慢性疼痛戰役-接受與靈活療法


  【24drs.com】隨著研究人員致力於尋找合適的心理治療方法,以最佳地幫助患者突破「持續的慢性疼痛具有破壞性」的思維模式,「接受和承諾治療(ACT) 」和「心理靈活性」受到青睞-且有證據。
  
  發表於美國疼痛協會第35屆年度科學會議、探討此議題的許多報告之一,研究者發現,接受對於抵銷患者的不公平感具有重要性,而不公平感與疼痛相關的結果有強烈關聯。
  
  第一作者、加拿大魁北克蒙特婁McGill大學疼痛失能暨社會整合研究中心、實驗心理學博士候選人Junie Carriere表示,變成慢性疼痛時,患者會體驗到很多損失:功能損失、就業的損失和獨立性的損失。這是相當直觀的,對它感到難以負責而最後發展出不公平感。
  
  不公平感接著會進一步造成負面結果,如功能下降和感知障礙的惡性循環。反之,接受疼痛與較少疼痛相關困難及更好的生活品質有關。
  
  Carriere表示,整體而言,接受度高的人在精神上和生理上都往前進,這樣一來,他們在健康與疼痛相關結果都有比較好的經驗。
  
  為了探討ACT在潛在調解這些認知的作用,Carriere和來自McGill大學與加州Palo Alto、史丹佛醫學院的研究夥伴,評估了史丹佛疼痛門診處理中心的344名慢性疼痛成年患者。
  
  在使用多個中介分析的分析中,他們發現,不公平感和接受疼痛呈現負相關,這與以前的研究結果一致。
  
  不過,接受疼痛調解了不公平感和疼痛干擾之間的關係(P < .001),接受並沒有完全抵消不公平感和疼痛強度之間的關係。
  
  作者們寫道,這些研究結果認為,不公平感和接受對於疼痛對慢性疼痛患者之生活干擾的程度有顯著影響。
  
  儘管這項研究的設計限制了我們建立因果關係的能力,它提供了一個理論架構-採用目標為接受疼痛的介入方式以改善對慢性疼痛的生理、心理和社會適應,特別是那些認為他們的疼痛是不公平的患者。
  
  Carriere指出,醫師應該意識到,對疼痛的結果衍生的不公平感覺會帶來不利影響。
  
  她表示,他們可能需要確定哪些患者有這種不公平的感受,並考慮將以接受為基礎的療法納入疼痛管理治療計畫內。
  
  許多其他研究都強調接受疼痛對慢性疼痛的影響,2015年時發表於疼痛期刊的一篇研究顯示,認知行為療法的5週門診多科別計劃中,諸多結果指標裡面,疼痛相關接受度是最強的調節因子。
  
  發表於APS會議,有關心理靈活性和功能情境的全體會談中,研究共同作者Lance M. McCracken博士推論,靈活性在轉變持續慢性疼痛之思維模式上的附加作用。
  
  英國倫敦國王學院精神病學、心理學和神經科學研究院McCracken教授表示,取代轉變我們的想法與感受,或許我們可以從我們怎麼想與感受改變成我們要做什麼。
  
  我會把這稱為從言語調節轉變成行為調節,而這個問題應該是:在某些情況下,我們可以減少言語調節而在其他方面增加嗎?
  
  這種努力的更廣泛的重點是,讓患者遠離疼痛災難化,疼痛災難化會造成不良結果與持續疼痛。
  
  McCracken教授表示,當你悲劇化,它就像生活在一個災難中-這當然會影響你。正確的思想與文字將對他們描述事情的經驗有所影響。
  
  問題是我們可以如何破壞它,我們如何對抗悲劇化,還是與它講和?我的想法是,我們正在學習的是:講和是一種選擇,而且我認為我們知道怎麼辦。
  
  ACT已被證明,用於有慢性疼痛的退伍軍人是特別有益的,有助於減輕疼痛干擾,提高生活品質。不過,取得上的受限是常見的一個限制,而使患者無法取得他們需要的幫助。
  
  發表於會議的另一篇研究中,研究者試圖確定遠端醫療是否可成為提供相同ACT效果的選項。
  
  在這個研究中,研究者隨機指派聖地亞哥退伍軍人事務部醫療保健系統的129名有慢性疼痛的退伍軍人透過視訊會議或面對面接受8週的ACT治療。
  
  根據這篇研究採用之簡明疼痛量表的疼痛干擾初步結果,顯示出遠端醫療方式的非劣效性,兩組研究對象的疼痛干擾分數都比開始時降低(P < .05),兩組在時間-治療交互作用上也沒有顯著差異。
  
  在減少憂鬱症狀和疼痛相關的焦慮、生活品質的改善方面,兩組也沒有顯著差異。
  
  雖然兩組在睡眠或創傷後壓力異常方面沒有顯著改善,遠端醫療組的流失率比較高,這是遠端醫療的關鍵挑戰之一。
  
  作者們結論指出,目前的研究結果認為,使用遠端或面對面方式對慢性疼痛進行ACT的效果是相當的,而這兩種方式的流失率會有差異。
  
  
  資料來源:http://www.24drs.com/
  
  Native link:Acceptance, Flexibility Key in Chronic Pain Battle

Acceptance, Flexibility Key in Chronic Pain Battle

By Nancy A. Melville
Medscape Medical News

AUSTIN, Texas — As researchers strive to find the right psychotherapeutic approaches to best help patients break destructive thought patterns that perpetuate chronic pain, acceptance and commitment therapy (ACT) and psychological flexibility are gaining favor — and evidence.

