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Neural Mechanisms of Acceptance and Commitment Therapy for Chronic Pain: A Network-Based fMRI Approach
Open accessAbstract
Over 100 million Americans suffer from chronic pain (CP), which causes more disability than any other medical condition in the U.S. at a cost of $560-$635 billion per year (IOM, 2011). Opioid analgesics are frequently used to treat CP. However, long term use of opioids can cause brain changes such as opioid-induced hyperalgesia that, over time, increase pain sensation. Also, opioids fail to treat complex psychological factors that worsen pain-related disability, including beliefs about and emotional responses to pain. Cognitive behavioral therapy (CBT) can be efficacious for CP. However, CBT generally does not focus on important factors needed for long-term functional improvement, including attainment of personal goals and the psychological flexibility to choose responses to pain. Acceptance and Commitment Therapy (ACT) has been recognized as an effective, non-pharmacologic treatment for a variety of CP conditions. However, little is known about the neurologic mechanisms underlying ACT. We conducted an ACT intervention in women (n=9) with chronic musculoskeletal pain. Functional magnetic resonance imaging (fMRI) data were collected pre- and post-ACT, and changes in functional connectivity (FC) were measured using Network-Based Statistics (NBS). Behavioral outcomes were measured using validated assessments such as the Acceptance & Action Questionnaire (AAQ-II), the Chronic Pain Acceptance Questionnaire (CPAQ), the Center for Epidemiologic Studies Depression Scale (CES-D), and the NIH Toolbox Neuro-QoL™ (Quality of Life in Neurological Disorders) scales. Results suggest that, following the four-week ACT intervention, participants exhibited reductions in brain activation within and between key networks including self-reflection (default mode, DMN), emotion (salience, SN), and cognitive control (frontal parietal, FPN). These changes in connectivity strength were correlated with changes in behavioral outcomes including decreased depression and pain interference, and increased participation in social roles. This study is one of the first to demonstrate that improved function across the DMN, SN, and FPN may drive the positive outcomes associated with ACT. This study contributes to the emerging evidence supporting the use of neurophysiological indices to characterize treatment effects of alternative and complementary mind-body therapies. Perspective: This article identifies neural mechanisms that may mediate behavioral changes associated with Acceptance and Commitment Therapy (ACT) in persons with chronic musculoskeletal pain. This information could potentially help clinicians to determine which mind-body therapies may benefit specific patients as part of an integrative pain management approach.
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“In our initial report [21] we tested for changes in brain networks underlying ACT-related outcomes in those with CMP using only triple network nodes without the inclusion of pain nodes (t > 2.1 for the 101 nodes of the DMN, FPN, and SN). We observed effects in 10 nodes out of 101 triple network nodes and used those same 10 for the following analysis in conjunction with Waller and colleagues’ [35]”
From Graph theory analysis of induced neural plasticity post-Acceptance and Commitment Therapy for chronic pain (2020) · cites this paper as [21]
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“These functional connectivity changes involving regions of the DMN, FPN, SN, and pain network (alongside previously reported positive behavioral outcomes, [21]) are convincing underlying reasons for the way ACT effectively alleviates chronic pain symptomology.”
From Graph theory analysis of induced neural plasticity post-Acceptance and Commitment Therapy for chronic pain (2020) · cites this paper as [21]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“So, decreased functional connectivity in these regions may contribute to enhanced quality of life that is reported post-ACT [21,40].”
From Graph theory analysis of induced neural plasticity post-Acceptance and Commitment Therapy for chronic pain (2020) · cites this paper as [21]
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“Those results suggest that levels of heightened connectivity between the triple network returned to a lower, healthier level of connectivity post-ACT.”
From Graph theory analysis of induced neural plasticity post-Acceptance and Commitment Therapy for chronic pain (2020) · cites this paper as [21]
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“Additionally, available evidence points to the neurophysiological brain correlates of clinical improvement after ACT in chronic pain [88,89], supporting the usefulness of ACT in chronic pain populations such as CPSS.”
From Effectiveness of acceptance and commitment therapy in central pain sensitization syndromes: A systematic review (2021) · cites this paper as [88]
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“A study exploring the mechanisms of ACT for persistent pain revealed statistically significant improvements in depression, satisfaction with social role and pain acceptance pre-to-post ACT [22].”
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“Individual sensitivity to sound varies considerably: while some individuals are highly sensitive to even minor sounds, others benefit from gentle background noise that masks disturbances [54,55].”
From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [55]
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New generation psychological treatments in chronic pain
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“Additionally, available evidence points to the neurophysiological brain correlates of clinical improvement after ACT in chronic pain [88,89], supporting the usefulness of ACT in chronic pain populations such as CPSS.”
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Metadata
- Authors
- Aytur, S. A., Ray, K. L., Meier, S. K., Campbell, J., Gendron, B., Waller, N., & Robin, D. A.
- Affiliations
- University of New Hampshire (US)
- The University of Texas at Austin (US)
- Wentworth Douglass Hospital (US)
- Corresponding author
- Aytur, Semra A.
- Venue
- Frontiers in Human Neuroscience
- Publisher
- openRxiv
- Published
- 2020-08-13
- Volume
- 15
- Pages
- 587018-587018
- ISSN
- 1662-5161 (ISSN-L)
- PMC
- PMC7892587
- OpenAlex
- W3129133049
- Cited by
- 49
- References
- 117
- Citations by year
- 2026: 4 · 2025: 10 · 2024: 7 · 2023: 12 · 2022: 10 · 2021: 5 · 2020: 1
- FWCI
- 5.80
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Frontiers in Human Neuroscience (publishedVersion, cc-by)
- medRxiv (acceptedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Life Sciences › Neuroscience › Cognitive Neuroscience › Pain Management and Placebo Effect
- Health Sciences › Medicine › Physiology (medical) › Pain Mechanisms and Treatments
- Keywords
- acceptance and commitment therapy, chronic pain, chronic musculoskeletal pain, functional connectivity, default mode network, salience network, frontoparietal network, psychological flexibility, pain interference, depression, quality of life, mind-body interventions, network-based statistics
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