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Cited by 43Musculoskeletal pain and rehabilitationPain Management and Placebo EffectMindfulness and Compassion Interventions

A Comparative Meta-Analysis of Unidisciplinary Psychology and Interdisciplinary Treatment Outcomes Following Acceptance and Commitment Therapy for Adults with Chronic Pain.

Open access
Vowles, Kevin E., Pielech, Melissa, Edwards, Karlyn A., McEntee, Mindy L., Bailey, Robert W.·2020·The Journal of Pain
DOI 10.1016/j.jpain.2019.10.004PMC PMC7477894
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Abstract

While much of the literature provides positive support for psychological interventions for chronic pain, 2 recent meta-analyses indicate small to moderate benefits only. This inconsistency in findings suggests that there are other treatment-related variables to consider. One possible consideration pertains to treatment format, as psychological models form the basis for both unidisciplinary psychology and integrated interdisciplinary treatments for chronic pain. Therefore, a comparative meta-analysis of unidisciplinary and interdisciplinary treatments was performed to determine whether there were differences in treatment effect size (ES) at post-treatment and follow-ups of up to 1 year. One specific treatment model, Acceptance and Commitment Therapy (ACT), was investigated as it was felt that this literature was extensive enough to perform the planned analysis, while also being circumscribed enough in size to make it feasible. In total, 29 articles met inclusion criteria, 13 reported outcomes for unidisciplinary ACT, and 15 for interdisciplinary ACT. At both post-treatment and follow-up, interdisciplinary ACT had a greater ES for physical disability, psychosocial impact, and depression compared to unidisciplinary ACT. No differences in ES were observed for pain intensity, pain-related anxiety, or pain acceptance. Findings remained the same when study heterogeneity was considered. There was a significant difference observed between treatment format and treatment duration-on average, unidisciplinary interventions were of shorter duration than interdisciplinary interventions. Moderation analyses examining the relation between total treatment duration and ES generally indicated a moderate positive relation between treatment length and ES. This relation was strong for psychosocial impact. PERSPECTIVE: A comparative meta-analysis examined the relative ES of unidisciplinary (ie, clinical psychology only) and interdisciplinary ACT for chronic pain in 29 studies. The ES for interdisciplinary ACT was larger than unidisciplinary ACT for physical disability, psychosocial impact, and depression. No differences were present for pain intensity, anxiety, and acceptance.

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Registry

Crossref · 10.1016/j.jpain.2019.10.004

Cites

61 of 61 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

11 of 51 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Prior reviews and meta-analyses of psychological approaches have mixed unidisciplinary and interdisciplinary treatments, potentially complicating interpretation.

    “Thus far, the reviews and meta-analyses regarding psychological approaches.18,22,29,33,45 have included a mix of both types of treatment, which may be a complicating factor with regard to interpretation of findings.”
    Quote in the paperSubstantial claim2 of 5 sources checked
    • cites [18] Gatchel, 2007, The biopsychosocial approach to chronic pain: Scientific advances and future directions, Psychol Bull source
    • cites [22] Hoffman, 2007, Meta-analysis of psychological interventions for chronic low back pain, Heal Psychol source
    • cites [29] Leeuw, 2007, The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence, J Behav Med source

      The “Effectiveness of Cognitive Behavioral Programs” section discusses programs with various techniques, but it does not say that prior reviews or meta-analyses mixed unidisciplinary and interdisciplinary treatments or that such mixing complicated interpretation. Searches for those treatment categories and the proposed interpretation problem found no passage addressing the claim; page numbers were not available in our copy. (LLM, conf=0.74)

      Experimental — accuracy not yet measured
    • cites [33] McCracken, 2002, A short version of the Pain Anxiety Symptoms Scale (PASS-20): Preliminary development and validity, Pain Res Manag source

      The Results and Discussion examine the development and validity of the PASS-20, not reviews or meta-analyses of psychological treatments. Searches for unidisciplinary and interdisciplinary treatments and for mixed treatment types found no passage addressing the claimed complication in interpreting reviews. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites [45] Veehof, 2011, Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis, Pain source
  • Premisecitation

    Chronic pain psychological interventions have substantial empirical backing over many years.

