Abstract
Background and aims
Exposure in vivo for patients with fear-related chronic pain has a strong theoretical base as well as empirical support. However, the treatment does not work for every patient and overall the effect size is only moderate, underscoring the need for improved treatments. One possible way forward might be to integrate an emotion regulation approach since emotions are potent during exposure and because distressing emotions may both interfere with exposure procedures and patient motivation to engage in exposure. To this end, we proposed to incorporate an emotion-regulation focus into the standard exposure in vivo procedure, and delivered in the framework of achieving relevant personal goals. The aim of this study then was to test the feasibility of the method as well as to describe its effects.
Method
We tested a hybrid treatment combining an emotion-regulation approach informed by Dialectical Behaviour Therapy (DBT) with a traditional exposure protocol in a controlled, single-subject design where each of the six participants served as its own control. In this design participants first make ratings to establish a baseline from which results during treatment and the five month follow-up may then be compared. To achieve comparisons, participants completed diary booklets containing a variety of standardized measures including pain catastrophizing, pain intensity, acceptance, and function.
Results
Compared to baseline, all subjects improved on key variables, including catastrophizing, acceptance, and negative affect, at both post treatment and follow up. For 5 of the 6 subjects considerable gains were also made for pain intensity and physical function. Criteria were established for each measure to help determine whether the improvements were clinically significant. Five of the six participants had consistent results showing clinically significant improvements across all the measures. The sixth participant had mixed results demonstrating improvements on several variables, but not on pain intensity or function.
Conclusions
This emotion-regulation hybrid exposure intervention resulted in considerable improvements for the participants. The results of this study underscore the potential utility of addressing emotions in the treatment of chronic pain. Further, they support the idea that targeting emotional stimuli and using emotion regulation skills in conjunction with usual exposure may be important for obtaining the best results. Finally, we found that this treatment is feasible to provide and may be an important addition to usual exposure. However, since we did not directly compare this hybrid treatment with other treatments, additional research is needed before firm conclusions can be made.
Implications
Addressing emotional distress in the treatment of patients suffering chronic pain appears to be quite relevant. Emotion regulation skills, employed together with exposure in vivo, hold the promise of being useful tools for achieving better results for patients suffering fear-related and emotionally distressing chronic pain.
1 Introduction
Chronic pain is a pervasive and difficult problem to treat and consequently exposure in vivo for pain-related fear of movement has offered a much welcomed treatment with a clear target and a strong theoretical base [1]. While this exposure-based treatment provided a breakthrough and has gained considerable empirical support, controlled trials nevertheless suggest that it has only a moderate effect [1,2]. Hence, while exposure is a step forward, more effective methods are clearly needed [1].
There are three salient problems that hamper exposure in vivo for pain-related fear. First, there is a problem in identifying the exact stimuli that provoke fear and are the targets for exposure [3]. Standard procedures assume fear of movement. However, there may be a host of other triggers such as emotional states [4] or internal stimuli including the pain itself [2]. Thus, restricting exposure only to movements may compromise its effectiveness. Second is the issue of safety behaviors. While exposure requires considerable effort from the patient, it also provokes intense fear and challenges common sense ideas that provoking pain is dangerous. It is not surprising then that exposure is often a least preferred treatment, with dropout rates of 30–50% [1] which may propel safety behaviours. The role of safety behaviours during exposure is hotly debated, since they might reduce the effects of exposure [5]. However, skilful reduction or titration of negative affect may actually allow the person to participate in the exposure [6]. One way of framing the issue is to cast it in a motivational context [7]. Thus, when presumed “safety behaviours” serve to achieve a goal they may instead be a valuable “coping” strategy [7]. Third, is the documented problem of generalizing results to daily life, where relapse after usual exposure procedures is common [8]. Improvements in these areas then should enhance the results of exposure treatments for pain-related fear and related problems.
One way to address these problems might be a hybrid treatment that combines usual exposure with an emotion regulation approach conducted in a goal pursuit context [9,10]. First, this would allow consideration of stimuli other than movements like emotions and pain. Indeed, chronic pain is clearly linked to emotional processes such as catastrophic worry, anger, shame, and depression [9]. Passionate emotions may generate unhelpful escape or safety behaviours [11]. Rather than only avoiding movement then, these patients may learn to avoid a variety of personally relevant, emotional stimuli [4]. And like other forms of phobia, this avoidance, which reduces negative affect in the short term, paradoxically may increase it in the long term. Second, engagement might be improved by providing support and skills to deal with the intense negative emotion involved (e.g. fear). Developing personally relevant goals also would seem to be essential from a motivational perspective [7]. Third, providing emotion regulation skills should encourage and empower patients to engage in exposure and continue until their personal goals are achieved [12]. Finally, tackling exposure from an emotion regulation angle might open the door for generalization since personal goals would be in focus rather than simply being able to do a certain movement [7].
