| 1. |
- DeLuca, Thomas H, et al.
(author)
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Ecosystem controls on nitrogen fixation in boreal feather moss communities.
- 2007
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In: Oecologia. - : Springer Science and Business Media LLC. - 0029-8549 .- 1432-1939. ; 152:1, s. 121-30
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Journal article (peer-reviewed)abstract
- N fixation in feather moss carpets is maximized in late secondary successional boreal forests; however, there is limited understanding of the ecosystem factors that drive cyanobacterial N fixation in feather mosses with successional stage. We conducted a reciprocal transplant experiment to assess factors in both early and late succession that control N fixation in feather moss carpets dominated by Pleurozium schreberi. In 2003, intact microplots of moss carpets (30 cm × 30 cm × 10–20 cm deep) were excavated from three early secondary successional (41–101 years since last fire) forest sites and either replanted within the same stand or transplanted into one of three late successional (241–356 years since last fire) forest sites and the transverse was done for late successional layers of moss. Moss plots were monitored for changes in N-fixation rates by acetylene reduction (June 2003–September 2005) and changes in the presence of cyanobacteria on moss shoots by microscopy (2004). Forest nutrient status was measured using ionic resin capsules buried in the humus layer. Late successional forests exhibit high rates of N fixation and consistently high numbers of cyanobacteria on moss shoots, but low levels of available N. Conversely, early successional forests have higher N availability and have low rates of N fixation and limited presence of cyanobacteria on moss shoots. Transplantation of moss carpets resulted in a significant shift in presence and activity of cyanobacteria 1 year after initiation of the experiment responding to N fertility differences in early versus late successional forests.
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| 2. |
- Gentili, Charlotte, et al.
(author)
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ACTsmart : Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain — A Pilot Trial
- 2021
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In: Pain medicine. - : Oxford University Press (OUP). - 1526-2375 .- 1526-4637. ; 22:2, s. 315-328
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Journal article (peer-reviewed)abstract
- BackgroundAcceptance and commitment therapy (ACT) is a behavioral health intervention with strong empirical support for chronic pain but, to date, widespread dissemination is limited. Digital solutions improve access to care and can be integrated into patients’ everyday lives.ObjectiveACTsmart, a guided smartphone-delivered ACT intervention, was developed to improve the accessibility of an evidence-based behavioral treatment for chronic pain. In the present study, we evaluated the preliminary efficacy of ACTsmart in adults with chronic pain.MethodsThe study was an open-label pilot trial. The treatment lasted for 8 weeks, and participants completed all outcome measures at pretreatment and posttreatment and at 3-, 6-, and 12-month follow-ups, with weekly assessments of selected measures during treatment. The primary outcome was pain interference. The secondary outcomes were psychological flexibility, values, insomnia, anxiety, depressive symptoms, health-related quality of life, and pain intensity. All outcomes were analyzed using linear mixed-effects models.ResultsThe sample consisted of 34 adults (88% women) with long-standing chronic pain (M=20.4 years, SD=11.7). Compliance to treatment was high, and at the end of treatment, we observed a significant improvement in the primary outcome of pain interference (d = –1.01). All secondary outcomes significantly improved from pretreatment to posttreatment with small to large effect sizes. Improvements were maintained throughout 12 months of follow-up.ConclusionThe results of this pilot study provide preliminary support for ACTsmart as an accessible and effective behavioral health treatment for adults with chronic pain and warrant a randomized controlled trial to further evaluate the efficacy of the intervention.
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| 3. |
- Gentili, Charlotte, et al.
(author)
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ACTsmart - development and feasibility of digital Acceptance and Commitment Therapy for adults with chronic pain
- 2020
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In: npj Digital Medicine. - : NATURE PUBLISHING GROUP. - 2398-6352. ; 3
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Journal article (peer-reviewed)abstract
- Accessibility of evidence-based behavioral health interventions is one of the main challenges in health care and effective treatment approaches are not always available for patients that would benefit from them. Digitization has dramatically changed the health care landscape. Although mHealth has shown promise in addressing issues of accessibility and reach, there is vast room for improvements. The integration of technical innovations and theory driven development is a key concern. Digital solutions developed by industry alone often lack a clear theoretical framework and the solutions are not properly evaluated to meet the standards of scientifically proven efficacy. On the other hand, mHealth interventions developed in academia may be theory driven but lack user friendliness and are commonly technically outdated by the time they are implemented in regular care, if they ever are. In an ongoing project aimed at scientific innovation, the mHealth Agile Development and Evaluation Lifecycle was used to combine strengths from both industry and academia in the development of ACTsmart - a smartphone-based Acceptance and Commitment Therapy treatment for adult chronic pain patients. The present study describes the early development of ACTsmart, in the process of moving the product from alpha testing to a clinical trial ready solution.
