Physical therapy informed by acceptance and commitment therapy (PACT) versus usual care physical therapy for adults with chronic low back pain: a randomized controlled trial.
Open accessAbstract
Chronic low back pain (CLBP) is a major cause of global disability and improving management is essential. Acceptance and commitment therapy (ACT) is a promising treatment for chronic pain but has not been modified for physical therapy. This randomized controlled trial (RCT) compared physical therapy informed by ACT (PACT) against standard care physical therapy for patients with CLBP. Patients with CLBP (duration ≥12 weeks, mean 3 years) were recruited from physical therapy clinics in 4 UK public hospitals. The Roland-Morris Disability Questionnaire (RMDQ) at 3 months' post-randomization was the primary outcome. Two hundred forty-eight participants (59% female, mean age = 48) were recruited and 219 (88.3%) completed measures at 3 and/or 12 months' follow-up. At 3 months, PACT participants reported better outcomes for disability (RMDQ mean difference = 1.07, p = .037, 95% CI = -2.08 to -.07, d = .2), Patient Specific Functioning (p = .008), SF12 physical health (p = .032), and treatment credibility (p < .001). At 12 months' follow-up, there were no significant differences between groups. PACT was acceptable to patients and clinicians and feasible to deliver. Physical therapists incorporated psychological principles successfully and treatment was delivered with high (≥80%) fidelity. Our results may inform the management of CLBP, with potential benefits for patients, health care providers, and society. PERSPECTIVE: Psychologically informed physical therapy has great potential but there are challenges in implementation. The training and support included in the PACT trial enabled the intervention to be delivered as planned. This successfully reduced disability in the short but not long term. Findings could inform physical therapists' treatment of CLBP.
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ACT-informed PiPT has demonstrated improvement for back-related disability, function, and pain interference, addressed barriers for engagement in physical activity, and patients report greater internal awareness that their whole being was not defined by their pain experience.
“ACT informed PiPT has demonstrated improvement for back-related disability, function, and pain-interference, addressed barriers for engagement in physical activity, and patients report the program supports greater internal awareness that their whole being was not defined by their pain experience.22,36,44,46”
From Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization (2023) · cites this paper as [44]
Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredContinued clarification is needed to implement all six interlinked processes of ACT for physical activity promotion and PiPT.
“Continued clarification is needed to implement all six interlinked processes of ACT for physical activity promotion and PiPT.”
From Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization (2023) · cites this paper as [44]
The Discussion (page not provided) calls for further work on PACT training and on how to influence its intended processes of change, specifically acceptance and committed action. It does not call for implementing all six ACT processes or establish that need for physical activity promotion generally; the trial concerns physical therapy for chronic low back pain. (LLM, conf=0.87)
Experimental — accuracy not yet measuredDelivery of ACT-informed PiPT by physical therapists is mixed and inconsistent for which of the six processes are utilized and for adherence to ACT methods throughout interventions.
“While ACT informed PiPT is promising, delivery by PTs is mixed and inconsistent for which of the six processes are utilized and for adherence to ACT methods throughout interventions.38,44”
From Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization (2023) · cites this paper as [44]
The Fidelity section reports that few core ACT methods were delivered, with average ACT fidelity of 16.4 out of 40, supporting concern about adherence to ACT methods. It does not assess inconsistent use of the six ACT processes across interventions; for this trial, it reports high overall adherence to the PACT intervention (88%). (LLM, conf=0.86)
Experimental — accuracy not yet measuredACT-informed PiPT may support fully embracing the current experience while encouraging commitment to valued living as ongoing motivation to explore movement in new and adaptive ways.
“ACT informed PiPT may support fully embracing the current experience (e.g. to both notice and allow for distressing thoughts, emotions, and/or body sensations without judging or trying to change or fix them) while encouraging the person’s commitment to valued living as ongoing motivation to explore movement in new and adaptive ways.38,44”
From Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization (2023) · cites this paper as [44]
The Procedures section describes PACT as including value-based goals, individualized exercise, and skills to promote psychological flexibility; the introduction describes ACT as using acceptance, mindfulness, and values-based action. These support the broad description, but the paper does not establish that PACT motivated people to explore movement in new ways. The Discussion says its mechanisms of action were unclear and found no between-group differences in acceptance or committed action. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe success of delivery of PiPT and PNE has been shown to be impacted by the PT's confidence and comfort with the program as well as the therapist having the qualities necessary to implement patient-centered care.
“The success of delivery of PiPT and PNE has been shown to be impacted by the PT’s confidence and comfort with the program as well as the therapist having the qualities necessary to implement patient-centered care.20,28,32,35,44,52”
From Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization (2023) · cites this paper as [44]
The Discussion (page unavailable) says physical therapists’ lack of confidence can hinder delivery of psychological interventions and that training and supervision enabled high-fidelity delivery of PACT. The paper does not establish the claimed effects of comfort with the program or therapist qualities for patient-centered care, and it does not address PNE delivery. (LLM, conf=0.86)
Experimental — accuracy not yet measured
In Godfrey et al. (2020), the ACT-informed physical therapy group reported significantly better outcomes than the physical therapy alone group for pain-related disability, physical health, and patient functioning at 3-month follow-up.
“the results showed the ACT-informed group reported significantly better outcomes than the physical therapy group for pain-related disability, physical health, and patient functioning at a 3-month follow-up (Godfrey et al., 2020).”
From Acceptance and Commitment Coaching for Music Performance Anxiety: Piloting a 6-Week Group Course With Undergraduate Dance and Musical Theatre Students (2022) · cites this paper as Godfrey et al., 2020
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- Authors
- Godfrey, E., Wileman, V., Galea Holmes, M., McCracken, L. M., Norton, S., Moss-Morris, R., Noonan, S., Barcellona, M., & Critchley, D.
- Affiliations
- King's College London (GB)
- St Thomas' Hospital (GB)
- King's College Hospital NHS Foundation Trust (GB)
- Corresponding author
- Godfrey, Emma
- ORCID
- Venue
- The Journal of Pain
- Publisher
- Elsevier BV
- Published
- 2020-01
- Volume
- 21
- Issue
- 1-2
- Pages
- 71-81
- ISSN
- 1526-5900 (ISSN-L)
- OpenAlex
- W2949021225
- Cited by
- 91
- References
- 50
- Citations by year
- 2026: 9 · 2025: 8 · 2024: 15 · 2023: 18 · 2022: 20 · 2021: 9 · 2020: 11 · 2019: 1
- FWCI
- 6.35
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of Pain (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Research Portal (King's College London) (submittedVersion, cc-by-nc-nd)
- Funders
- National Institute for Health Research
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Keywords
- chronic low back pain, acceptance and commitment therapy, physiotherapy, disability, treatment credibility, intervention fidelity, treatment acceptability
- MeSH terms
- Adult, Combined Modality Therapy, Exercise Therapy, Feasibility Studies, Female, Follow-Up Studies, Humans, Male, Middle Aged, Outcome and Process Assessment, Health Care, Single-Blind Method, Low Back Pain, Chronic Pain, Acceptance and Commitment Therapy
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