    “Psychological interventions for chronic pain have a longstanding history of empirical support.26 Support for psychological approaches can be found in both systematic reviews18,29,33 and meta-analyses.22,45”
    Quote in the paperNot a substantial claim2 of 6 sources checked
    • cites [26] Jensen, 2014, Contributions of psychology to the understanding and treatment of people with chronic pain: Why it matters to ALL psychologists, Am Psychol source
    • cites [18] Gatchel, 2007, The biopsychosocial approach to chronic pain: Scientific advances and future directions, Psychol Bull source
    • cites [29] Leeuw, 2007, The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence, J Behav Med source

      The “Effectiveness of Cognitive Behavioral Programs” section reviews studies from 1999–2006 and reports that cognitive-behavioral programs can reduce disability, supporting an established empirical basis for some psychological approaches. Its discussion focuses on musculoskeletal pain and particular interventions, however, rather than documenting longstanding support for psychological interventions across chronic pain generally. No page number is available in our copy. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [33] McCracken, 2002, A short version of the Pain Anxiety Symptoms Scale (PASS-20): Preliminary development and validity, Pain Res Manag source

      The passage labeled Abstract (page unavailable) reports that reductions in pain-related anxiety predict improvement after multidisciplinary treatment for chronic pain. That offers limited treatment-related evidence, but the paper does not establish a longstanding history of empirical support for psychological interventions broadly. (LLM, conf=0.73)

      Experimental — accuracy not yet measured
    • cites [22] Hoffman, 2007, Meta-analysis of psychological interventions for chronic low back pain, Heal Psychol source
    • cites [45] Veehof, 2011, Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis, Pain source
  • Premisecitation

    Hedges g is considered more conservative than effect size calculations previously recommended for within-participant data.

    “Hedges g is viewed as more conservative than ES calculations that have previously been recommended for within-participant data.12,28,39”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [12] Dunlap, 1996, Meta-analysis of experiments with matched groups or repeated measures designs, Psychol Methods source

      In “Past Treatment of Problem” (p. 4), the paper reports that previously reported effect sizes from correlated designs were larger than those calculated with its recommended equation. That supports the comparison for within-participant data, but the paper discusses Cohen’s d, not Hedges g, so it does not establish the claim specifically about Hedges g. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [28] Lakens, 2013, Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and ANOVAs, Front Psychol source

      In the correlated-samples section (page not provided), Lakens describes Hedges’ correction for within-participant effect sizes, and Table 1 calls Hedges’ grm more conservative than Hedges’ gav. But the paper does not make the broader claim that Hedges’ g is generally more conservative than previously recommended within-participant calculations; it says the comparison with Cohen’s dz depends on the correlation between measurements. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [39] Morris, 2002, Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs, Psychol Methods source
  • Premisecitation

    The existing literature on exposure for high fear of pain indicates that psychology-only interventions may be sufficient to achieve significant reductions in problematic fear avoidance.

    “The extant literature on exposure for high fear of pain indicates that psychology only interventions may be sufficient to achieve significant reductions in problematic levels of fear avoidance.46,47,58”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [46] Vlaeyen, 2001, Graded exposure in vivo in the treatment of pain-related fear: A replicated single-case experimental design in four patients with chronic low back pain, Behav Res Ther source
    • cites [47] Vlaeyen JWS, de Jong J, Sieben J, Crombez G: Graded exposure in vivo for pain-related fear. In: Turk DC, Gatchel RJ, editors. Psychological Approaches to Pain Management: A Practitioner's Handbook (2 ed.). New York: Guilford Press.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [58] Woods, 2008, Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: A randomized controlled clinical trial, Pain source
  • Findingown data

    For pain-related anxiety from pretreatment to post-treatment, unidisciplinary ACT produced a medium treatment effect, with an effect size of .65 (95% CI .38-.91).

    “The treatment effect for unidisciplinary ACT was medium, ES: .65 (CI: .38–.91).”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 26
  • May combine two claims. 30
  • The quote only partly states this claim. 5

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    ACT, a behavior-change approach, has been applied to chronic pain for over twenty years.

    “One specific approach to treatment is that of Acceptance and Commitment Therapy (ACT20), a behavior change intervention that has been used for chronic pain for more than 2 decades.10,19,31”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [10] Dahl, 2004, Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial, Behav Ther source

      The section “Acceptance and Commitment Therapy as a Contemporary Behavioral Treatment for Pain” describes ACT as a behavioral approach to chronic pain, and the study evaluates an ACT intervention for people at risk of disability from stress and pain. Our copy does not establish that ACT had been used for chronic pain for more than two decades. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [19] Geiser, 1992

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [31] McCracken, 1998, Learning to live with the pain: Acceptance of pain predicts adjustment in persons with chronic pain, Pain source

  • May combine two claims.

