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Acceptance and commitment therapy and selective optimization with compensation for older people with chronic pain: A pilot study.

Introduction

It is estimated that the world population aged over 60 will reach 2000 million by the year 2050 (World Health Organization [WHO], 2012). According to the available Spanish data provided by the census on elderly people (Instituto de Mayores y Servicios Sociales [IMSERSO], 2008), of those aged between 75 and 84, 1.5% are in nursing home care, a figure that rises to 4.6% if those aged over 85 are taken into account. In turn, of those living in nursing homes, between 71 and 83% suffer from at least one chronic illness involving pain (Ferrel, Ferrel, & Osterweil, 1990), the most common pathologies being those of a musculoskeletal nature (IMSERSO, 2008). Elderly people who live in nursing home care contexts report that the pain interferes in their everyday functioning and quality of life (Ferrel et al., 1990; Gagliese, 2009), confirming the significant association between pain and altered physical functioning and psychological distress (Lopez, Montorio, Izal, & Velasco, 2008; Lopez, Montorio, Izal, Gonzalez, & Alonso, 2010). In spite of this, 15% of the elderly living in nursing home care and of 23% those living in the community receive no treatment for pain (Miller, Mor, Wu, Gozalo, & Lapane, 2002). In Spain, 93% of those aged over 64 and with pain are dissatisfied with their ability to control their pain (Gil, 2009).

Recent years have seen a significant increase in the number of studies aimed at providing elderly people with resources for coping with their pain. According to different reviews and meta-analyses, cognitive behavioral treatment (CBT) interventions appear to be the most effective up to now for the treatment of chronic pain in adult population (Duarte, Gajos, Armynd, & Fregni, 2010; Wetering, Lemmens, Nieboer, & Huijsman, 2010) and in the elderly (Lunde, Northus, & Pallesen, 2009), highlighting the importance of cognitive-behavioural factors in modulating pain and adaptation to different types of chronic pain (Ramirez-Maestre, Esteve, & Lopez-Martinez, 2008).

In the case of older people with chronic pain, the goal of CBT is to try to control pain and reduce or eliminate those thoughts and feelings that cause distress, as well as the symptoms deriving from the pain (McCracken, 2005). However, despite the effectiveness demonstrated by the CBT approach (Duarte et al., 2010) for the reduction of pain levels, in some cases it has proved unattainable (Turk, 1990). Paradoxically, some of the people who invest considerable effort in controlling their pain would be those who least benefit from CBT (Dahl, Wilson, Luciano, & Hayes, 2005; McCracken, 2005). These and other studies suggest that, in the elderly, the goal of reducing or eliminating symptoms associated with chronic pain through direct control may not be the most appropriate approach in all cases since, moreover, it has been pointed out that in this age group strategies based on the exercise of control often turn out to be maladaptive (Melding, 1995). In this line, McCracken, Eccleston, and Bell (2005) maintain that intention to control would be related to greater likelihood of disability or distress deriving from attempts to control uncontrollable dimensions such as pain; disability and distress are the two most important dimensions in the adjustment to chronic pain conditions (Ramirez-Maestre & Valdivia, 2003). On the other hand, there is evidence that strategies based on direct control would only be effective when the pain is mild or moderate, or of short duration (Gutierrez, Luciano, Rodriguez, & Fink, 2004; Mullen & Suls, 1982).

Recent studies have highlighted the pertinence of interventions promoting adaptation toward those pain-related factors that may be unmodifiable. It has been suggested that acceptance and commitment therapy (ACT), based on the idea that pain and suffering are of a universal nature (Hayes, Strosahl, & Wilson, 1999), may provide an appropriate response to this goal in the field of chronic pain (Lopez et al., 2010; Redondo, Leon, Perez, Jover, & Abasolo, 2008; Vowles, Wetherell, & Sorrell, 2009). This assertion would be backed up by studies showing that the process of acceptance of chronic pain is associated with better emotional, physical and social management of the symptoms of pain and of the limitations that pain involves, resulting in improvements in the person's activities of daily living (ADLs) (McCracken & Eccleston, 2003; McCracken & Vowles, 2006, Viane et al., 2003; Vowles, McCracken, & Eccleston, 2008), greater tolerance to pain (Gutierrez et al., 2004; Hayes et al., 1999), less disability (McCracken, Vowles, & Eccleston, 2004; McCracken & Yang, 2006), and less use of health resources (McCracken, 1998; McCracken et al., 2005; McCracken, Spertus, Janeck, Sinclair, & Wetzel, 1999). Whilst chronic pain pathologies and the unpleasant experiences that accompany them can generate behaviors in the individual for fighting against such unpleasantness--which would lead to the abandonment of roles and behaviors that are positive for the person (Roper Starch Worldwide, 1999), promoting activities or managing one's life within the roles desired by the individual in spite of the pain might be more effective for reducing the negative effects of pain on the person.

