As a physical therapist, you are well aware of how psychology drives the behavior of your patients and how it can derail good pain care.
Complementing your expertise in therapeutic exercise and manual therapy with psychological informed techniques can dramatically improve and accelerate treatment results.
Cognitive behavioural therapy (CBT) is a traditionally key feature of pain rehabilitation programs (1) . However, in the last few years, a trend toward psychological therapies promoting “psychological flexibility” has gained considerable traction. Among these approaches, is Acceptance and Commitment Therapy (ACT); a third-wave psychology that applies mindfulness and acceptance principles to help patients cope with physical or emotional discomfort they are enduring, committing to values-based behaviors.
Listen to How To Live An ACTive Life Beyond Pain Combining ACT & PT with Jennifer Battles
Although physical therapy training often includes behavioral and psychological treatment techniques, Physical Therapy schools strongly favor a classical bio-mechanical approach to treating pain and injury. Even though the biopsychosocial model of pain is more and more appreciated by physical therapists, psychologically informed care is not an area of expertise for most.
So how can ACT be incorporated into Physical Therapy practice?
What are the obstacles to its integration and how can we make it easier to apply?ACT has shown effectiveness in improving coping skills and treatment outcomes in patients with chronic pain Click To Tweet
Implementing ACT in Physical Therapy Practice
A 2016 research article in the British Journal of Pain describes how Action Research methodology was applied to implement ACT into a physiotherapy-led pain rehabilitation program within a musculoskeletal hospital setting in the UK (5). The project lasted one year, and reviewed practicing physical therapists who were already familiar with CBT-based pain management, as well as psychological therapeutic techniques such as motivational interviewing and mindfulness.
Method: The Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework focuses on implementing research into practice. It seeks to empower practitioners by engaging them in the research process and implementation activities (6). Its premise can be reduced to a simple equation:
SI = f (E,C,F)
Where successful implementation (SI) is a function (f) of the relation between the nature of the evidence (E), the context (C) in which the proposed change is to be implemented, and the mechanisms by which the change is facilitated (F).
Specifically, physical therapists in the pain rehabilitation unit were trained using Emancipatory Action Research. This method includes members of the clinical team as research participants through a process of collaborative and systematic reflection and critique, in order to solve a problem or issue of concern in their own practice (7).
Results: There were 4 main themes arising from the overall experience representing potential barriers and facilitators of a ACT in the physiotherapy-led pain management service (5):
#1 The need to view pain as ’embodied’, rather than dualistic
By reflecting on how their thoughts and emotions could affect the experience of pain, participants explored the need to understand it as an embodied, rather than dualistic, experience of the body and mind. They also explored the need to validate a person’s experience and to assure them that you believe them:
“I think it’s so important for the person to feel believed, that they don’t have to keep trying to persuade you that they have got pain.”
#2 The need for a more therapeutic construction of “acceptance”
Does ‘acceptance’ equal ‘defeat’?
The use of the term “acceptance” was conflicted among the physiotherapists, as it was felt to imply giving up and passivity rather than promoting positivity and a proactive approach to therapy. They worked to reformulate acceptance as a dynamic (not passive) and challenging process:
“We are saying it’s not a passive process and it’s not giving up, it could actually be a very brave process if it’s taking you towards some really difficult emotions.”
However, physiotherapists felt uncomfortable with ACT’s proposed shift from diagnosis and ‘fixing’ towards ‘sitting with’ patients. As ACT removes the emphasis on getting rid of a physical or emotional problem, participants sometimes equated this with failing in their professional role:
“You can sit with the distress without having to resolve it right there, it is about approaching these really uncomfortable things … actually that is part of ACT, it’s uncomfortable for us as well as for the patients because we can’t necessarily resolve it.”
However, with more practice, participants achieved a deeper understanding of the process and described mindfulness as a kinder way to approach the experience of chronic pain:
“I think ACT is much more compassionate … not [what] dwelling on certain thoughts and analysing certain thoughts as a cognitive behavioural approach would do. [ACT] allows a patient to have that experience without being judgmental about it, feeling that it’s ‘wrong’ and that they shouldn’t have it.”
#3 Value-based goals as profound motivation for positive change
There was shared appreciation among participants about the value-based goals of ACT, and how these could help patients stay on track, even in the face of difficulty. Participants worried, however, that setting value-based goals might expose distress and cause emotional discomfort for both patients and physiotherapists:
“Someone bringing out a lot about their past or perhaps a very complex situation … we don’t want to say it’s the wrong thing or that it will be to someone’s detriment … [but] you don’t want to open this can of worms … you can’t put any of those worms back again.”
The practice of setting value-based goals for the physiotherapists was positive in that it helped them to understand the central tenets of ACT. They found that the process could bring strong emotions too:
“It’s quite profound; it’s quite personal and can be quite emotional … It’s something that is very core to one’s being and to an individual as a person.”
To learn more about ACT for Pain and training for practitioners click here!