    Premisecitation

    Hedges g corrects for small-sample bias and avoids inflating the overall treatment effect when within-subject data are correlated above .50.

    “The advantages of using Hedges g for correlated data (cf.39) include the fact that it controls for small sample size bias9 and does not risk inflation of the overall treatment effect when the data are correlated across time in excess of .50.28”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [9] Cummings, 2012

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [28] Lakens, 2013, Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and ANOVAs, Front Psychol source
    • cites [39] Morris, 2002, Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs, Psychol Methods source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Hedges' g was selected as the effect size based on recent guidelines indicating it is more conservative than previously recommended effect sizes for correlated data, particularly for bias associated with small sample size.

    “We selected Hedges’ g as our ES based on recent guidelines that indicate it is more conservative than previously recommended ES for use in correlated data, particularly for bias associated with small sample size.12,28,39”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [12] Dunlap, 1996, Meta-analysis of experiments with matched groups or repeated measures designs, Psychol Methods source

      The paper shows that some methods overestimate effect sizes in correlated designs (Past Treatment of Problem, p. 4; Discussion, p. 5). It also reports slight overestimation of d that becomes trivial at a sample size of 50 (p. 3). These passages do not recommend Hedges’ g or establish that it is more conservative than other effect sizes for small samples. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [28] Lakens, 2013, Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and ANOVAs, Front Psychol source

      In “Cohen’s d in one-sample or correlated samples comparisons” (page unavailable), Lakens recommends Hedges’ correction for the positive bias in correlated-sample estimates. The paper also says the corrected correlated-sample estimates are not completely unbiased. Table 1 calls Hedges’ grm more conservative than Hedges’ gav, not Hedges’ g in general more conservative than previously recommended effect sizes for correlated data; the explicit small-sample comparison concerns between-subjects estimates. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [39] Morris, 2002, Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs, Psychol Methods source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Follow-up length ranged from 3 to 12 months, averaging 5.0 months (SD 2.8).

    “Follow-up length ranged from 3 to 12 months, with an average of 5.0 months (SD: 2.8).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Seven outcome domains qualified for meta-analysis: physical disability, psychosocial impact, depression, pain-related anxiety, pain intensity, and pain acceptance.

    “Seven measure domains met this requirement. These domains included physical disability, psychosocial impact, depression, pain-related anxiety, pain intensity, and pain acceptance.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Interdisciplinary intervention studies involved an average of 3.5 providers (SD 1.5, range 2-5).

    “For the interdisciplinary intervention studies, an average of 3.5 providers (SD: 1.5, range: 2–5) were involved in treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    2,672 participants completed treatment (mean 95.4, SD 120.9, range 6-476).

    “and 2,672 participants completed treatment (mean: 95.4, SD: 120.9, range: 6–476).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Across studies, 3,086 participants started treatment (mean 110.2, SD 138.4, range 6-590).

    “Across studies, a total of 3,086 participants began treatment (mean: 110.2, SD: 138.4; range: 6–590)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Abstract screening excluded 63 records, leaving 50 articles for full-text review.

    “After abstract screening, 63 records were excluded for not meeting inclusion criteria, leaving a total of 50 articles for full text review.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Seventeen studies provided follow-up data for 1,322 participants (mean 77.8, SD 67.8, range 10-213).

    “Seventeen studies reported follow-up data for a total of 1,322 participants (mean: 77.8, SD: 67.8, range: 10–213).”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    For pain-related anxiety from pretreatment to follow-up, the 95% confidence intervals for unidisciplinary and interdisciplinary ACT overlapped substantially, indicating no difference in treatment effect between the two treatment types.

    “The 95% CI’s for the overlapped substantially, indicating no differences in treatment effect across the 2 treatment types.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    After duplicate removal, the initial search produced 1135 records for screening.

    “The initial search yielded a total of 1135 records for screening after removing duplicates.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    All interdisciplinary treatments included a clinical psychologist; 80.0% included a physician, 73.3% a physical therapist, 53.3% a nurse, and 46.7% an occupational therapist.

    “All interdisciplinary treatments included a clinical psychologist, 80.0% included a physician, 73.3% included a physical therapist, 53.3% included a nurse, and 46.7% included an occupational therapist.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For pain-related anxiety from pretreatment to post-treatment, the 95% confidence intervals for unidisciplinary and interdisciplinary ACT overlapped substantially, indicating no difference in treatment effect between the two treatment types.