A hybrid treatment might be based on the available exposure in vivo method combined with an emotion regulation approach informed by procedures in Dialectical Behaviour Therapy (DBT) since DBT highlights emotion regulation skills and incorporates goal pursuit. Thus, integrating emotion focused DBT techniques into the exposure in vivo treatment for pain related fear might be a way to discover triggers and address the intense emotional states, the avoidance of negative affect, and the catastrophic worry so common in chronic pain. In fact, two studies have explored treatments focusing on emotion [4,13]. While showing promise, both involved pilot studies with treatments that were not fully developed and more data is urgently needed.
The purpose of this paper is to test a hybrid treatment that combines a DBT inspired, emotion-regulation focused, treatment with standard exposure treatment as a proof of concept. We hypothesized that targeting negative affect, pain, and movements would result in a reduction of their threat value, thereby reducing their potential as negative reinforcers. Therefore, we expected that this treatment would reduce negative affect such as catastrophic worry and enhance rehabilitation as seen in acceptance and activities of daily living while not provoking average pain intensity ratings.
2 Method
2.1 Overview of the design
A replicated single-case AB design [14] was employed to test the hypothesis that the DBT exposure therapy would reduce catastrophizing, negative emotions, and increase function, while not exacerbating pain intensity. Repeated measures, for each participant, were first taken during the baseline phase (A), when no treatment was provided. Subsequently, repeated measures were taken during the treatment (B) phase so that a comparison could be made. Thus, the baseline (A) serves the same function as a no treatment control group and if changes during treatment occur relative to the baseline, it can be assumed that this is related to the intervention. Follow up data provides comparison for determining longer term utility. Replication was achieved via additional participants which strengthens the findings and increases generality.
2.2 Participants
Six volunteer patients participated in the study. Inclusion criteria were: chronic low back pain (current episode >3 mo), a high level of catastrophic worry (Pain Catastrophizing Scale, >24), and no red flags, co-morbid medical problems, or other ongoing treatments. Fifty-three patients applied to an advertisement in a local newspaper and the first 8 who fulfilled the screening criteria were invited for a full assessment. Two were excluded (1 = co-morbid disease (Parkinson’s disease); 1 = ongoing medical treatment (physical therapy)). A description of the 6 participants is presented in Table 1. We followed the Helsinki ethical guidelines and obtained informed consent.
An overview of the participants including the duration of the problem as well as of the baseline and treatment.
| ID # | Age | Sex | Pain problem | Duration of pain problem | Length of baseline (days) | Length of treatment (sessions/h) |
|---|---|---|---|---|---|---|
| 1 | 54 | F | Low back pain, shoulders and knees | 15 years | 11 | 9 sessions/11 h |
| 3 | 39 | M | Low back pain | 25 years | 11 | 10 sessions/15.3 h |
| 4 | 71 | F | Low back pain, knees | 1.5 years | 15 | 10 sessions/10.5 h |
| 5 | 55 | F | Low back pain, hips | 19 years | 9 | 10/11 h |
| 6 | 33 | F | Low back pain | 4 years | 12 | 9/12 h |
| 8 | 57 | F | Low back pain, shoulders, arms | 23 years | 12 | 9/12 |
2.3 Assessment
Outcome and process variables were assessed via diaries and standardized questionnaires. A booklet contained daily ratings, questionnaires to be completed every third day as well as questionnaires that were completed once during baseline, post treatment, and at the five month follow up. Booklets were completed throughout the baseline, treatment, and during one week after treatment and follow-up respectively and they were also used for detailed chain analyses. For benchmarking purposes, levels considered to be clinically relevant [15] were determined from the literature and are indicated for each measure.
2.3.1 Primary measures
A daily diary was used to capture pain while the other primary variables were assessed every third day during the course of the study.
Pain Catastrophizing Scale (PCS). This questionnaire has good psychometric properties and assesses catastrophic thinking with 13 assertions that are rated on 0–4 Likert scales where higher scores indicate higher levels of catastrophizing [16]. Scores over 20 indicate an increased risk for poor outcome including functional impairment and is used as a cut-off [17].