According to a review of Acceptance-Based interventions for the treatment of chronic pain, ACT can be a good alternative to CBT, through which medium effect sizes have been found for pain intensity, depression, anxiety, physical wellbeing, and quality of life (Veehof, oskam, Schreurs, & Bohlmeijer, 2011). Thus, ACT could help people with chronic pain to perceive their pain as less harmful in their lives, more understandable and more manageable (Fernandez & Vilchez, 2007). ACT has received empirical support in relation to its positive effects for the improvement of different pathologies, including works on intervention in chronic pain among young people (Dahl, Nilson, & Wilson, 2002; Geiser, 1992; Luciano, Visdomine, Gutierrez, & Montesinos, 2001; McCracken, 1998; Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney, 1985), and has enormous potential for improving the capacity to understand and respond to the needs of the elderly (Marquez-Gonzalez, 2010). In spite of this, there is a marked absence of research assessing the use of this approach for attention to elderly people with chronic pain. To our knowledge, the efficacy of ACT has only been analyzed in a case study by Lunde and Nordhus (2009), whose results from an intervention with a 70-year-old woman with chronic pain were encouraging.

ACT can be compared with the behavioral activation therapy (BAT) of Lejuez (Lejuez, Hopko, LePage, Hopko, & McNeil, 2001), although unlike ACT, BAT does not focus on an increase in behavioral activation based on acceptance and individual values. As pointed out, ACT promotes activities linked to the values of each person. However, it is well known that aging is associated with significant losses in different areas of importance for people that can also affect the extent to which they are able to carry out activities related to their values. The reason why these aging-associated losses do not affect the emotional state of elderly people as would be expected--referred to as the paradox of well-being in old age (Mroczek & Kolarz, 1988)--led Baltes and Baltes (1990) to develop the theory of selective optimization with compensation (SOC). According to this theory, old age is understood as a process of development and loss in which, through mechanisms of selection of situations, optimization of performance and compensation of losses, people adapt successfully to life challenges and show levels of emotional welfare similar to or higher than those of young people. Through ACT, elderly people can be trained in strategies to select, optimize and compensate situations, but the specific situations must be subordinated to their values. Training in these strategies permits individuals to continue maintaining the tasks and roles most closely related to their values or to their desired life projects.

Considering this background, and taking into account that clinical research with elderly people in this area is scarce, the aim of the present work is to describe and assess the efficacy of a psychological treatment program based on the ACT model and on strategies of selection, optimization and compensation for people over 65 years old with pathologies of chronic pain of a musculoskeletal nature and who live in nursing care homes. Specifically, the program sets out to: improve the functional autonomy of participants through the use of selection, compensation and optimization strategies and to increase the quantity of activities and roles, principally those related to their values or desires in life, through the modification of attitudes of struggle against pain and of negative attitudes toward age. It is hypothesized that after the intervention we shall observe: a) greater use of SOC strategies and a reduction of the interference of pain in ADLs, (b) a greater perception of success in the achievement of one's life goals (values), (c) a reduction in struggle against the pain, and (d) a reduction in the frequency of maladaptive beliefs related to pain and age and lower levels of depression.

Method

Participants

The data of the final sample participating in the study are shown in table 1 and figure 1.

[FIGURE 1 OMITTED]

Variables and measures

The assessment protocol (pre and post-intervention) included the following variables:

SOCIODEMOGRAPHIC AND HEALTH-RELATED VARIABLES OF THE SAMPLE

In addition to age, sex and marital status, we obtained data on the different diagnoses of chronic pain of a musculoskeletal nature, the medication prescribed to each participant and the years since diagnosis of the musculoskeletal pain problem.

EXTENT OF INTERFERENCE OF PAIN

The extent to which the pain interfered in basic activities of daily living (ADLs) was assessed by means of the interference subscale of the Spanish adaptation of the Brief Pain Inventory (BPI; Cleeland, 1991) drawn up by Badia et al., (2003). Participants responded on a scale with small squares of gradated shades of red coded from 0 (no interference) to 10 (maximum interference). The full BPI scale has shown good reliability indexes (Cronbach's alpha = 0.89; test-retest= 0.77), and the original factor structure of the scale has been found for the Spanish version (Badia et al., 2003).

ACTIVITIES OF DAILY LIVING (ADLs)

For the assessment of ADLs we used the Modified Health Assessment Questionnaire (MHAQ; Pincus, Summey, Soraci, Wallston, & Hummon; 1983) adapted by Escalante and his colleagues (Escalante et al., 1996). It consists of 8 items about activities of daily living (ADLs). Participants were required to indicate the degree of difficulty they found for doing each one of the activities. Responses were made on a four-point scale, from 1 "no difficulty" to 4 "I cannot do it." Test-retest reliability ranged from 0.90 to 0.99 (Escalante et al., 1996). According to Escalante and his colleagues (Escalante et al., 1996), the items of the Spanish MHAQ are equivalent to the original English version.

