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Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain.
This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries.
Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups.
A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone–based ACT intervention (
In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference.
ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546
Public health concerns regarding opioid medications persist, and health care systems are currently seeking solutions to the ongoing epidemic [
Patient-reported outcomes (PROs) allow patients to quantify aspects of their orthopedic condition in a standardized fashion [
Acceptance and commitment therapy (ACT) is a cognitive contextual behavioral therapy that employs a pragmatic approach to help individuals decrease pain and live according to self-identified personal values [
Acceptance and commitment therapy core principles with associated messages.
Core principle | Example mobile phone message |
Values: know what matters most | Stop for a moment and remember the 3 values you identified earlier today. Remind yourself how important these values are in your life. As your day comes to an end, remember that YOU are in control of the thoughts that exist in your mind. We encourage you to spend time thinking about your 3 core values identified earlier today. |
Acceptance: setting expectation that pain is a part of surgery | Feelings of pain and feelings about your experience of pain are normal after surgery. Acknowledge and accept these feelings as part of the recovery process. Remember how you feel now is temporary and your healing process will continue. Call to mind pleasant feelings or thoughts that you experienced today. |
Present moment awareness: mindfulness and awareness for our thoughts in the present moment | Awareness of the present moment and your breathing may change with pain-related emotions or thoughts. Remember you can always count on your breathing to bring you back to the present moment and help you move through your current experience of pain. |
Self-as-context: awareness of what is being observed and noticed by ourselves | We cannot change that a feeling or thought may arise, but we can choose how we respond to our feelings and thoughts. Remember that dwelling on pain, discouraging feelings, and thoughts after surgery are NOT consistent with your life goals and values. Observe things that try to move you away from your values and only act on things that are compatible with who you want to be and what matters to you. |
Committed action: doing what it takes to live according to our values | Healing after surgery requires you to act. We previously discussed your life goals, meaning, and purpose. Take action today and move closer toward what you want in life. Recognize that pain may be present but make the choice that it will not impede your progress toward what you really want in life. Be present in the moment and ensure your actions remain true to what you want most. All actions you make no matter how small, are an important steppingstone on your road to recovery. |
Defusion: watch your thinking and interact with thoughts in a way consistent with your values | If you ever feel pain after surgery know that the feeling is real but what it actually represents is not what you might think. Our mind is capable of making us feel pain, even though there is no damage going on in our body. Pause, become more aware in the moment and chose a skillful response that will help you move toward your overall goals and values. |
Evolving communication methods, such as automated mobile phone messaging [
Health care teams caring for patients with traumatic orthopedic injuries have traditionally used opioid medication in the postoperative setting, and these patients are at risk for prolonged opioid utilization in the postoperative period. We theorized that the combination of ACT delivered via automated mobile phone messaging may help to decrease pain and opioid utilization in the acute postoperative setting. The aim of this prospective randomized controlled trial was to evaluate the effectiveness of ACT delivered via an automated mobile messaging robot on (1) decreasing early postoperative opioid utilization and (2) pain-related PROs in the first 2 weeks following surgery for acute traumatic orthopedic injuries.
This randomized controlled trial was registered with ClinicalTrials.gov (NCT03991546) and reporting is consistent with the Consolidated Standards of Reporting Trials guidelines (
Adults presenting to a university hospital level 1 trauma center indicated for operative fixation of a traumatic upper or lower fracture were considered for the study (
Participants were randomized to either the control or intervention group using a standard web-based random number generator with a range set from 1 to 10 and a 1:1 ratio by a research assistant. Owing to the nature of this study, subjects and the enrolling research assistant were not blinded to the participant’s study group following randomization.
At the time of consent, subjects were required to complete paper forms comprising a basic demographics questionnaire and baseline PROs consisting of the PROMIS Pain Intensity 1A Short form, PROMIS Pain Intensity 3A Short form, PROMIS Pain Interference 8A Short form, and PROMIS Emotional Distress-Anxiety 8A Short form (
Injury by final study group (N=76).
Injury | Acceptance and commitment therapy group participants, n | Control group participants, n |
Acetabular fracture | 1 | 1 |
Ankle fracture | 15 | 14 |
Calcaneus fracture | 0 | 1 |
Clavicle fracture | 0 | 1 |
Distal femur fracture | 0 | 2 |
Distal humerus fracture | 1 | 0 |
Elbow fracture | 2 | 5 |
Femoral neck fracture | 2 | 2 |
Femoral shaft stress fracture | 0 | 1 |
Intertrochanteric hip fracture | 1 | 0 |
Navicular fracture | 1 | 0 |
Patella fracture | 1 | 0 |
Polytraumaa | 2 | 1 |
Proximal humerus fracture | 2 | 1 |
Subtrochanteric femur fracture | 0 | 2 |
Tibial plateau fracture | 4 | 3 |
Tibial plafond fracture | 6 | 4 |
aPolytrauma was defined as a patient with a fracture to more than one upper or lower extremity.