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| 4. |
- Gentili, Charlotte
(author)
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Digital acceptance and commitment therapy for adults with chronic pain
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Background: Chronic pain is common and usually associated with co-morbid difficulties, which further reduces function and quality of life in those afflicted. Chronic pain also creates a great economic burden on both health-care and society at large. Pharmacological treatment is often not sufficient to solve the chronic pain problem and a combination of pharmacological and behavioral treatment are often needed. Although both CBT and ACT have been found promising to increase function and quality of life in the chronic pain population there is still room for improvement and access to treatment is low. The need for an increased access to treatment could be met by the development of new delivery formats, such as internet- and smartphone delivered treatment. Aims: The overall objective of the present doctoral thesis was to increase access and reach of evidence-based behavioral treatment for chronic pain by transforming a well proven face-to-face ACT treatment into viable digital formats. Another aim was to gain more knowledge of what predicts treatment results. A successful translation of the treatment would result in accessible, feasible and effective digital treatment that contributes to increased function and quality of life. The primary outcome of the intervention was reduced pain interference but the intervention was also aiming to improve secondary outcomes anxiety, depression, psychological flexibility, valued living, health related quality of life, insomnia and pain intensity. Methods: Four individual studies have been conducted, where the first (study I) was a randomized controlled trial evaluating the immediate and long-term efficacy of internet delivered ACT (iACT) for chronic pain compared to a waiting list control group. The second study (study II) documented the methodological process of transforming iACT in to a clinical trial ready treatment intervention feasible with smartphone and tablet (ACTsmart). Study II also reports on alpha and beta testing with end users. Subsequently, the immediate and prolonged preliminary efficacy of ACTsmart was evaluated in a non-randomized pilot trial (study III) where participants underwent 8 weeks of treatment and were repeatedly assessed on outcome measures. In study IV data from study I and III as well as data from a pilot that preceded study I was pooled and analyzed to examine potential predictors of treatment outcome in digitally delivered behavioral treatment for adult chronic pain patients. Results: In study I, significant improvements in favor of the active treatment, iACT, were seen for the primary outcome pain interference as well as for a majority of the secondary outcomes. Between-group effect sizes were large for pain interference (d = 0.99), psychological flexibility (d = 1.00) and pain intensity (d = 1.20). All improvements were maintained at 1-year follow-up. In study II, the alpha and beta testing of ACTsmart resulted in further optimization of the treatment. Following optimization, the treatment was accessible for patients regardless of location or physical functioning and considered feasible with regards to usage, acceptability and practicality. This made the treatment a trial ready solution that was “good enough” to undergo efficacy testing. In study III, the preliminary efficacy testing of ACTsmart showed high treatment compliance among the 34 participants as well as significant improvement in all outcomes with large effect sizes for primary outcome pain interference (d = 1.01) as well as secondary outcomes avoidance (d = 1.34) and value obstruction (d = 1.02). Effects were maintained throughout 12 months of follow-up. In study IV, an examination of 30 potential predictor variables in a sample of pooled data from study I, study III and a pilot study that preceded study I, showed that shorter pain duration and higher levels of insomnia pre-treatment predict greater improvement in pain interference at post treatment. Conclusion: Internet-delivered ACT (iACT) is clinically effective for treating adult patients with chronic pain. The treatment can improve pain interference, pain intensity, mood and sleep up to 1 year following treatment. The treatment is also feasible with regards to usage, acceptability and practicality when delivered via smartphone and tablet and there is preliminary support for the efficacy of smartphone delivered ACT (ACTsmart) when it comes to improving functioning in adult individuals with chronic pain. Examination of potential predictors of treatment effect show that shorter pain duration and higher degree of insomnia severity at baseline predict larger treatment effect of digital Acceptance and Commitment Therapy (desktop and smartphone/tablet).
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| 5. |
- Gentili, Charlotte, et al.
(author)
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Examining predictors of treatment effect in digital Acceptance and Commitment Therapy for chronic pain
- 2023
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In: Cognitive Behaviour Therapy. - : Taylor & Francis Group. - 1650-6073 .- 1651-2316. ; , s. 1-17
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Journal article (peer-reviewed)abstract
- Digitally delivered behavioral interventions for chronic pain have been encouraging with effects similar to face-to-face treatment. Although many chronic pain patients benefit from behavioral treatment, a substantial proportion do not improve. To contribute to more knowledge about factors that predict treatment effects in digitally delivered behavioral interventions for chronic pain, the present study analyzed pooled data (N = 130) from three different studies on digitally delivered Acceptance and Commitment Therapy (ACT) for chronic pain. Longitudinal linear mixed-effects models for repeated measures were used to identify variables with significant influence on the rate of improvement in the main treatment outcome pain interference from pre- to post-treatment. The variables were sorted into six domains (demographics, pain variables, psychological flexibility, baseline severity, comorbid symptoms and early adherence) and analysed in a stepwise manner. The study found that shorter pain duration and higher degree of insomnia symptoms at baseline predicted larger treatment effects. The original trials from which data was pooled are registered at clinicaltrials.gov (registration number: NCT03105908 and NCT03344926).