SELECTION, OPTIMIZATION AND COMPENSATION FOR ADAPTING TO ADVERSE CIRCUMSTANCES

We used the Selection, Optimization and Compensation (SOC) Questionnaire, created by Baltes, Freund, and Lang (1999). Based on the theoretical perspective of Baltes and Baltes (1990), it measures the frequency with which participants use strategies of selection (S), loss-based selection (LBS), optimization (O) and compensation (C) to adapt to adverse circumstances. The questionnaire includes a total of 48 items (12 items for each subscale). Each item consists of two statements (response options), one of which denotes the response coherent with SOC strategies and the other denoting a behavioral response not related to SOC strategies. The person must choose the option that best reflects his or her way of adapting to changes. The four subscales have shown good psychometric properties (Cronbach's alpha: selection = 0.78, loss-based selection = 0.72, optimization = 0.68 and compensation = 0.67) (Baltes et al., 1999). Further study of the validity of the instrument (Freund & Baltes, 2002) shows evidence of the usefulness of psychometric measures of the SOC self-report. Furthermore, analysis showed high test-retest stability over a period of 4 weeks. Exploratory factor analysis of the data revealed a clear three-factor solution, each factor reflecting one of the three expected component processes of the SOC.

EXPERIENTIAL AVOIDANCE

This was assessed through the Spanish adapted version of the Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004) by Barraca (2004). This instrument measures experiential avoidance and psychological acceptance. The questionnaire is made up of 9 items with seven response alternatives in Likert scale, from 0 "Never true" to 6 "always true." The higher the score, the greater the acceptance and the lower the avoidance. The original scale shows adequate internal consistency (Cronbach's alpha = 0.85) (Barraca, 2004). Analysis of the concurrent validity of the Spanish version yields similar results to those reported by Hayes et al. (2000), and the scale has good predictive validity to discriminate between a general sample and a clinical group.

ACCORDANCE WITH VALUES

Participants' success in living according to their roles, values or desires to achieve a particular goal was assessed with the Chronic Pain Values Inventory (CPVI; McCracken & Yang, 2006). It rates the dimensions' degree of importance and degree of perceived success in the following areas of life: family, intimate partner relationship, friends, work, health, and learning or personal development. On being used with older people, the work area was changed to daily activities. Responses were made on a six-point Likert scale, from 0 "not at all important" to 5 "extremely important". Two scores can be obtained: success, as the average of the six success ratings, and discrepancy, as the mean of the differences between importance and success. The original scale showed good internal consistency (Cronbach's alpha = 0.82) (McCracken et al., 2006). Both success and discrepancy scores were significantly correlated with avoidance, as measured by the Chronic Pain Acceptance Questionnaire (CPAQ; McCracken et al., 2004).

DEPRESSIVE SYMPTOMS

For the assessment of this aspect we used the brief version of the Geriatric Depression Scale (GDS-10; Izal, Montorio, Nuevo, Perez-Rojo, & Cabrera, 2010). This scale is made up of 10 items with yes/no response. Higher score indicates greater depressive symptomatology. The internal consistency index is acceptable (Cronbach's alpha = 0.73) (Cabrera, Izal, Montorio, Nuevo, & Perez-Rojo, 2006), and has shown to correctly categorize 97.4% of cases with clinical depression. Its sensitivity is 100%, and its specificity 97.2%. Moreover, the instrument showed excellent fit in tests of its unidimensionality with a confirmatory factor analysis (CFA) for categorical outcomes (Izal et al., 2010).

SATISFACTION WITH LIFE

Satisfaction with life was assessed with the Spanish version of the Satisfaction With Life Scale (SWLS; Diener, Emmons, Larsen & Griffin, 1985; Spanish adaptation by Pons, Atienza, Balaguer & Garcia-Merita, 2002). It has 5 items that are rated on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The internal consistency index was good (Cronbach's alpha = 0.87). This questionnaire has been used in other studies with the elderly in Spain, showing adequate internal consistency (Cronbach's alpha = 0.77; Marquez-Gonzalez, Izal, Montorio, & Losada, 2008).

ATTITUDES TOWARD PAIN

We used the Survey of Pain Attitudes (SOPA; Tait & Chibnall, 1997) for measuring attitudes toward pain. This instrument is made up of 30 items with Likert-type response options from 0 (very false) to 4 (very true). It rates seven beliefs about pain control: family's response to the patient's requests about pain (solicitude; 5 items), usefulness of medication (medication; 3 items), beliefs of disability (disability; 4 items), belief that there is a relation between mood and perceived pain (emotionality; 4 items), belief that pain signifies harm, and that it is therefore harmful to do exercise or to move much (harm; 4 items), belief that it is possible to control the pain (control; 5 items) and belief that there is a medical remedy for one's own pain (cure; 5 items). The higher the score on each of the subscales, the greater the weight of the beliefs in that construct. The subscales showed acceptable and good reliability indices (Cronbach's alpha), of between 0.70 and 0.83, except in the case of the "usefulness of medication" subscale, which yielded an alpha value of 0.56 (Tait et al., 1997). Jensen and Karoly (1991) found that the dimensions of the SOPA were associated with patient ratings of their psychosocial, social and medical adjustment.