Screening questions
No personal mobile phone with text messaging capabilities
Poor familiarity reading or sending mobile messages
Patient factors
Open fracture
Infection at the fracture site
Prior fracture temporization with an external fixator
Revision surgery for nonunion or hardware failure
Bilateral upper extremity injuries impeding their ability to use a mobile phone
Fractures of the distal hand or distal foot only
Admission to an intensive care unit
Current cancer diagnosis or dementia
Inpatient for more than 7 days of the 2-week study period
Discharged without an opioid pain medication prescription
Initial plan for operative fixation changed to treatment with joint arthroplasty
The intervention group received twice-daily, text-based mobile messages communicating an ACT-based intervention for the first 2 weeks following surgery (
Maintaining focus on what you value most in life is sometimes difficult after surgery. Do not let the momentary discomforts due to surgery take away from what you want most in life. Pick 3 things that matter most to you in life. Remind yourself of these 3 things you value most during your recovery process.
Outside of the mobile messaging intervention, both groups received the same standard postoperative care, health care team communications, and instructions for completing the study follow-up.
A chart review was performed to collect demographic information such as subject age, comorbid conditions, and preoperative outpatient opioid medication prescriptions for treatment of their current traumatic orthopedic injury. All subjects, regardless of group, were seen by a research team member after surgery to review which of their discharge medications was the medication of interest for the study and to confirm that the intervention group subjects received their first mobile phone ACT message. Participants in both groups were instructed to have their opioid medication bottle available at follow-up to confirm their opioid tablet consumption. Owing to the changes in health care teams, staff preferences, and allergies, the opioid pain medications administered at discharge were not standardized between study groups. Following discharge on POD 14, subjects were contacted by phone or seen in the clinic by the research team for follow-up. At this time, the subjects’ opioid pain medication consumption was assessed, and they completed a second set of PROs.
The primary outcome of this study was the amount of opioid pain medication consumed by subjects, and the secondary outcomes analyzed were net changes from baseline PRO scores at the 2-week follow-up.
The method that participants employed to report their opioid medication consumption and how PROs were captured during follow-up were recorded (
Comparison of subject demographics by enrolled study group.
Subject characteristic | Acceptance and commitment therapy group (n=42) | Control group (n=40) | |||||
Age (years), mean (SD) | 45.5 (15.9) | 48.7 (14.6) | .41 | ||||
BMI (kg/m2), mean (SD) | 30.5 (7.3) | 31.1 (8.3) | .94 | ||||
|
.65 | ||||||
|
Female | 22 (52) | 19 (48) |
|
|||
|
Male | 20 (48) | 21 (52) |
|
|||
Subjects removed or lost to follow-up, n (%) | 4 (10) | 2 (5) | N/Aa | ||||
Preoperative PROMISb Pain Intensity 1A Score, mean (SD) | 5.4 (2.9) | 6.2 (2.6) | .20 | ||||
Preoperative PROMIS Pain Intensity 3A Score, mean (SD) | 54.9 (7.3) | 57.1 (8.2) | .23 | ||||
Mean Preoperative PROMIS Pain Interference 8A Score, mean (SD) | 63.6 (11.4) | 66.1 (8.4) | .30 | ||||
Mean Preoperative PROMIS Emotional Distress-Anxiety 8A Score, mean (SD) | 56.5 (11.4) | 56.5 (9.2) | .99 | ||||
Days between injury and surgery, mean (range) | 4 (1-33) | 3 (1-50) | .26 | ||||
|
.68 | ||||||
|
Home | 36 (95) | 34 (90) |
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|||
|
Skilled nursing facility or acute rehabilitation | 2 (5) | 4 (10) |
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|||
|
.86 | ||||||
|
White | 37 (88) | 35 (88) |
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|||
|
African American | 4 (10) | 4 (10) |
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|||
|
Asian | 1 (2) | 0 (0) |
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|||
|
Hispanic | 0 (0) | 1 (2) |
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|||
Preoperative outpatient opioid prescription, n (%) | 23 (55) | 17 (43) | .17 | ||||
Current psychiatric diagnosis, n (%) | 15 (36) | 9 (23) | .14 | ||||
History/current substance abuse diagnosis, n (%) | 8 (19) | 3 (8) | .10 | ||||
Diabetes diagnosis, n (%) | 2 (5) | 7 (18) | .15 | ||||
Current smoker, n (%) | 7 (17) | 9 (23) | .57 | ||||
Current lumbago diagnosis, n (%) | 1 (2) | 2 (5) | >.99 | ||||
History of/current chronic pain diagnosis, n (%) | 10 (24) | 8 (20) | .59 | ||||
Number of opioid tablets prescribedc, mean (SD) | 58.8 (27.3) | 61.6 (22.0) | .62 | ||||
|
.47 | ||||||
|
Pill count | 34 (90) | 30 (79) |
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|
Daily log | 3 (8) | 6 (16) |
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|
Estimate | 1 (2) | 2 (5) |
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Patients filling only one postoperative opioid prescriptionc, n (%) | 34 (90) | 34 (90) | >.99 |
aN/A: not applicable.