    “The 95% CI’s for the overlapped substantially, indicating no differences in treatment effect across the 2 treatment types.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Across all studies, treatment duration averaged 41.7 hours (SD 42.0, range 4-128).

    “Treatment duration averaged 41.7 hours (SD: 42.0; range: 4–128) across all studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    General anxiety, pain-related healthcare visits, general acceptance, values-based action, mindfulness, and committed action were excluded from the meta-analysis because too few studies reported them.

    “Excluded domains and the total number of studies reporting them for unidisciplinary ACT and interdisciplinary ACT, respectively, were: General Anxiety: 2, 4; Pain-related Healthcare Visits: 1, 5; General Acceptance: 1, 1; Values-based Action: 0, 4; Mindfulness: 0, 4, and Committed Action: 0, 1.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Twenty-nine articles satisfied the inclusion criteria for the meta-analysis.

    “In total, 29 articles met inclusion criteria”
    • Also stated in: § Search Results and Data Extraction · plain
      “leaving a total of 29 articles for inclusion in the meta-analysis”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For pain-related anxiety, pain intensity, and pain acceptance, treatment effects ranged from small for follow-up pain intensity, .46 (95% CI .37-.58), to large for post-treatment and follow-up pain acceptance, .93 (95% CI .75-1.12) and 1.02 (95% CI .87-1.17), respectively.

    “Descriptively, treatment effects for these 3 variables ranged from small for follow-up pain intensity, .46 (95% CI: .37–.58), to large for post-treatment and follow-up pain acceptance, .93 (95% CI: .75–1.12), and 1.02 (95% CI: .87–1.17), respectively.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For pre-to-post depression, removing one study from the unidisciplinary ACT calculations reduced heterogeneity to 10.3%, and removing one study from the interdisciplinary ACT calculations reduced heterogeneity to 49.1%.

    “For pre-post treatment effect for depression, the removal of 1 study30 from the unidisciplinary ACT calculations reduced heterogeneity to 10.3% and the removal of 1 study3 from the interdisciplinary ACT calculations reduced heterogeneity to 49.1%.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [30] Luciano, 2014, Effectiveness of group acceptance and commitment therapy for fibromyalgia: A 6-month randomised controlled trial (EFFIGACT study), Pain source
    • cites [3] Baranoff, 2016, Changes in acceptance in a low-Intensity, group-based Acceptance and Commitment Therapy (ACT) chronic pain intervention, Int J Behav Med source

  • May combine two claims.

    Findingown data

    For pain intensity from pretreatment to follow-up, the 95% confidence intervals for unidisciplinary and interdisciplinary ACT overlapped substantially, indicating no difference in treatment effect between the two treatment types.

    “The 95% Cl’s for the overlapped substantially, indicating no differences in treatment effect across the 2 treatment types.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The correlation between treatment duration and effect size was moderate, with an overall mean correlation of .33 (SD .18), indicating that 10.9% of the variance in effect size was accounted for by treatment duration.

    “Finally, the correlation between treatment duration and ES was moderate, with an overall mean correlation of .33 (SD = .18), indicating that 10.9% of the variance (ie, r2) in ES was accounted for by treatment duration.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Treatment duration is a proxy for treatment intensity.

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    For pain intensity from pretreatment to post-treatment, the 95% confidence intervals for unidisciplinary and interdisciplinary ACT overlapped substantially, indicating no difference in treatment effect between the two treatment types.

    “The 95% CI’s for the overlapped substantially, indicating no differences in treatment effect across the 2 treatment types.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    For pretreatment-to-follow-up depression, removing one study from the unidisciplinary ACT calculations reduced heterogeneity to 0%.

    “For the pretreatment to follow-up effect for depression, the removal of 1 study30 from the unidisciplinary ACT calculations reduced heterogeneity to 0%.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Luciano, 2014, Effectiveness of group acceptance and commitment therapy for fibromyalgia: A 6-month randomised controlled trial (EFFIGACT study), Pain source

  • May combine two claims.

    Findingown data

    For pain acceptance from pretreatment to follow-up, the 95% confidence intervals for unidisciplinary and interdisciplinary ACT overlapped substantially, indicating no difference in treatment effect between the two treatment types.

    “The 95% Cl’s for the overlapped substantially, indicating no differences in treatment effect across the 2 treatment types.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Study quality was weakly related to 4 of 12 outcomes (33%) and moderately related to 3 of 12 outcomes (25%), with the remaining correlations below weak (<.10).

