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Terms Used In This Article

chronic pain - pain which lasts for more than 3 months

cognitive based therapy - type of psychological therapy which focuses on how people think about their problems and tries to enact change by teaching people how to think differently

prospective - type of research study which tracks subjects going forward in time

randomized - type of research study in which subjects are randomly selected to either receive the treatment under study or a placebo type control

Common Chiari Terms

cerebellar tonsils - portion of the cerebellum located at the bottom, so named because of their shape

cerebellum - part of the brain located at the bottom of the skull, near the opening to the spinal area; important for muscle control, movement, and balance

cerebrospinal fluid (CSF) - clear liquid in the brain and spinal cord, acts as a shock absorber

Chiari malformation I - condition where the cerebellar tonsils are displaced out of the skull area into the spinal area, causing compression of brain tissue and disruption of CSF flow

decompression surgery - general term used for any of several surgical techniques employed to create more space around a Chiari malformation and to relieve compression

syringomyelia - condition where a fluid filled cyst forms in the spinal cord

May 31, 2008 --  The impact of dealing with chronic pain has been well chronicled in Chiari & Syringomyelia News.  People living with chronic pain have poorer health, anxiety, depression, and general physical and social limitations.  While billions are spent researching new pain medications, psychologists have been having success in helping chronic pain patients through cognitive behavioral therapies. 
     Cognitive behavioral therapy is an intellectual type of treatment which focuses on how people think about their problems and tries to teach people how to refrain their thoughts and thus improve the situation.  One such treatment model which research has shown to be effective across a variety of problems is known as Acceptance and Commitment Therapy (ACT).  ACT therapy stresses six key elements:

• Acceptance

• Cognitive defusion

• Contact with the present moment

• Self as context

• Values based actions

• Committed action

Of the six core elements, both acceptance and values based actions have been shown in studies of chronic pain patients to be associated with better emotional, physical, and social functioning. 
     Acceptance, which has been discussed in Chiari & Syringomyelia News before, focuses on acknowledging that pain is present, but not letting it interfere with activities.  Many people with chronic pain start to believe that they can't do anything because it might make the pain worse.  Acceptance means that a person literally accepts the fact that pain will be part of certain activities but engages in them regardless. [Ed. Note:  As I have expressed before, I am a big believer in the acceptance theory of dealing with chronic pain.  When people ask me how I deal with the constant pain I tell them two things.  First, I try to put it in a box in the corner of my mind and I don't let it encompass my entire brain and thought process.  Over time the box has become smaller and the walls of the box have become stronger.  Second, I tell myself that the pain will be there whether I do things or not, so I might as well do things.  Thus, when presented with a choice of engaging in an activity or not, I always try to choose the activity (within reason of course).]
     Values based actions refers to the concept of undertaking activities that are directed by a person's goals and desires of how they want to live their life, rather than trying to avoid experiences or behaving in response to social pressures.  [Ed. Note:  Also in the past - and in the book, A Patient's Guide - I have discussed how Chiari patients can benefit from prioritizing their lives; in other words, deciding what is most important to them and focusing their energies on those things while not getting distracted and dragged down by what is unimportant.  I think this is essentially the same thing as values based actions.]
      A recent study by researchers from England (McCracken, Vowles) published in the March, 2008 issue of the journal, Health Psychology, demonstrates the association between acceptance and improved functioning with chronic pain.  The research involved 115 chronic pain patients who were seeking help for the first time at a pain clinic in England.  Slightly more than half of the group was comprised of women and the average age of the pain patients was 48 years.  Lower back pain was the most common problem (Figure 1), followed by lower limb pain and whole body pain.  Most of the patients had been suffering for a long time, with the average being 77 months.  Demonstrating the impact which chronic pain can have, only 6.1% of the group was employed full time.
     The research did not involve any interventions, but rather each participant answered a battery of tests and surveys at their first evaluation appointment and then again right before their treatment started (an average of 18 weeks later).  The tests assessed their pain intensity, use of pain medications, their level of acceptance, their success at values based action, their emotional functioning, and their levels of disability.
     When the scientists examined the data they found that acceptance and values based actions were significantly associated with lower pain levels, less pain related distress, less depression, and lower physical and psychosocial disability. In other words, people who had accepted their pain and tried to engage in the activities they thought were important, in general reported being more functional.  It is important to note though, that there was no correlation between acceptance and employment. 
     While a study like this does have limitations, there are now more than 15 published research studies indicating that acceptance can have a positive impact on chronic pain patients.  The authors believe this supports the use of ACT type therapies as described above and propose a randomized, controlled clinical trial to truly assess the potential of such therapy to help chronic pain patients.  A similar study among Chiari patients, perhaps combined with physical therapy and occupational therapy as well, would be a welcome addition to the Chiari research.
     To this point, there has been virtually no research on after surgery interventions for Chiari patients, and such work is long overdue.

-- Rick Labuda

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Key Points

1. Chronic pain is common among Chiari and especially syringomyelia patients

2. While medications have limited effectiveness, cognitive based therapies have been shown to improve quality of life and functioning

3. Specifically, research has shown that acceptance and values based actions are correlated with lower disability and improved functioning

4. Acceptance refers to engaging in actions even though pain is present; values based actions refer to activities directed by how someone wants to live their life

5. This study assessed 115 chronic pain patients at two points in time using a battery of validated surveys

6. Found that the levels of both acceptance and values based actions were associated with lower pain related distress, anxiety, depression, physical and psychosocial disability

7. Model of therapy known as ACT tries to increase acceptance and values based action in chronic pain patients

Figure 1: Pain Location (115 Total Patients)
 

Source:  McCracken LM, Vowles KE.  A prospective analysis of acceptance of pain and values-based action in patients with chronic pain.Health Psychol. 2008 Mar;27(2):215-20

Related C&S News Articles: 

Chronic Pain Disrupts The Brain's Natural Activity State

Comprehensive Pain Programs Benefit Patients

Some People Are Able To Move Past Chronic Pain; How Do They Do It?

Accepting Chronic Pain Can Improve Quality Of Life