bPROMIS: Patient-Reported Outcome Measures Information System.
cData calculated using final study population only (n=38).
Participant characteristics were described using mean (SD) or median (minimum to maximum) for continuous variables and frequencies (percentages) for categorical variables. Visual review of histograms and the results of the Shapiro-Wilk test of continuous variables revealed that only age and BMI were not normally distributed. Between-group differences were evaluated using
To evaluate whether the intervention versus control group had a lower opioid use on average, we determined the number of tablets and MME taken in each group and compared means using
A total of 125 individuals were approached regarding the study over the 5-month enrollment period between February 2019 and June 2019. Of the 125 individuals, 2 patients were excluded at this time, as they were non–English-speaking, and an additional 24 patients were excluded because they did not use mobile phone messaging or did not have a personal mobile phone. This resulted in a total of 99 eligible people who were presented the study, 17 of whom declined participation (
Consolidated Standards of Reporting Trials flowchart detailing the selection of eligible patients for study enrollment and their status through study completion. ACT: acceptance and commitment therapy.
No differences between groups were observed in the amount of opioid medication tablets or MME prescribed at discharge (tablets for the ACT group: mean 58.8, SD 27.3 vs tablets for the control group: mean 61.6, SD 22.0). A further breakdown of the medications prescribed to subjects within the study period is presented in
Frequency of outpatient opioid pain medications prescribed by enrolled study group (N=82).
Medication | Morphine milliequivalents per tablet | Frequency | |
|
|
Acceptance and commitment therapy | Control |
Hydrocodone-acetaminophen 5-325 mg | 5 | 1 | 2 |
Hydrocodone-acetaminophen 10-325 mg | 10 | 2 | 0 |
Hydromorphone 2 mg | 8 | 6 | 6 |
Oxycodone 5 mg | 7.5 | 27 | 27 |
Oxycodone-acetaminophen 5-325 mg | 7.5 | 10 | 8 |
Total opioid prescriptions provided | N/Aa | 46 | 43 |
aN/A: not applicable.
Opioid pain medication utilization by group during the 2-week study period.
Attribute | Opioid tablets dispensed | Opioid tablets consumed | Morphine milliequivalents consumed | ||||||||
|
ACTa (n=38) | Control (n=38) | ACT (n=38) | Control (n=38) | Decreaseb (%) | ACT (n=38) | Control (n=38) | Decrease (%) | |||
Mean (SD) | 58.8 (27.3) | 61.6 (22.0) | .62 | 26.2 (21.4) | 41.1 (22.0) | 37 | .004 | 199.9 (163.2) | 307.0 (166.0) | 35 | .006 |
Median (minimum-maximum) | 60.0 (10-146) | 60.0 (15-120) | .62 | 21.0 (0-80) | 43.5 (0-80) | 37 | .004 | 157.5 (0-600) | 307.5 (0-600) | 35 | .006 |
aACT: acceptance and commitment therapy.
bCalculated by the formula
PROMIS instrument
Mean Patient-Reported Outcome Measures Information System score and change within the 2-week study period by study group.