Daily measure of pain. Pain intensity was rated on an item from the Örebro Musculoskeletal Pain Screening Questionnaire: “How much pain have you experienced today?” with a 0–10 Likert scale anchored by “no pain” and “worst possible pain” [18]. Clinically relevant outcome involves an improvement of at least 2 points and in surgical settings levels of 4 or less are considered not in need of more analgesics [15,19].
Chronic Pain Acceptance Questionnaire (CPAQ). The CPAQ measures the impact of negative affect on the participant since acceptance of pain is a proxy for experiential avoidance with 20-items answered on a 0 (“never true”) to 6 (“always true”) Likert scale [20]. A score of 47.8 has been reported at pre-treatment for highly disabled patients suffering chronic pain and a post treatment value of 71.4, a 49% increase is considered a good improvement [20].
Quebec Back Pain Disability Scale (QBPS). The QBPS measures how difficult it is to perform 20 daily activities rated from 0 (not at all difficult) to 5 (impossible to do) and has good reliability and validity [21]. An established benchmark for improvement is a reduction of 15 points or more [21], while another is a score of 30 or below which is related to improvements ranging from “much better” to “completely well” [22].
2.3.2 Secondary measures
Tampa Scale for Kinesiophobia (TSK). The TSK consists of 17 assertions rated on a four-point Likert scale (1 = strongly disagree; 4 = strongly agree) and the Swedish version has good reliability and validity [23]. A cut-off score of 39 has been recommended for exposure treatment and individual scores at post-exposure range from 18 to 44 with an average of 27 [1].
Hospital Anxiety and Depression Scale (HADS). The HADS consists of 14 statements divided into an anxiety (HAD-A) and a depression subscale. The HADS has been shown to be reliable in a Swedish sample [24]. Scores are interpreted as 8–10, mild; 11–15 moderate; and >15 severe levels of anxiety and depression respectively [25].
Adverse Effects. Possible events that might be harmful or adverse were recorded in session notes and a list of possible events was reviewed at regular meetings of the therapists.
2.4 Treatment
The hybrid treatment was developed by combining a basic exposure in vivo approach [26,27] with a DBT informed approach [12]. A manual was developed to guide therapists in conducting the treatment. Sessions were held once or twice a week over 6–9 weeks with a range of 9–12 sessions (see Table 1).
2.4.1 Content
The treatment was conducted in stages and Table 2 provides an overview and examples of the content. The first stage focused on three things: dialectical validation of the patient’s experience (i.e., complete validation of his or her experience, but also dialectically noticing that current “solutions” are not effective, and exploring other emotions that she or he might have missed), helping the patient to develop concrete personal goals, and chain analyses to identify important stimuli that triggered pain as well as emotions. Considerable time was spent validating the patient’s own personal experiences and developing a working analysis (chain analyses) of the problem. We examined, for example, how feelings, thoughts, and behaviours were related to the patient’s pain and difficulties. As an illustration, some patients identified guilt and shame as potent emotions. We helped them to identify situations where these occur, for example letting a partner do household chores rather than being able to doing them for one’s self. These were used in developing targets and hierarchies for exposure. In addition, the Photographic Series of Daily Activities (PHODA) was employed to help develop a hierarchy of movements for exposure [1]. The idea of “dialectics” was introduced and explored e.g. avoidance versus confrontation. Finally, a key feature of Stage one was developing personal goals. We spent time during each session to explore what each patient’s valued activities were and what might constitute important, challenging, and exciting goals to achieve. A plan was made to pursue these goals in steps that were clearly defined. These were referred to when designing exposure and the dialectical behavioural experiments described below.
An overview of the content of the DBT inspired exposure treatment.