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| 6. |
- Gentili, Charlotte, et al.
(author)
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Exploring psychological flexibility as in-treatment behaviour during internet-delivered acceptance and commitment therapy for paediatric chronic pain : Occurrence and relation to outcome
- 2024
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In: Journal of Contextual Behavioral Science. - : Elsevier. - 2212-1447. ; 31
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Journal article (peer-reviewed)abstract
- Acceptance and Commitment Therapy has gained preliminary evidence for paediatric chronic pain. Several studies show that psychological flexibility/inflexibility is a process driving treatment change in ACT for chronic pain. The literature supporting psychological flexibility as a change process in ACT is typically based on selfreport. The aim of the present study was to investigate psychological flexibility (i.e. acceptance, defusion, values formulation and committed action) as in-treatment behaviour during internet-delivered Acceptance and Commitment Therapy for paediatric chronic pain, by having two independent observers rating patient written statements. The sample was self-recruited and consisted of 28 girls between ages 13 and 17 years. Results showed that psychological flexibility could be operationalised as in-treatment behaviours and reliably assessed using observer ratings. Also, data illustrated a within subject variability in ratings of acceptance and defusion, with a considerable difference in degree of acceptance or defusion evoked by different experiential exercises. Furthermore, analyses showed that a higher average degree of acceptance in patient statements during the early phase of treatment was related to larger treatment effects. Defusion, values formulation and committed action showed no significant influence on outcome. Results should be interpreted with caution due to the small sample size.
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| 7. |
- Gentili, Charlotte, et al.
(author)
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Psychological Flexibility as a Resilience Factor in Individuals With Chronic Pain
- 2019
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In: Frontiers in Psychology. - : FRONTIERS MEDIA SA. - 1664-1078. ; 10
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Journal article (peer-reviewed)abstract
- Resilience factors have been suggested as key mechanisms in the relation between symptoms and disability among individuals with chronic pain. However, there is a need to better operationalize resilience and to empirically evaluate its role and function. The present study examined psychological flexibility as a resilience factor in relation to symptoms and functioning among 252 adults with chronic pain applying for participation in a digital ACT-based self-help treatment. Participants completed measures of symptoms (pain intensity, and anxiety), functioning (pain interference and depression), as well as the hypothesized resilience factor psychological flexibility (measured as avoidance, value obstruction, and value progress). As expected, symptoms, functioning and resilience factors were significantly associated. Hierarchical linear regression analyses showed that psychological flexibility significantly contributed to the prediction of pain interference and depression when adjusting for age, pain and anxiety. Also, participants with low levels of psychological flexibility were more likely to be on sick leave. Furthermore, a series of multiple mediation analyses showed that psychological flexibility had a significant indirect effect on the relationship between symptoms and functioning. Avoidance was consistently shown to contribute to the indirect effect. Results support previous findings and suggest the importance of psychological flexibility as a resilience factor among individuals with chronic pain and anxiety.
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| 8. |
- Gentili, Francesco, et al.
(author)
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Physiological and molecular diversity of feather moss associative N2-fixing cyanobacteria.
- 2005
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In: Journal of Experimental Botany. - : Oxford University Press (OUP). - 0022-0957 .- 1460-2431. ; 56:422, s. 3121-7
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Journal article (peer-reviewed)abstract
- Cyanobacteria colonizing the feather moss Pleurozium schreberi were isolated from moss samples collected in northern Sweden and subjected to physiological and molecular characterization. Morphological studies of isolated and moss-associated cyanobacteria were carried out by light microscopy. Molecular tools were used for cyanobacteria identification, and a reconstitution experiment of the association between non-associative mosses and cyanobacteria was conducted. The influence of temperature on N2 fixation in the different cyanobacterial isolates and the influence of light and temperature on N2-fixation rates in the moss were studied using the acetylene reduction assay. Two different cyanobacteria were effectively isolated from P. schreberi: Nostoc sp. and Calothrix sp. A third genus, Stigonema sp. was identified by microscopy, but could not be isolated. The Nostoc sp. was found to fix N2 at lower temperatures than Calothrix sp. Nostoc sp. and Stigonema sp. were the predominant cyanobacteria colonizing the moss. The attempt to reconstitute the association between the moss and cyanobacteria was successful. The two isolated genera of cyanobacteria in feather moss samples collected in northern Sweden differ in their temperature optima, which may have important ecological implications.