    “When overall correlation magnitude was examined using the same gradings as in the treatment duration moderation analyses (ie, r= ≥ .10 weak relation, ≥ .30 moderate relation, ≥ .50 strong relation), study quality was weakly related to 4 of 12 outcomes (33%) and moderately related to 3 of 12 outcomes (25%). The remaining correlations were less than weak (ie, < .10).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    For pre-to-post pain-related anxiety, removing one study from the entire pool reduced heterogeneity to 34.4%.

    “For pre-post treatment effect for pain-related anxiety, the removal of 1 study3 from the entire pool of studies reduced heterogeneity to 34.4%.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Baranoff, 2016, Changes in acceptance in a low-Intensity, group-based Acceptance and Commitment Therapy (ACT) chronic pain intervention, Int J Behav Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    For pretreatment-to-follow-up pain acceptance, removing one study reduced heterogeneity to 0%.

    “For pretreatment to follow-up treatment effect for pain acceptance, the removal of 1 study53 reduced heterogeneity to 0%.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [53] Wetherell, 2011, A randomized, controlled trial of Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy for chronic pain, Pain Int Assoc Study Pain source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    For pretreatment-to-follow-up pain-related anxiety, removing one study reduced heterogeneity to 25.3%.

    “For pretreatment to follow-up effect, the removal of 1 study53 reduced heterogeneity to 25.3%.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [53] Wetherell, 2011, A randomized, controlled trial of Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy for chronic pain, Pain Int Assoc Study Pain source

  • May combine two claims.

    Findingown data

    Across the two treatment intervals, the relation between effect size and treatment duration was weak for 5 of 12 outcomes (42%), moderate for 3 of 12 (25%), and strong for 3 of 12 (25%).

    “Overall, across the 2 treatment intervals, there was a weak relation between ES and treatment duration for 5 of the 12 outcomes (42%), a moderate relation for 3 of 12 outcomes (25%), and a strong relation for 3 of 12 outcomes (25%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    High heterogeneity was present for five of the six outcome measures; only physical disability had all I2 values below 50%.

    “High heterogeneity was indicated for 5 of the 6 outcome measures, with only physical disability having all I2 values under 50%.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For physical disability, psychosocial impact, and depression, the average correlation between effect size and treatment length was r=.40 (SD=.18), which was larger than the r=.26 (SD=.16) for pain intensity, pain-related fear, and acceptance.

    “Specifically, for physical disability, psychosocial impact, and depression, average correlation between ES and treatment length, r = .40 (SD = .18), was larger than for pain intensity, pain-related fear, and acceptance, r = .26 (SD = .16).”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    For pain acceptance from pretreatment to post-treatment, the 95% confidence intervals for unidisciplinary and interdisciplinary ACT overlapped substantially, indicating no difference in treatment effect between the two treatment types.

    “The 95% Cl’s for the overlapped substantially, indicating no differences in treatment effect across the 2 treatment types.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data

    The remaining effect sizes for pain-related anxiety, pain intensity, and pain acceptance were of medium magnitude.

    “The remaining ESs were of a medium magnitude.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Although significant heterogeneity was present across studies, much of it was accounted for by two studies, and the pattern of findings did not change when studies contributing to heterogeneity were removed.

    “Fourth, while there was evidence of significant heterogeneity in findings across studies, much of the heterogeneity was accounted for by 2 studies,3,30 and the pattern of findings was not changed when studies contributing to heterogeneity were removed.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [3] Baranoff, 2016, Changes in acceptance in a low-Intensity, group-based Acceptance and Commitment Therapy (ACT) chronic pain intervention, Int J Behav Med source
    • cites [30] Luciano, 2014, Effectiveness of group acceptance and commitment therapy for fibromyalgia: A 6-month randomised controlled trial (EFFIGACT study), Pain source

  • May combine two claims.

    Premisecitation

    A recent meta-analysis of 11 randomized trials of ACT for chronic pain reported small-to-medium effects on functioning, anxiety, and depression, and medium-to-large effects on process measures like pain acceptance.

    “A recently published meta-analysis of 11 RCTs of ACT for chronic pain indicated small to medium effect sizes (ES) for functioning, anxiety and depression, and medium to large ES for ACT treatment process measures, such as pain acceptance.23”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] Hughes, 2017, Acceptance and Commitment Therapy (ACT) for chronic pain: A systematic review and meta-analysis, Clin J Pain source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Inter-rater reliability for abstract screening was good, with Kappa = .80 and raw agreement = 90.4%.

