Lowry, D., Flanagan, D., McCracken, L., & Doody, C. (2022). Exercise combined with Acceptance and Commitment Therapy compared with a standalone supervised exercise programme for adults with chronic pain: A randomised controlled trial. Pain, 163, 1158–1171. https:// doi. org/ 10. 1097/j. pain. 00000 00000 002487

Casey, M. B., Takemasa, S., O’Reilly, T., Leamy, M., Mc Kearney, E., Buckley, M., Smart, K. M., Segurado, R., Lowry, D., Flanagan, D., Gopal, H., Hearty, C., & Doody, C. (2024). Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial. European Journal of Pain. https://doi.org/10.1002/ejp.2229

McCallin, A. (2005). Interprofessional practice: learning how to collaborate. Contemp Nurse, 20(1), 28-37. https://doi.org/10.5172/conu.20.1.28