CATASTROPHIZING BELIEFS

This was assessed through the Spanish version of the Pain Catastrophizing Scale (PCS; Sullivan, Bishop, & Pivik 1995) by Garcia-Campayo et al. (2008). This instrument is made up of 13 items with Likert-type response options from 0 (nothing at all) to 4 (all the time). Higher the scores on scale are indicative of more catastrophizing beliefs. The Spanish version of the PCS has shown good internal consistency (Cronbach's alpha = 0.79; test-retest reliability .84) and a sensitivity to change with an effect size [greater than or equal to] 2 (Garcia-Campayo et al., 2008).

AGE-RELATED STEREOTYPES

The Attitudes Toward Own Aging (Liang & Bollen, 1983) scale was used for assessing possible stereotypes held by participants in relation to age. The items of this instrument derive from the Philadelphia Geriatric Center Morale Scale (PGCMS; Lawton, 1975), and are 5 in number. The first four have yes/no responses, while the other uses the categories "better", "worse" and "the same." Participants obtained a maximum of five points, higher scores indicating a more positive perception of age. This scale has shown adequate psychometric properties, such as an internal consistency of 0.81 (Liang et al., 1983). The instrument reveals that age-related stereotypes were associated with longevity in older people. Specifically, those with lower levels of age-related stereotype lived 7.5 years longer (Levy, Slade, Kunkel, & Kasl, 2002).

Procedure

Before carrying out the study, we contacted two nursing care homes for the elderly in the Region of Madrid (Spain), requesting their collaboration. Inclusion criteria were as follows: (a) a diagnosis of musculoskeletal pain of articular origin lasting at least six months, (b) age 65 or over, (c) without cognitive deterioration, (d) without oncological pain, (e) no kind of sensory disability that would hinder correct participation in the study, and (f) ability to read and write. A potential sample of 28 people who met the inclusion criteria was obtained.

ATTRITION

Given that the nursing care homes involved in the study were in similar social environments and offered the same medical care services and social-health activities, and with the aim of avoiding possible conflict between residents, each home was randomly assigned to one of two experimental conditions: Nursing home 1 (intervention group) and Nursing home 2 (control group in waiting list format) (figure 2).

After the basic characteristics of the study had been explained and informed consent had been obtained, 16 participants (9 in the intervention group [IG] and 7 in the control group [CG]) agreed to participate in the study and were assessed (pre-intervention assessment). Subsequently, both groups, control and experimental, were assessed again (post-intervention assessment).

Of the 9 people making up the intervention group, 1 dropped out before the application of the program due to health problems, 1 attended just two sessions due to health problems and 1 rejected the post-treatment assessment because he was the caregiver of his wife who had Alzheimer's. Of the 7 participants in the control group, none dropped out of the study. The intervention was delivered in group format, and all 9 participants received the interventions at the same time. Figure 2 shows the flow diagram of the study participants.

[FIGURE 2 OMITTED]

EXPERIMENTAL CONDITIONS

The intervention program is made up of ten sessions of approximately two hours' duration each, with two sessions scheduled per week. The intervention is based on ACT (Hayes et al., 1999; Hayes & Duckworth, 2006) and on the SOC model (Baltes et al., 1999). The goals of the intervention are to apply and assess the effect of a group psychological treatment program for people aged over 65 with chronic pain of musculoskeletal origin and living in nursing care homes. The program sets out to promote the use of SOC strategies and reduce attitudes of struggle in relation to pain. Thus, it is hypothesized that in the wake of participation in the intervention, those involved in the study will increase the quantity of activities and roles, principally those associated with their personal values, and will hence improve their functional autonomy and emotional well being. Table 2 provides a summarized description of the program content. All sessions had the same structure: a) review of the tasks carried out during the week, analysis of difficulties, clarification of any doubts arising and correction of errors, b) introduction of new therapeutic tools and training with them, and c) explanation of the tasks or exercises proposed for working outside the workshop. The therapist was a psychologist with specific training in ACT and with experience in clinical geropsychology.

Data analysis

Prior to testing the working hypotheses, a univariate analysis of outliers was carried out, using standardized scores (z) in the pre-intervention scores of the continuous variables studied and performing the analyses separately for the experimental and control groups, with the aim of eliminating those participants whose z values surpassed the critical value of 3.29 (p< 0.00, bilateral test) (Tabachnick & Fidel, 2001). Using this criterion we eliminated two participants from the control group and one from the intervention group. Therefore, the analyses described were carried out with a sample of ten (five in the intervention group and five in the control group).

First of all we performed the descriptive analyses (frequencies, means and standard deviations) of the variables assessed.

To analyze pre-intervention differences between the control group and the intervention group we carried out a non-parametric analysis using the Mann-Whitney U test with a confidence interval of 95%.

We analyzed the results in two different ways. First, we analyzed intragroup changes by comparing pre-intervention and post-intervention scores for each condition (intervention and control group). For the analysis of intragroup differences we used the Wilcoxon test with a confidence interval of between 95% and 90%. Second, intergroup differences were analyzed through gain variables, calculated by subtracting the pre-treatment scores from the post-treatment scores. In this way, we obtained as many gain variables as variables analyzed, providing for all participants (both intervention and control) a measure of change in each one of them.