PROMISa instrument | Preoperative score | Postoperative score | Net score change | ||||||||||||||||||||||
|
ACTb | Control | ACT | Control | ACT | Control | |||||||||||||||||||
|
Mean (SD) | Range | Mean (SD) | Range | Mean (SD) | Range | Mean (SD) | Range |
|
Mean (SD) | Range | Mean (SD) | Range |
|
|||||||||||
Pain Intensity 1Ac | 5.4 (2.9) | 0 to 10 | 6.2 (2.6) | 1 to 10 | 3.4 (2.2) | 0 to 9 | 4.1 (2.4) | 1 to 9 | .22 | −2.0 (2.9) | −10 to 7 | −2.1 (2.3) | −9 to 2 | .79 | |||||||||||
Pain Intensity 3A | 54.9 (7.3) | 36.3 to 71.8 | 57.1 (8.2) | 40.2 to 71.8 | 45.9 (7.2) | 30.7 to 64.1 | 49.7 (8.8) | 30.7 to 67.4 | .04 | −9.0 (8.5) | −25.5 to 10 | −7.4 (7.7) | −23.9 to 6.1 | .38 | |||||||||||
Pain Interference 8A | 63.6 (11.4) | 40.7 to 77 | 66.1 (8.4) | 40.7 to 77.0 | 56.6 (9.4) | 40.7 to 72.0 | 60.6 (8.2) | 40.7 to 77.0 | .048 | −7.1 (13.7) | −36.3 to 24.8 | −5.4 (10.4) | −26.2 to 19.5 | .55 | |||||||||||
Emotional Distress-Anxiety 8A | 56.5 (11.4) | 37.1 to 80 | 56.5 (9.2) | 37.1 to 76.7 | 51.5 (10.4) | 37.1 to 75.4 | 52.3 (10.6) | 37.1 to 76.7 | .76 | −4.9 (10.1) | −33.7 to 12.3 | −4.2 (9.4) | −20.3 to 16.5 | .74 |
aPROMIS: Patient-Reported Outcome Measures Information System.
bACT: acceptance and commitment therapy.
cScores presented are raw numerical scores, as no
This randomized trial delivered an ACT-based intervention via an automated mobile messaging robot to postoperative orthopedic patients. The subjects who received the ACT-based mobile phone intervention used a lower number of opioid tablets and consumed less MME in the first 2 weeks after their injury. We also found that the intervention group reported less pain intensity and pain interference at the 2-week follow-up. These data demonstrate that ACT-based automated mobile messaging protocols may be effective in reducing the amount of opioid medication used and may positively affect postoperative PROs in patients undergoing operative fixation of their acute fractures.
Improved mood symptoms, less pain interference, and faster cessation of opioid pain medication are some of the recognized benefits of using ACT in clinic-based, interdisciplinary approaches to pain management after surgery [
PROs, such as PROMIS, allow patients to quantify aspects of their orthopedic condition in a standardized fashion [
Several limitations were present in this study. First, we were limited to a single level 1 trauma center, which may affect the reproducibility of our results across other health care settings. Next, the exclusion criteria for this study were extensive, and thus, the results may not be generalizable to the entire scope of orthopedic trauma patients. We attempted to include a diverse set of injuries and yet excluded patients with a high likelihood of confounding problems from open fractures or prolonged initial hospitalization. Future studies assessing the effects of ACT-based interventions similar to ours should aim for less restrictive exclusion criteria to apply this intervention to a larger, more diverse population. The research assistants were not blinded to the patients’ study group. In addition, patients understood the outcomes of interest in this study, which could be susceptible to reporting bias. In addition, participants were not blinded to their treatment group. The lack of blinding could potentially introduce response or reporting bias, making this a potential area of improvement for studies seeking to follow the present methodology. This could be accomplished through the implementation of a control messaging protocol. Moreover, a retrospective chart review was used to obtain several patient factors, including comorbid conditions and dispensing of preoperative outpatient opioid medication prescriptions. The collection of information in this manner relies on accurate charting and transfer of documents from outside institutions, which may have been incomplete.
In this study, delivering an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid utilization in orthopedic trauma patients in the first 2 weeks after their injury. Subjects in the ACT-based intervention group also reported lower pain intensity and pain interference after 2 weeks, although this likely did not represent a clinically important difference. Future studies may apply this intervention in other patient populations to assess its efficacy on a larger scale and may include assessment of pain and opioid use in a longer time frame after injury.
CONSORT-EHEALTH checklist (V 1.6.1).
Patient-Reported Outcome Measure Information System tools completed by the study subjects.
Acceptance and commitment therapy–based automated mobile phone messaging protocol.
acceptance and commitment therapy
morphine milliequivalents
postoperative day
patient-reported outcome
Patient-Reported Outcome Measure Information System
This study was possible thanks to a generous grant from the Orthopaedic Trauma Association.
CA reports personal fees from McKinsey & Company, outside the submitted work. MW reports nonfinancial support from Zimmer Biomet, outside the submitted work. MK reports stock or stock options from Iowa Simulation Solutions LLC and stock or stock options from Mortise Medical LLC, outside the submitted work. JM reports stock or stock options from Zimmer Biomet, stock or stock options from FxRedux, nonfinancial support and stock or stock options from Oxford Press, and stock or stock options from Tornier, outside the submitted work.