    “Inter-rater reliability in relation to abstract screening was good, Kappa = .80, with an overall raw inter-rater agreement of 90.4%.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    There is an inconsistency in the literature: some research concludes psychological approaches work reasonably well, while some meta-analytic results suggest limited effectiveness.

    “Thus, there is an inconsistency in the literature, where 1 conclusion from the extant research is that psychological approaches for chronic pain work reasonably well while some meta-analytic results of RCTs suggests that psychological approaches have only limited effectiveness.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    When abstract screeners disagreed, a third reader made a tie-breaking decision.

    “For all articles where there was disagreement amongst raters, a third reader evaluated the abstract as a tie-breaking vote.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Rater disagreements occurred 49 times, a raw discrepancy rate of 1.1%.

    “Disagreements across raters occurred a total of 49 times, yielding a raw discrepancy rate of 1.1%.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Data extraction discrepancies were resolved through discussion among three authors.

    “All discrepancies were resolved via discussion amongst 3 authors (K.E.V., M.P., and K.A.E.).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Every article that passed screening was fully reviewed and coded by two or more raters.

    “All articles that met screening criteria were reviewed in full and coded by a minimum of 2 raters.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Abstracts were screened by two reviewers to assess eligibility for full-text extraction.

    “The abstracts of all studies identified in the literature search were read by a pair of reviewers to assess eligibility for full text data extraction.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Each rater evaluated study quality with the NIH Quality Assessment Checklist for Observational Cohort and Cross-Sectional Studies.

    “Each rater provided an assessment of study quality, using the NIH Quality Assessment Checklist for Observational Cohort and Cross-Sectional Studies.40”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [40] National Heart, Lung and BIood Instsitute: Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Available at: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools. Accessed September 15, 2019.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Interdisciplinary approaches to chronic pain are grounded in psychological and behavioral models.

    “These treatment approaches are grounded in psychological and behavioral models.17”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Gatchel, 2014, Interdisciplinary chronic pain management, Am Psychol source

  • May combine two claims.

    Interpretationreasoning

    Treatment format is a relevant variable when evaluating chronic pain psychological approaches, since both unidisciplinary and interdisciplinary treatments are based on psychological models.

    “One possible consideration pertains to treatment format, as psychological models form the basis for both unidisciplinary psychology and integrated interdisciplinary treatments for chronic pain.”
    • Also stated in: § Abstract · plain
      “One salient consideration pertains to treatment format, specifically treatment provided in a unidisciplinary format by clinical psychology alone in contrast to treatment offered by an interdisciplinary team.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Recent qualitative work by the authors' group indicates that patients themselves see value in integrating physical therapy with psychology.

    “Recent qualitative work by our group indicates that patients themselves also see the value of this integration.44”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [44] Thompson, 2018, A qualitative analysis of patient-identified adaptive behaviour changes following interdisciplinary Acceptance and Commitment Therapy for chronic pain, Eur J Pain source

  • May combine two claims.

    Study design and conductown data

    All effect-size calculations used within-subjects data and therefore do not indicate the efficacy of ACT compared with alternative interventions.

    “Third, all ES calculations were for within subjects data and do not allow an indication of the efficacy of ACT in comparison to alternative interventions.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The difference in variance accounted for suggests that longer treatments were more powerful in changing pain's impact on functioning.

    “While any comparisons of these percentages are descriptive only, and thus largely hypothetical, the difference in variance accounted for suggests that longer treatments were more powerful in changing pain’s impact on functioning.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    The conclusions about unidisciplinary and interdisciplinary ACT may apply only to ACT for chronic pain, rather than to the broader literature on psychological approaches to chronic pain.

    “First, the conclusions drawn here regarding unidisciplinary and interdisciplinary ACT may be applicable to ACT for chronic pain only, rather than the broader literature on psychological approaches to chronic pain.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The outcomes where interdisciplinary ACT had a stronger effect can be grouped as measures of chronic pain's impact on physical and emotional functioning, while the outcomes with no difference can be grouped as facets of the pain experience.

    “The outcomes for which interdisciplinary ACT had a stronger effect can be grouped as measures of chronic pain’s impact on physical and emotional functioning, while the measures for which there was not a difference can be grouped as facets of the pain experience.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The overall answer to whether treatment type influenced outcomes is that it did for some outcomes but not for others.

    “Thus, the overarching answer to our question of whether treatment type influenced treatment outcomes is - for some outcomes, but not for others.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Treatment duration matters, and a larger dose of integrated treatments may contribute to more efficacious and robust outcomes, particularly among patients with complex symptomatology.