For the analysis of inter-group differences in the outcome variables, and given the small sample size (which precluded the use of repeated-measures ANOVAs), we used non-parametric tests, following the customary procedure (e.g., Yip et al., 2007). Specifically, we used the Mann-Whitney U non-parametric technique for independent samples, under a confidence interval of between 95% and 90%. Effect size was calculated for all variables with Cohen's d scores (Cohen, 1988). A d of 0.20 is indicative of a small effect, while a d of 0.50 is indicative of medium effect, and a d of 0.80 or more indicates a large effect.

Results

Pre-intervention differences between the two groups

The results indicated significant differences between the intervention and control groups in two variables: in the "cure" subscale of the Survey of Pain Attitudes and, as shown in table 1, in the variable time since diagnosis of the musculoskeletal pain. The data indicated that the people whose pain showed significantly more long-term prevalence were in the intervention group.

Effects of the intervention

INTRAGROUP ANALYSIS. Table 3 shows the results found in the different assessment phases. With a confidence interval of 95% we observed a significant change in the subscale success in living according to one's own values, which indicates that those participating in the intervention program were more satisfied with the time and effort they devoted to the things they valued in their lives (success). A trend for a pre/post difference in the intervention group was found for the subscales cure, harm and medication, all subscales of the SOPA attitudes toward pain questionnaire. There is also a trend for significance shown by the variable loss-based selection, indicating that those in the intervention group benefit from greater use of the selection strategy when faced with an age-related loss. In turn, attitudes toward age show changes when a confidence interval of 90% is considered.

INTERGROUP ANALYSIS. A significant difference with strong effect size was found for level of change on the medication subscale of the SOPA questionnaire. A trend toward significance was observed in the acceptance variable and on the loss-based selection subscale, with strong effect sizes in both cases.

Despite the fact that the difference between pre- and post-intervention results was not significant, it was in the hypothesized direction, which may suggest that the intervention group benefited more than the control group in pain interference in self-care of the BPI questionnaire, medication, solicitude and cure subscales of the SOPA questionnaire, age-related stereotypes of the PGCMS questionnaire, depression, levels of acceptance and satisfaction with life. No changes were observed in the following variables: pain interference in ADLs, selection, optimization and compensation strategies and beliefs related to the pain.

Discussion

The goals of the present study were to design, apply and assess the efficacy of a group psychological intervention program for people over 65 years old living in nursing homes and with chronic pain of a musculoskeletal nature. The program involved ACT (Hayes et al., 1999) and training in strategies of SOC (Baltes & Baltes, 1990). The main purpose of the program was to increase functional capacity through attitudinal change in the struggle against pain, promoting an acceptance of pain that leads participants to increase the quantity of activities and roles, which in turn leads to better emotional well-being and increased life satisfaction.

In line with what was expected, the results of comparing pre-treatment and post-treatment scores for the intervention group show that, with a confidence interval of 95%, there is a significant increase in the perception of success for living according to one's own values on the part of program participants. These results indicate that the members of the intervention group were more likely to act in the direction of living according to their personal values, and therefore to feel more satisfied and successful in relation to their efforts for achieving that goal.

In addition, although with a confidence level of 90%, it is observed that the intervention group improves more than the control group in the acceptance variable. This finding is in line with the results found previously for older people with chronic pain (Lunde & Nordhus, 2009). Moreover, near-significant differences were observed (with a confidence interval of 92.2%) between pre-intervention and post-intervention scores in the catastrophizing variables, loss-based selection, attitudes toward age and beliefs about medication, harm and cure. The decrease in catastrophizing suggests that participants changed the perception of their pain as something threatening in their lives. Given the inverse relation between catastrophizing and levels of functional capacity (Geisser & Roth, 1998; Jensen, Turner & Romano, 2007), this result once more points to the program's potential for influencing participants' functional capacity. Vowles, McCracken, & Eccleston (2007) report similar results, finding that, after the application of a treatment program revolving around ACT with adults suffering from chronic pain, scores in disability, catastrophizing and depression decrease significantly.

The loss-based selection variable also shows increased values in comparisons between pre-and post-intervention scores in the treatment group and between the gains experienced by this group and the gains made by the control group. These results support the initial hypothesis that training in loss-based selection strategies would lead, among participants, to an increase in the use of such strategies. However, the selection strategy in situations in which there are no associated losses did not yield significant changes, in spite of the fact that the rank means of the intragroup analysis indicate a direction of increased use on the part of the intervention group.

Intervention group participants' attitudes toward age also show a near-significant reduction with a confidence interval of 90%. The importance of the maintenance of such attitudes is reflected in the study by Levi et al. (2002), who found that maintaining positive attitudes toward age has positive consequences for health.

As hypothesized, the intervention produced a reduction in the belief that medication is the sole or principal treatment for their pain in members of the intervention group, comparing the gains in the two groups of the sample. These results are similar to those obtained by other authors through an intervention program based on ACT (Lunde & Nordhus, 2009; McCracken, 2005).