| Stage | Methods (examples) | Focus |
|---|---|---|
| I. Analysis of emotions and pain | • Validation • Chain analysis • Values & goals |
Soothe emotions to promote emotional experiencing and regulation. Identify important personal goals; connect treatment targets to goals, and get commitment to targets. Identify relationships among pain, negative emotion, and other stimuli for exposure. |
| II. Developing skills | • Dialectics • Self-validation • Emotion regulation/coping skills |
Use dialectic opposites as an aid to increase flexible problem-solving. Self-validation to promote emotional experiencing and decrease emotional reactivity. Various emotion regulation strategies also to promote experiencing emotions and prepare for exposure. Provide acceptance and change skills for negative emotions, and acceptance skills for pain. |
| III. Exposure training | • Exposure for emotionally sensitive stimuli • Exposure in vivo for avoided movements |
Exposure for emotionally sensitive stimuli in session and in behavioural experiments at home. It particularly focused on worry, guilt and repetitive thoughts that triggered negative affect. Exposure for movements was done in session and keyed on a hierarchy developed with the patient using the PHODA. Generalization was done with homework and the promotion of goal activities that included the movements, plus emotion management. |
| IV. Maintenance | • Identifying key elements • Planning for flare-ups |
Patients identified the key elements to the improvements made. A tool kit was formed consisting of regularly employed methods and others in reserve for flare-ups. |
Stage two consisted of systematic skills development designed to enhance emotional regulation and prepare the patient for the upcoming exposure. We worked with patients to develop selected emotion regulation skills designed to enhance exposure [12,13]. For example, disturbing thoughts and feeling were identified, labelled, but not judged or acted upon. Another example is savouring where patients practiced about 15 min per day to enjoy the moment and positively attend to i.e. “savor” them. Self-validation was also practiced as a way of soothing negative emotions. Diary records were kept as one way of evaluating goal pursuit attainment.
Stage three consisted of the exposure training. This encompassed applying the emotion-regulation skills from Stage two to both feared movements and emotionally sensitive stimuli. For movements, the standard procedure was used where patients were asked to engage in feared movements according to the hierarchy but they also were encouraged to practice emotion regulation strategies both in and out of the session. For both movements and emotions, dialectical behavioural experiments were developed, where the patient would engage in an avoided activity or emotion with the help of, if desired, an emotion regulation strategy so as to achieve a personal goal. The experiments were developed by identifying how the patient was currently responding to sensitive emotional or movement stimuli and then looking at alternative responses e.g. doing the opposite. These experiments then were designed so that patients would confront feelings, situations, and movements i.e. a form of exposure. For instance, to expose for the guilt of having a partner do one’s household chores, the experiment involved doing exactly the opposite, i.e. doing a defined chore even though the partner “offers to help”. The results are recorded and reflection used to see how the dialect worked and what might be learned from this.
Stage four sought to identify key elements in the programme that contributed to progress, as well as factors that increased risk for flare-ups. Thus each patient identified the main things he or she believed was a key to bringing about change and that would be vital for long-term results. A plan was made for how these skills would be used and how flare-ups could be handled. Commitment to using the skills learned and managing risks were then used to develop generalization and maintenance plans.
2.4.2 Therapists
Three therapists delivered the therapy per the manual. One therapist was a certified psychologist and psychotherapist while the other two were students in their final term of a clinical psychology programme.
3 Results
The results are presented for the primary and secondary measures of outcome using descriptive statistics and visual graphics as recommended by experts in the field [14,28,29]. First, the individual results for each measure are presented. For two of the primary measures, we show the diary ratings across baseline, treatment, and follow-up. To concisely provide an overview of results for all participants, we use figures showing the baseline, posttreatment and follow up values. For an overview of the results across measures for each individual we provide a summary description. Finally, in order to judge clinical relevance, we have employed the standards described above.
Fig. 1 illustrates the diary ratings for each individual participant over the course of the study on the variable of pain catastrophizing. As seen in Fig. 1, there were substantial, and sometimes dramatic, decreases in scores on the PCS from baseline to the end of treatment. These improvements were maintained or improved upon at follow-up for five of the six subjects, while one (#4) showed some deterioration at follow up. All of the participants were well above the cut-off score for “catastrophing” (>20) at the baseline and all had a decrease to the cut-off (#4) or below it (#1, 3, 5, 6, 8) at the follow-up.
Ratings (3-day) on the Pain Catastrophizing Scale during baseline, treatment, and follow-up for each participant.
Pain was rated daily throughout the study and our assumption was that the exposure would not provoke pain intensity. Fig. 2 shows the daily diary pain ratings for each individual at baseline, through treatment, and at the follow-up. The variability of the pain ratings was relatively high. All of the participants enjoyed some decreases over treatment, although occasional days of high intensity ratings occurred. In terms of clinical significance, four of the participants (#s 1, 3, 5, 6) met the criteria as their follow up ratings fell below the lower level of the baseline range, and these four participants also met the criteria of at least a two point decrease from baseline to follow-up (#s 1, 3, 5, 6). At follow up, five of the six participants (not #6) had a rating of 2 which is less than the absolute criteria set for a low level of pain intensity. Participant #6 had an increasing baseline ranging from 5 to 9 that decreased during treatment (with some days of high ratings) and a follow up rating of 4. No individual participant had an increase in pain at follow-up relative to the baseline.