#4 It’s quite a long way from “physiotherapy”
As experts in exercise prescription and manual therapy, physiotherapists are trained to ‘fix’ problems, rather than help patients cope with suffering. In this study, PTs initially perceived that ACT’s non-prescriptive exercise approach (where exercise intensity and dosage were determined by patients’ own choices) was in conflict with the traditional exercise therapy they were used to:
“We struggle with the non-prescriptive component, the experiential component. Allowing the patient to work out for themselves what is too much and what is too little. Traditionally there is a protocol of exercises and ACT doesn’t really follow that. ACT allows the patient to make their own judgments on how they would like to respond … that is quite hard when you are watching a patient over-do [exercise].”
Physiotherapists complained that allowing patients to ‘make mistakes’ and over-do exercises might increase their pain, and that ignoring their training and experience would be similar to ‘throwing the baby out with the bathwater’.
On the other hand, some felt that graded progressive exercises could place a lot of pressure on patients, making them feel that they are failing if they are unable to progress through the exercise plan:
“I think pacing puts a lot of pressure on patients ’cause they think if they are not doing it, they are going to fail. It sets them up for a failure… doesn’t it? Especially if the patients are really chronic … it somehow enforces a sense of ‘you are not disciplined enough if you can’t pace’, and it [becomes] a way for patients to beat themselves up.”Physiotherapists are trained to ‘fix’ problems, rather than help patients cope with suffering Click To Tweet
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Physical Therapists: Are You Ready to Take on the ACT Challenge?
Despite concerns about ACT’s departure from the ‘tried and tested model of care’, “… the group recognised both before the project started and afterwards that ACT was a positive progression in the field of pain management and one that sat comfortably with the skill set of other psychological-based therapeutic tools used by physiotherapists.” (5)
These conclusions align well with previous experiences where members of chronic pain rehabilitation centers transitioned from CBT to ACT (8, 9), adding to a growing consensus about the usefulness of ACT in chronic pain management (10, 11).
Core competencies of an ACT therapist include (12):
- Demonstration of equality, vulnerability, compassion, and a sharing point of view.
- Flexibility to suit the needs of the team and patients.
- Self-disclosure as well as acceptance of challenging content.
The take away?
Evidence is quickly adding up to ACT’s effectiveness as a powerful way to inform physical therapy practice, promote exercise and activity, and create value-based goal setting to support chronic pain. This helps patients make lifestyle changes that allow them to live with vitality (13).
Have you considered using ACT in your practice, or are you currently? To learn more about ACT for Pain and training for practitioners click here!
1- Williams, A. C., Eccleston, C., & Morley, S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults.
2- McCracken, L. M., & Gutiérrez-Martínez, O. (2011). Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy. Behaviour research and therapy, 49(4), 267-274.
3- Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, A. J., … & Atkinson, J. H. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152(9), 2098-2107.
4- Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., & McMillan, D. (2017). Acceptance and commitment therapy (ACT) for chronic pain. The Clinical journal of pain, 33(6), 552-568.
5- Barker, K. L., Heelas, L., & Toye, F. (2016). Introducing Acceptance and Commitment Therapy to a physiotherapy-led pain rehabilitation programme: an Action Research study. British journal of pain, 10(1), 22-28.
6- Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: a conceptual framework. BMJ Quality & Safety, 7(3), 149-158.
7- Zuber-Skerritt, O. (2003). Emancipatory action research for organisational change and management development. In New directions in action research (pp. 78-97). Routledge.
8- Trompetter, H. R., Schreurs, K. M., Heuts, P. H., & Vollenbroek-Hutten, M. M. (2014). The systematic implementation of acceptance & commitment therapy (ACT) in Dutch multidisciplinary chronic pain rehabilitation. Patient education and counseling, 96(2), 249-255.
9- Barker, E., & McCracken, L. M. (2014). From traditional cognitive–behavioural therapy to acceptance and commitment therapy for chronic pain: a mixed-methods study of staff experiences of change. British journal of pain, 8(3), 98-106.
10- Thompson, M., & McCracken, L. M. (2011). Acceptance and related processes in adjustment to chronic pain. Current pain and headache reports, 15(2), 144-151.
11- Feliu-Soler, A., Montesinos, F., Gutiérrez-Martínez, O., Scott, W., McCracken, L. M., & Luciano, J. V. (2018). Current status of acceptance and commitment therapy for chronic pain: a narrative review. Journal of pain research, 11, 2145.
12- Luoma, J. B., & Vilardaga, J. P. (2013). Improving therapist psychological flexibility while training acceptance and commitment therapy: A pilot study. Cognitive Behaviour Therapy, 42(1), 1-8.
13- Critchley, D.J. et al. (2016) “A light bulb moment!” Physiotherapists’ experiences of delivering Physiotherapy informed by Acceptance and Commitment Therapy (PACT). Physiotherapy, Volume 102 , e230 – e231