    “Third, treatment duration matters. A larger dose of integrated treatments may contribute to more efficacious and robust outcomes, particularly among patients with complex symptomatology.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Treatment duration is a proxy for treatment intensity.

  • May combine two claims.

    Study design and conductown data

    For some follow-up comparisons, including physical disability, psychosocial impact, pain-related anxiety, and pain acceptance, only a few unidisciplinary ACT studies were available, which places potential limits on the reliability of those effect-size calculations.

    “Further, for some follow-up comparisons, including physical disability, psychosocial impact, pain-related anxiety, and pain acceptance, only a few studies were available for unidisciplinary ACT and this places potential limits on the reliability of these ES calculations.”
    Quote in the paperNot a substantial claim
53 of 53

  • The paper relies on this without support.

    The ACT literature is extensive enough to support the planned comparative meta-analysis while being limited enough to be feasible.

    “It was felt that the ACT treatment literature was developed enough to provide insight into whether type of treatment was a useful variable to consider when examining the effectiveness of psychological approaches for chronic pain, while also being circumscribed enough in size to make such an analysis feasible.”

  • The paper relies on this without support.

    There is a discrepancy in the literature on psychological approaches for chronic pain, with some data indicating reasonable effectiveness and other data indicating weak effects.

    “The impetus for this meta-analysis came from the observed discrepancy regarding the effectiveness of psychological approaches for chronic pain, where 1 set of data indicate these approaches work reasonably well and another indicate they have weak effects only.”

  • The authors state this as an assumption.

    Treatment duration is a proxy for treatment intensity.

    “Further, while we used treatment duration as a proxy for treatment intensity, it may be that there are other markers of intensity that were not reported”

  • The paper relies on this without support.

    The subset of the ACT literature was large enough for a meaningful analysis and circumscribed enough to be feasible.

    “It was felt that this subset of the broader literature was large enough to allow for a meaningful analysis, while also being circumscribed enough to be feasible.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • This training, combined with behavioral therapies, has shown promising results in the treatment of depression in patients with chronic pain.

    “This training, combined with behavioral therapies, has shown promising results in the treatment of depression in patients with chronic pain (De Jong et al., 2018;Vowles et al., 2020).”

    From Acceptance and commitment therapy for chronic pain: a quasiexperimental study (2023) · cites this paper as Vowles et al., 2020

    The Results (Comparison of Treatment Effects: Depression) report improved depression outcomes in adults with chronic pain receiving interdisciplinary Acceptance and Commitment Therapy, supporting the claim of promising results. The paper does not identify the unspecified “training” or test its combination with behavioral therapies as described in the citing sentence. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • The effectiveness of online interventions appears to increase with a minimum of sessions and in a guided format.

    “their effectiveness appears to increase with a minimum of sessions and in a guided format (Lin et al., 2015; Vowles et al., 2020).”

    From Online ACT intervention for fibromyalgia: An exploratory study of feasibility and preliminary effectiveness with smartphone-delivered experiential sampling assessment (2022) · cites this paper as Vowles et al., 2020

    The Results (Moderation Analyses for Treatment Duration; page unavailable) associate longer ACT treatment with larger effect sizes. But the paper measures treatment duration in hours, not a minimum number of sessions, and does not establish that guided online interventions are more effective. Its Methods (Abstract Screening; page unavailable) required included treatments to be primarily face-to-face. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • The number of clinical trials assessing possible benefits of ACT for chronic pain has increased in the last decade, producing a plethora of systematic reviews on this topic during the last 5 years.

    “The number of clinical trials assessing the possible benefits of ACT for chronic pain has in­ creased in the last decade, producing, in turn, a ple­ thora of systematic reviews on this topic during the last 5 years.”

    From Acceptance and Commitment Therapy for Chronic Pain: An Overview of Systematic Reviews with Meta-Analysis of Randomized Clinical Trials (2024) · cites this paper as [56]

    The introduction describes a recently published meta-analysis of 11 ACT trials for chronic pain, and the Methods and Results report 29 articles included in this meta-analysis. These passages establish a body of trials and reviews, but do not establish that trial numbers increased over the last decade or that this growth produced a plethora of systematic reviews in the last five years. Page numbers are unavailable in our copy. (LLM, conf=0.81)

    Experimental — accuracy not yet measured

  • The effectiveness of acceptance and commitment therapy for chronic pain conditions is well established.

    “The effectiveness of ACT for chronic pain conditions is well established (Galvez-Sánchez et al., 2021; Vowles et al., 2020).”