The reduction, at post-intervention, in the belief that pain signifies harm, with a confidence interval of 92.2%, is also in line with our initial hypothesis. The belief about cure refers to the conviction that there is a medical remedy for the pain being suffered, and other authors have found a relation between reduction in the cure belief and a reduction in depressive symptomatology (Tait, Duckro, Margolis, & Weiner, 1988). The intragroup analyses suggest a decrease in the weight of this belief in those who participated in the treatment program.

In addition, unexpected and non-significant changes were found in some dependent variables of pain interference in ADLs: daily activities, mood, walking, family and rewarding activities and sleep measured with the BPI questionnaire. Also unexpected were the results found in the optimization variable measured with the SOC and emotion, control and disability subscales of the SOPA. While no significant change was found in depression scores for the participants in the intervention, a non-significant increase in depression was found in the control group. Kazdin (1999) suggested that with regard to problems characterized by chronic symptoms or deteriorating symptoms, a clinically meaningful outcome would be to halt or postpone deterioration. The finding obtained could indicate the appropriateness of the intervention for avoiding further worsening of the problem situation.

The described study has certain limitations that may affect the generalization of the results. Despite the fact that the obtained results seem to suggest that the intervention may be useful for positively influencing the well-being and functional capacity of older people with chronic pain, the small sample size may be affecting these results. Increasing the sample size would also help to obtain a better description or solution regarding outliers: participants considered outliers due to the small sample size may be able to enter the normal range of scores. Another issue to consider is the use of change scores (gain variables) in the examination of treatment efficacy and intra-group comparisons. Although this analytic strategy has been used in similar studies (e.g., Yip et al., 2007), it has also been considered problematic by some authors (Wise, 2004). The results should also be treated with caution given that some were reported using confidence intervals of 90%, in a similar way as in some comparable previous research (e.g., Vowles & McCracken, 2008), even though we were fully aware of the potential limitations of this strategy.

In addition, despite the socioeconomic context of each of the interventions having been similar, there may be significant differences between the two nursing homes in which the study was carried out (e.g., staff characteristics), and this may influence the data. Moreover, significant pre-intervention score differences between conditions were found for the cure subscale of the SOPA and for pain duration. A larger sample would permit control of the influence these variables may have on the effects of the intervention. The small sample size also precludes the psychometric analysis of instruments that were used and were not previously available in the Spanish language. Also, the scarcity of instruments validated in Spanish for assessing elderly people may have influenced participants' responses to the questionnaires, given that the linguistic restrictions of translations and cultural differences may be influencing the results. The availability of validated measures adapted to the Spanish elderly population would certainly help analysis of the efficacy of interventions with elderly people such as that described here. The intervention sessions took place twice per week, and this may be too little to ensure proper training and assimilation of the trained skills. A larger sample would also permit a dismantling study that could provide information regarding the differential effect of the ACT or the SOC components in elderly people with chronic pain and an analysis of the clinical significance of the results using procedures such as the one recommended by Jacobson and Truax (1991). The lack of follow-up assessment also constitutes a significant limitation. Future studies should address such limitations. An intervention with spaced sessions would probably make it easier for participants to assimilate the strategies trained in the sessions. Likewise, reducing the number of participants in each group would help to make the training more individualized. Finally, it would be interesting to study the differential contribution to the treatment effects of the ACT and SOC strategies, and a larger sample would allow for the necessary dismantling analysis.

ACT could be an alternative treatment for chronic pain, in order to help older people to improve their emotional, physical and social management of pain symptoms, with a view to reducing the interference of pain in their lives and increasing their functional performance. This increase in functional performance would probably be more successful if older people were trained in the use of strategies of selection, optimization and compensation, which would help them to live in accordance with their own values and achieve their life goals. Future studies with a larger sample will provide more substantial evidence of the effectiveness of an ACT vis-a-vis chronic pain for elderly people in nursing care homes.

In spite of the commented limitations, the obtained results suggest that a psychological treatment within the ACT and SOC approaches may be an appropriate option for the population aged over 65 with chronic pain of a musculoskeletal nature living in a nursing home. Considering that studies such as the one described here are scarce in the literature, the findings are encouraging, since those persons who benefited from the therapy reduced their beliefs related to catastrophizing, medication, harm, cure and age stereotypes, as well as increasing their feelings of success for living in accordance with their own values and raising their level of acceptance of pain.

Acknowledgements: We thank the Geriatros SAU group, who provided us with the necessary clinical data and access to their nursing home centres. This study was supported by a grant from the MAPFRE Foundation, Primitivo de Vega, and a grant from the Spanish Ministry of Science and Innovation (PSI2009-08132).