Daily ratings of pain (0–10) over baseline, treatment, and at follow up for each participant.
A third primary outcome was negative emotion and acceptance. We employed the CPAQ to capture this variable where higher scores indicate greater acceptance. Since the CPAQ is designed to be used at intervals and also to provide an overview of results we present the pre, post and follow-up values for each participant in Fig. 3. The baseline values ranged between 29 and 47. Moreover, every participant clearly had a higher score at post-treatment (range 67–114) relative to the baseline. Three of the participants continued to improve at follow-up (#1, 3, 8) while three maintained their improvements (4, 5, 6). All of the participants had scores at follow-up that exceeded 71, which was set a priori as a benchmark for clinical improvement.
Scores on the Chronic Pain Acceptance Questionnaire for each participant at the baseline, post treatment and follow up. The dotted red line indicates the defined level of clinical significance based on post treatment values from earlier treatment results.
Function was a fourth primary variable and the results for the QBPS scale, which measures dysfunction, are graphically depicted in Fig. 4. Baseline levels ranged from 24 to 70. Three participants had higher levels of dysfunction (>50) at baseline (#4, 5, 8), while three had relatively low scores indicating lower levels of physical dysfunction (#1, 3, 6). Despite the wide range, the level of dysfunction at post treatment was lower for all subjects compared to the baseline and this result was maintained at the follow up for five of the six subjects (not # 6). One benchmark was an improvement of 15 points or more [21], while another was a score of 30 or below [22]. Three participants easily met the first criteria at follow up (#s 4, 5, 8), while three did not (#s 1, 3, 6); while all subjects had a score of 31 or less at follow up.
Mean scores on the Quebec Back Pain Disability Scale at baseline, post treatment, and Follow up for each of the 6 participants. The dotted red line indicates that scores under are defined as clinically significant.
Two important secondary measures assessed emotions. First, the TSK was used to assess fear beliefs and the mean score for the baseline, post treatment and follow up for each participant is shown in Fig. 5. Five of the six patients had scores above 39 which is the cut-off recommended for offering exposure treatment [1]. All participants enjoyed a decrease between baseline and the post test and three continued to improve at follow up (#1, 3, 8). While all had a score of 39 or less at follow-up, indicating a lower level of fear beliefs, three were also clearly below the benchmark criteria of a score of 28 (#s 5, 6, 8), and two were within three points of this level (#s 1, 3, 4).
Mean scores on the Tampa Scale of Kinesiophobia for each participant. Five of the 6 participants had high scores at baseline and all had lower scores at post treatment and follow up than at the baseline. The dotted red line indicates the cut-off level for “high” scores on the measure.
Second, the HADs instrument was used to monitor levels of anxiety and depression. Figs. 6 and 7 show the results for each participant from baseline to post treatment and follow up for anxiety and depression respectively. The HADS-A shows that only two participants had scores indicating moderate anxiety at the baseline. Nevertheless, all participants had lower scores at post treatment as compared to the baseline. The follow up shows that 5 of the 6 had even lower scores as compared to post treatment. All participants were under the benchmark of 8 points indicating no observable problem with anxiety. Similarly, the HADS-D indicated that 2 of the 6 participants had scores indicating moderate depression at the baseline, but even here all subjects had a decrease in scores at post treatment and three (#1, 3, and 8) continued to improve at follow up. As with anxiety, all subjects were below the benchmark level of 8 points at the end of the follow-up, indicating no observable problem with depression.
Mean scores on the HADS-Anxiety scale for all participants. Although only two participants (3, 6) had moderate scores at the start, all subjects had lower scores at post treatment and follow up relative to the baseline. The dotted line indicates the norm below which anxiety is not considered to be at all problematic.
Mean scores on the HADS-Depression scale over the course of the study. While only two participants had moderately elevated scores at the start, all enjoyed a decrease at post treatment and follow up relative to the baseline. The dotted line indicates the norm below which depression is not considered to be problematic.
3.1 Overview of effects
In order to obtain an overall picture of the results for each individual on all of the measures, we summarize the results for each participant across all of the measures, thus underscoring the clinical result on an individual basis. Taken together, five of the participants had relatively consistent results showing relevant improvements across all the measures, although #4 had somewhat smaller improvements. The exception is subject 6 who had improvements on several variables, but not on two important variables, pain and function.
3.2 Adverse events
No potentially adverse or harmful events were recorded during therapy sessions, homework, or between sessions during the study.