    From Online ACT intervention for fibromyalgia: An exploratory study of feasibility and preliminary effectiveness with smartphone-delivered experiential sampling assessment (2022) · cites this paper as Vowles et al., 2020

  • Online interventions are effective even in one-session and self-help format.

    “Although online interventions have demonstrated to be effective even in one-session and in a self-help format”

    From Online ACT intervention for fibromyalgia: An exploratory study of feasibility and preliminary effectiveness with smartphone-delivered experiential sampling assessment (2022) · cites this paper as Vowles et al., 2020

    The Methods (Abstract Screening; page unavailable) require included treatments to be primarily face-to-face. The Results discuss treatment duration and outcomes for unidisciplinary and interdisciplinary ACT, but do not assess whether online, one-session, or self-help interventions are effective. Searches for those formats found no supporting passage in our copy. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • ConsistentF(1, 16) = 3.1reported p = .1 · recomputed p = .097

    “F (1, 16) = 3.1, p = .10”

  • ConsistentF(1, 27) = 19.9reported p < .001 · recomputed p < .001

    “F (1, 27) = 19.9, p < .001”

2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Discussion changes the post-treatment psychosocial effect

    Major

    The results report an interdisciplinary psychosocial-impact effect of .68, whereas the discussion gives .72 for the same outcome and assessment point. The associated confidence intervals also differ.

  • Abstract-screening totals do not reconcile

    Major

    The search yielded 1,135 records for screening. Excluding 63 would leave 1,072, not the reported 50 articles for full-text review.

    Reported 50 · recomputed 1072

  • Seven domains are claimed, but six are listed

    Minor

    The sentence names six qualifying outcome domains, consistent with the later reference to six outcome measures, rather than the stated seven.

  • Overall follow-up pain-intensity interval has two lower bounds

    Minor

    For the same overall effect of .46, the results give a confidence-interval lower bound of .34, while the discussion gives .37.

  • The number of included studies changes

    Minor

    The treatment-format counts total 28 studies, but the outcome-domain section says 25 studies were included in the meta-analysis.

  • Follow-up pain-intensity estimate is not centered in its interval

    Minor

    The reported unidisciplinary effect is .37, but the midpoint of its stated .34-.58 confidence interval is .46. The asymmetry is much larger than rounding to two decimal places could explain.

    Reported 0.37 · recomputed 0.46

6 of 6

Cites

Flagged first, then by citations

8 of the 69 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Alonso, 2013, Acceptance and commitment therapy and selective optimization with compensation for older people with chronic pain: A pilot study, Behav Psychol, 21, 59
  2. British Pain Society: Guidelines for Pain Management Programmes for adults: An evidence-based review prepared on behalf of the British Pain Society. London; 2013. Available at : britishpainsociety.org/static/uploads/resources/files/pmp2013_main_FINAL_v6.pdf. Accessed September 15, 2019.
  3. Williams, 2012, Psychological therapy for adults with longstanding distressing pain and disability, Cochrane Database Syst Rev, 2, 1

Cited by

Sorted by citations

Related

Authors
Vowles, K. E., Pielech, M., Edwards, K. A., McEntee, M. L., & Bailey, R. W.
Affiliations
  • Queen's University Belfast (GB)
  • Brown University (US)
  • University of New Mexico (US)
  • Arizona State University (US)
Corresponding author
Vowles, Kevin E.
ORCID
Venue
The Journal of Pain
Publisher
Elsevier BV
Published
2020-05
Volume
21
Issue
5-6
Pages
529-545
ISSN
1526-5900 (ISSN-L)
DOI
10.1016/j.jpain.2019.10.004
PMC
PMC7477894
OpenAlex
W2985953827
Cited by
43
References
69
Citations by year
2026: 3 · 2025: 3 · 2024: 7 · 2023: 8 · 2022: 11 · 2021: 5 · 2020: 3
FWCI
1.00
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Pain (publishedVersion)
  • PubMed (publishedVersion)
  • Research Portal (Queen's University Belfast) (publishedVersion, cc-by-nc-nd)
  • PubMed Central (submittedVersion)
Topics
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Pain Management and Placebo Effect
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
Keywords
acceptance and commitment therapy, chronic pain, interdisciplinary treatment, treatment format, treatment duration, physical disability, psychosocial impact, depression
MeSH terms
Humans, Outcome Assessment, Health Care, Chronic Pain, Acceptance and Commitment Therapy

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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