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RECEIVED: November 8, 2011

ACCEPTED: January 3, 2012

Miriam A. Alonso, Almudena Lopez, Andres Losada, and Jose Luis Gonzalez

Rey Juan Carlos University (Spain)

Correspondence: Miriam A. Alonso, Psychology Department, Faculty of Health Sciences, Rey Juan Carlos University, Avda. Atenas, s/n, 28922 Alcorcon (Spain). E-mail: miriam.alonso@urjc.es
Table 1
Sample characteristics

Variables Intervention Control group
 group (n = 5) (n = 5)

Age (years old)
M 87 83,8
SD 2.44 3.82
Range 84-90 78-91

Sex
Women 4(80%) 4(80%)
Men 1(20%) 1(20%)

Marital status
Married 1(20%)
Widowed 5(100%) 3(60%)
Single -- 1(20%)

Education
None 2 (40%) 2 (40%)
Primary education 3 (60%) 2 (40%)
Secondary education -- 1 (20%)

Time with chronic pain
M (years) 35 11
SD 6.37 5.65
Range 26-40 5-20

Types of chronic
 musculoskeletal pain
Arthrosis 3 (60%) 4 (80%)
Polyarthrosis 1 (20%) 1 (20%)
Osteoporosis 1 (20%) 5 (100%)
Espondylarthrosis 5 (100%) 1 (20%)
Gonarthrosis 5 (100%) 2 (40%)
Coxoarthrosis 5 (100%) 5 (100%)

Medication
Narcotic 1(20%) 2 (40%)
Anti-inflammatory 2 (40%) 4 (80%)
Analgesic and/or antidepressant 3 (60%) 3 (60%)
No analgesic 5 (100%) 5 (100%)

Variables and measures

Table 2 Overview of treatment sessions

Sessions Components included in the ACT condition

1 Presentation and establishment of the therapeutic bond with
 the group First contact with personal values

2 Reduce stereotypes about aging and pain Understanding the
 disease and pain as a phenomenon of universal suffering
 Work on the evolution of program expectations Analyze the
 individual values of each participant

3 Analyze individual barriers that prevent attainment of the
 values Studying the strategies themselves prior to
 resolution of the problems and their utility based on
 personal experience Identifying the characteristics of
 rumination and their relation to habitual coping strategies
 Assess the need to change the coping style

4 Analyze life goals. Establish a commitment to addressing
 the values Analyze coherence between the desired values and
 actual behavior to attain them

5 Learn to direct one's behavior toward one's values,
 managing ruminations Analyze aspects that can be controlled
 and the repercussions of the control strategy Mindfulness
 practice

6 Understand the importance of behavioral intention to
 achieve progress towards the values, despite the
 ruminations and negative events Mindfulness practice

7 Direct one's behavior towards one's values, attempting to
 manage ruminations Understanding the consequences of trying
 to control the thoughts and emotions Understanding the
 relationship between activity level and mood

8 Absorbing the impact of age on the level of activity
 Analyze the style of coping difficulties and practice new
 coping style based on selection and optimization of
 activities and roles Analyze the quantity and subjective
 value of activity Learn to prioritize activities based on
 the subjective value and importance Enhance performance on
 the priority activities Learn more adaptive functional
 management in accordance with one's personal values

9 Teach new coping style based on the compensation of
 activities and roles Show technical aids Learn different
 ways to achieve the same goal Train the ability to ask for
 help

10 Strengthen the knowledge and skills acquired Reinforce
 autonomy from the acceptance of functional limitations
 Relapse prevention

Table 3
Before and after intervention scores by condition

Variable Groups Pre- Post-
 (n = 5) intervention intervention
 M (SD) M (SD)

Pain interference in IG 4.40 (4.39) 4.80 (4.43)
daily activities CG 2.60 (2.96) 2.40 (3.36)

Pain interference in IG 1.80 (2.16) 4.00 (3.80)
mood CG 3.80 (4.49) 1.20 (2.68)

Pain interference in IG 3.00 (4.47) 5.80 (3.83)
walking CG 6.80 (4.14) 5.60 (3.64)

Pain interference in IG 2.00 (2.82) 3.00 (3.74)
personal relationships CG .80 (1.78) 1.60 (3.57)

Pain interference in IG 3.00 (4.47) 6.20 (3.19)
sleep CG 1.80 (3.03) 1.60 (3.57)

Pain interference in IG 3.00 (3.00) 2.20 (3.49)
enjoying life CG 4.40 (3.78) 1.20 (2.26)

Pain interference in IG 1.40 (1.67) 2.40 (3.91)
family CG 1.00 (2.23) 0.00 (0.00)

Pain interference in IG .40 (.89) 3.00 (4.12)
rewarding activities CG 1.40 (3.13) 0.20 (0.44)

Pain interference in IG 3.00 (4.12) 1.60 (3.57)
self-care CG 1.40 (3.13) 1.80 (3.03)

Functional IG 1.60(0.66) 1.45 (0.73)
performance CG 1.90 (0.86) 1.68 (0.74)

Selection (SOC) IG 7.20 (1.92) 8.40 (1.51)
 CG 6.40 (2.60) 7.60 (1.81)

Loss-based selection IG 5.80 (3.03) 8.40 (3.28)
(SOC) CG 5.80 (1.48) 5.60 (1.51)

Optimization (SOC) IG 7.80 (2.28) 7.40 (2.07)
 CG 8.60 (1.14) 8.00 (2.00)