In one of several papers looking at the issue presented here at the American Pain Society (APS) 35th Annual Scientific Meeting, researchers showed the importance of acceptance in offsetting patient perceptions of injustice, which are known to be strongly associated with pain-related outcomes.

"When pain becomes chronic, patients can experience many losses: loss of function, loss of employment, and loss of independence. It's very intuitive to not feel responsible for it and develop a sense of injustice," first author Junie Carriere, a PhD candidate in experimental psychology at the Center for Research on Pain, Disabilityand Social Integration at McGill University, Montreal, Quebec, Canada, told Medscape Medical News.

"The sense of injustice can further set the wheels in motion for a vicious cycle of negative outcomes, such as decreased function and perceived disability."

Conversely, an acceptance of pain has been associated with fewer pain-related difficulties and better quality of life.

"Overall, people with high acceptance push forward, mentally and physically. As a result, they experience better health and pain outcomes," Carriere said.

To study the role of ACT in potentially mediating those perceptions, Carriere and her colleagues from McGill University and Stanford Medical School, Palo Alto, California, evaluated 344 adult patients with chronic pain who presented at the Stanford Outpatient Pain Management Center.

In analyses using multiple mediation analysis, they found a negative correlation between perceived injustice and pain acceptance, which is consistent with previous research.

The acceptance of pain, however, mediated the relation between perceived injustice and pain interference (P < .001). Acceptance did not fully offset the relation between perceived injustice and pain intensity.

"These findings suggest that perceived injustice and acceptance have significant roles in the degree to which pain interferes with the lives of individuals with chronic pain," the authors write.

"Although the study design limits our ability to establish causal relationships, it provides a theoretical framework for the use of interventions that target pain acceptance in order to improve physical, mental and social adjustment to chronic pain, particularly in patients who perceive their pain as unjust."

Carriere added that "clinicians should be made aware of the detrimental impacts of feelings of injustice on pain outcomes."

"They may want to identify patients who express high feelings of injustice and consider including acceptance-based therapy as part of their pain management treatment plan," she said.

Numerous other studies have underscored the role of pain acceptance in chronic pain, and one recent study published in the Journal of Pain in 2015, showed that pain-related acceptance, part of a 5-week outpatient multidisciplinary program of cognitive-behavioral therapy, was the strongest mediator across several different indices of outcome.

In a plenary talk on psychological flexibility and functional contextualism presented at the APS meeting, Lance M. McCracken, PhD, a coauthor on that study, speculated on the additional role of flexibility in shifting the patterns of thought that perpetuate chronic pain.

"Instead of shifting what we think and feel, maybe we can shift whether what we think and feel is in charge of what we do," said Dr McCracken, a professor in the Institute of Psychiatry, Psychology and Neuroscience at King's College London, United Kingdom.

"I would call that a shift in looking at verbal regulation over behavior. And the question should be, can we decrease verbal regulation in some situations and increase it in others?"

The broader focus of such efforts is to turn patients away from pain catastrophizing, known to be a critical driver of poor outcomes and continued pain.

"When you catastrophize, it's like living in a catastrophe — of course it affects you," Dr McCracken said. "Thoughts and words, given the right context, carry the influence of the experience of the things is they describe."

"The question is how can we undermine it, and should we do battle with catastrophizing, or make peace with it? I think what we're learning is that making peace is an option, and I think we know how."

ACT and Telehealth

ACT has been shown to be particularly beneficial for veterans with chronic pain, helping to reduce pain interference and improve quality of life. However, restricted access is a common limitation in preventing patients from getting the help they need.

In another study presented at the meeting, researchers sought to determine whether telemedicine could offer an equally effective option for ACT.

For the study, the researchers randomly assigned 129 veterans with chronic pain in the Veterans Affairs San Diego Healthcare System to receive 8 weeks of ACT therapy through video conferencing or in-person.

On the study's primary outcome of pain interference on the Brief Pain Inventory, results showed noninferiority of the telehealth approach, with participants in both groups having lower pain inference scores compared with baseline (P < .05), and no significant differences between groups in time-by-treatment interaction.

There were also no significant differences between groups in terms of reductions in depressive symptoms and pain-related anxiety, and improvements in quality of life.

Despite no significant improvements in sleep or post-traumatic stress disorder between groups, attrition rates were higher in the telehealth group, underscoring one of the key challenges with telemedicine.

"The findings of the present study suggest that ACT for chronic pain delivered [by] telehealth or in-person are comparable, though attrition rates may differ based on delivery type," the authors concluded.

Ms Carriere and Dr McCracken have disclose no relevant financial relationships. The research at Veterans Affairs San Diego was supported by a Veterans Affairs Rehabilitation Research and Development grant.

American Pain Society (APS) 35th Annual Scientific Meeting. Presented May 13, 2016.

    
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