4 Discussion
As a proof of concept, our findings demonstrate the feasibility of providing a hybrid treatment combining an emotion regulation focused DBT approach with a standard exposure treatment for patients suffering chronic pain and they highlight overlooked factors in exposure e.g. the role of personal goals, emotions, and skills. All of the participants completed the treatment (no dropouts), were engaged (attended all sessions; completed homework assignments), and also experienced substantial improvements. As we anticipated, negative affect as measured by acceptance and catastrophic worry significantly decreased and physical function improved. Moreover, we noted a remarkable decrease in ratings of pain given the hypothesis that we would simply not provoke more pain. Since previous studies have had difficulty in lowering variables such as catastrophizing and pain intensity for patients with chronic pain, these results are noteworthy and suggest that the method is sufficiently promising to continue researching it.
Although there is variation from patient to patient, our results demonstrate rather large improvements. Four of the participants (#1, 3, 5, 8) had consistent and large improvement across variables, while two (#4, 6) had medium improvements. In particular, participants enjoyed substantial improvements in catastrophizing, acceptance, and pain intensity where PCS values decreased an average of 72%, pain intensity 51%, and acceptance more than doubled. Function as measured by the QBPS also improved. However, three participants (#1, 3, 6) had relatively low levels of physical dysfunction, as measured by the QBPS, at the baseline and these three also had the smallest percentage of improvement, indicating a possible basement effect. In addition, pain levels were rated at just 2 (0–10 scale) for five subjects and at 4 for the sixth. Our results also show that the participants often meet predetermined criteria for clinically significant improvements, noteworthy since this is rare for patients with chronic pain [30].
Comparing our results with two of the randomized trials of exposure in vivo [31,32] also sheds light on the size of the improvement. For pain, the present study demonstrates an average 51% reduction from pre to follow-up whereas Leeuw et al. reports a 17% and Linton et al. a 23% reduction. Similarly for the QBPS, the current finding is an average improvement of 41% while Leeuw et al. show a 26% and Linton et al. a 15% improvement. Finally, for the PCS, we find a 71% reduction as compared to a 35% reduction for Leeuw et al. and a 25% reduction for Linton et al. These results provide hope that this hybrid treatment may produce larger effects than traditional exposure, with further development and evaluation.
The present findings support the idea that negative emotions play an important role in chronic pain and exposure treatment for distressed patients. While our findings are in line with the fear-avoidance model, they also suggest that actively dealing with other negative emotions, in a goal-pursuit context, might be helpful clinically. These results also add fuel to the debate about safety behaviours during exposure where judicious use of safety behaviour is asserted to be helpful [6]. Perhaps this suggests a finer distinction can be made between successful management of negative emotion and safety behaviours per se since safety behaviours provide more dysfunctional escape from situations and negative emotion) The current findings support this view as well as the idea that the goal context is important [7]. Indeed, this study highlights that the function of avoidance and the context in which it occurs are vital aspects [9] and require further exploration.
This study has some limitations that should be kept in mind when interpreting the results and designing future studies. First, we have employed a single-subject design which prohibits drawing conclusions about how well this treatment would fair against usual exposure in vivo since these were not directly compared. Second, generalization is limited and there is a profound need to evaluate the treatment with other samples and in other settings. Future research should therefore replicate this single-subject design or consider employing randomized designs utilizing a larger sample. Third, one might question introducing yet another “treatment” for these patients. However, this treatment is not a new procedure, but rather the integration of existing ones. We believe that this particular combination has merit and therefore we report on its utility. Finally, a longer follow-up would provide more information concerning the durability of the effects.
In summary, this study has demonstrated that a hybrid treatment combining an emotion regulation-focused DBT inspired treatment with standard exposure for patients with chronic low back pain resulted in considerable improvements. It is striking that patients achieved clinically relevant improvements, often to “normal” ranges, on key outcome variables. The results suggest that treatments focusing on emotion regulation are helpful. While this approach shows promise, future research is direly needed to test its effects in other settings.
Highlights
Exposure in-vivo is helpful, but not sufficient for patients suffering chronic pain.
We developed a hybrid by combining exposure with an emotion-focused approach.
We tested the hybrid in a single-subject controlled design.
Participants improved on key outcomes often to normal levels.
The hybrid shows promise and should be further tested in RCTs.
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.05.005.
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Funding Economical support from a grant from the Swedish Council for Work Life and Social Research awarded to Steven J. Linton is gratefully acknowledged.
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Conflicts of interest None.
Acknowledgements
We wish to thank Helena Kryning and Robert Sjölund for their expert help in executing this research.
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