Compensation (SOC) IG 8.40 (0.89) 7.40 (2.07)
 CG 8.20 (2.68) 8.20 (2.28)

AAQ IG 41.80 (9.01) 34.60 (5.98)
 CG 31,40 (1.51) 35,60 (4,82)

Solicitude (SOPA) IG 15.60 (3.04) 12.80 (6.45)
 CG 10.80 (7.66) 11.00 (5.65)

Emotionality (SOPA) IG 12.00 (3.67) 15.00 (0.70)
 CG 8.40 (5.41) 9.00 (5.09)

Cure (SOPA) IG 15.20 (5.01) 11.20 (6.34)
 CG 5.60 (3.36) 6.40 (4.82)

Control (SOPA) IG 10.00 (5.19) 13.00 (2.23)
 CG 14.60 (2.60) 15.20 (3.70)

Harm (SOPA) IG 4.20 (2.68) 1.60 (1.94)
 CG 4.80 (4.08) 2.80 (1.78)

Disability (SOPA) IG 5.60 (4.27) 7.00 (2.00)
 CG 8.80 (3.11) 12.60 (1.94)

Medication (SOPA) IG 10.00 (2.91) 8.20 (2.94)
 CG 9.80 (2.16) 10.20 (1.30)

Attitudes toward age IG 1.60 (0.89) 0.80 (0.44)
 CG 1.20 (0.44) 1.40 (0.89)

Depression IG 3.80 (2.28) 3.00 (1.87)
 CG 3.00 (1.87) 3.60 (2.40)

Satisfaction with life IG 21.80 (8.61) 24.20 (6.05)
 CG 21.00 (5.43) 20.40 (9.07)

Means success values IG 3.60 (0.52) 4.44 (0.51)
(CPVI) CG 4.14 (0.48) 4.72 (0.43)

Means discrepancy IG 0.72 (0.67) 0.16 (0.57)
(CPVI) CG 0.31 (0.30) 0.10 (0.36)

Variable Intragroup Intergroup d
 differences differences
 Z Sig. U Sig.

Pain interference in -0.27 0.78 10.00 0.59 0.23
daily activities -0.27 0.78

Pain interference in -1.09 0.27 6.50 0.20 0.87
mood -1.09 0.27

Pain interference in -1.46 0.14 5.00 0.10* 1.25
walking -1.34 0.18

Pain interference in -0.53 0.59 11.50 0.81 0.06
personal relationships -1.00 0.31

Pain interference in -1.48 0.13 5.00 0.11 1.13
sleep -0.44 0.65

Pain interference in -1.06 0.28 8.50 0.39 0.63
enjoying life -1.28 0.19

Pain interference in -0.18 0.85 10.00 0.57 0.51
family -1.00 0.31

Pain interference in -1.06 0.28 8.00 0.29 1.01
rewarding activities -1.00 0.31

Pain interference in -1.34 0.18 8.00 0.28 -0.78
self-care -0.44 0.65

Functional -1.60 0.10 * 12.0 0.91 0.24
performance -1.4 0.14

Selection (SOC) -1.34 0.18 12.00 0.91 0.00
 -1.28 0.19

Loss-based selection -1.76 0.07 * 4.50 0.09* 1.05
(SOC) -0.18 0.85

Optimization (SOC) -0.44 0.65 10.00 0.58 0.12
 -7.36 0.46

Compensation (SOC) -0.73 0.46 8.00 0.33 -0.48
 0.00 1.00

AAQ -1.21 0.22 4.00 0.07* -1.39
 -1,76 0.07

Solicitude (SOPA) -1.46 0.14 8.00 0.34 -0.70
 -0.36 0.71

Emotionality (SOPA) -1.48 0.13 8.00 0.34 0.69
 -0.40 0.68

Cure (SOPA) -1.84 0.06 * 7.00 0.24 -0.92
 0.00 1.00

Control (SOPA) -0.94 0.34 10.00 0.59 0.50
 -0.18 0.85

Harm (SOPA) -1.84 0.06 * 9.50 0.51 -0.95
 -1.41 0.15

Disability (SOPA) -0.55 0.58 9.50 0.52 -0.63
 -2.03 0.04

Medication (SOPA) -1.84 0.06 * 3.50 0.04** -1.39
 -0.44 0.65

Attitudes toward age -1.63 0.10* 6.00 0.14 -1.03
 -0.44 0.65

Depression -0.73 0.46 9.00 0.45 -0.75
 -0.81 0.41

Satisfaction with life -0.54 0.58 9.50 0.53 0.43
 -0.13 0.89

Means success values -2.04 0.04 ** 11.00 0.74 0.48
(CPVI) -2.03 0.04

Means discrepancy -1.30 0.19 8.50 0.39 -0.51
(CPVI) -0.53 0.59

Note: * p< 0.10; ** p< 0.05
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Author:Alonso, Miriam A.; Lopez, Almudena; Losada, Andres; Gonzalez, Jose Luis
Publication:Behavioral Psychology/Psicologia Conductual
Article Type:Report
Date:Jan 1, 2013
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