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| 9. |
- Rickardsson, Jenny, et al.
(author)
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Internet-delivered acceptance and commitment therapy as microlearning for chronic pain : A randomized controlled trial with 1-year follow-up
- 2021
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In: European Journal of Pain. - : John Wiley & Sons. - 1090-3801 .- 1532-2149. ; 25:5, s. 1012-1030
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Journal article (peer-reviewed)abstract
- Background: Studies of Internet-delivered acceptance and commitment therapy (ACT) for chronic pain have shown small to moderate positive effects for pain interference and pain acceptance. Effects on pain intensity, depression, anxiety and quality of life (QoL) have been less favourable, and improvements for values and sleep are lacking. In this randomized controlled trial iACT - a novel format of Internet-ACT using daily microlearning exercises - was examined for efficacy compared to a waitlist condition. Methods: Adult participants (mean age 49.5 years, pain duration 18.1 years) with diverse chronic pain conditions were recruited via self-referral, and randomized to iACT (n = 57) or waitlist (n = 56). The primary outcome was pain interference. The secondary outcomes were QoL, depression, anxiety, insomnia and pain intensity. The process variables included psychological inflexibility and values. Post-assessments were completed by 88% (n = 100) of participants. Twelve-month follow-up assessments were completed by 65% (iACT only, n = 37). Treatment efficacy was analysed using linear mixed models and an intention-to-treat-approach. Results: Significant improvements in favour of iACT were seen for pain interference, depression, anxiety, pain intensity and insomnia, as well as process variables psychological inflexibility and values. Between-group effect sizes were large for pain interference (d = 0.99) and pain intensity (d = 1.2), moderate for anxiety and depressive symptoms and small for QoL and insomnia. For the process variables, the between-group effect size was large for psychological inflexibility (d = 1.0) and moderate for values. All improvements were maintained at 1-year follow-up. Conclusions: Internet-ACT as microlearning may improve a broad range of outcomes in chronic pain. Significance: The study evaluates a novel behavioral treatment with positive results on pain interference, mood as well as pain intensity for longtime chronic pain sufferers. The innovative format of a digital ACT intervention delivered in short and experiential daily learnings may be a promising way forward.
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| 10. |
- Rickardsson, Jenny, et al.
(author)
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Internet-delivered acceptance and commitment therapy (iACT) for chronic pain : feasibility and preliminary effects in clinical and self-referred patients
- 2020
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In: JMIR mhealth and uhealth. - : AME Publishing Company. - 2291-5222. ; 6
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Journal article (peer-reviewed)abstract
- Background: Acceptance and commitment therapy (ACT) is an evidence-based treatment to improve functioning and quality of life (QoL) for chronic pain patients, but outreach of this treatment is unsatisfactory. Internet-delivery has been shown to increase treatment access but there is limited evidence regarding feasibility and effectiveness of web-based ACT for chronic pain. The aim of the study was to evaluate and iterate a novel internet-delivered ACT program, iACT, in a clinical and a self-referred sample of chronic pain patients. The intervention was developed in close collaboration with patients. To enhance learning, content was organized in short episodes to promote daily engagement in treatment. In both the clinical and self-referred samples, three critical domains were evaluated: (I) feasibility (acceptability, practicality and usage); (II) preliminary efficacy on pain interference, psychological inflexibility, value orientation, QoL, pain intensity, anxiety, insomnia and depressive symptoms; and (III) potential treatment mechanisms.Methods: This was an open pilot study with two samples: 15 patients from a tertiary pain clinic and 24 self-referred chronic pain participants, recruited from October 2015 until January 2017. Data were collected via an online platform in free text and self-report measures, as well as through individual oral feedback. Group differences were analyzed with Chi square-, Mann-Whitney U- or t-test. Preliminary efficacy and treatment mechanism data were collected via self-report and analyzed with multilevel linear modeling for repeated measures.Results: Feasibility: patient feedback guided modifications to refine the intervention and indicated that iACT was acceptable in both samples. User insights provided input for both immediate and future actions to improve feasibility. Comprehensiveness, workability and treatment credibility were adequate in both samples. Psychologists spent on average 13.5 minutes per week per clinical patient, and 8 minutes per self-referred patient (P=0.004). Recruitment rate was 24 times faster in the self-referred sample (24 patients in 1 month, compared to 15 patients in 15 months, P<0.001) and the median distance to the clinic was 40 km in the clinical sample, and 426 km in the self-referred sample (P<0.001). Preliminary effects: post-assessments were completed by 26 participants (67%). Significant effects of time were seen from pre- to post-treatment across all outcome variables. Within group effect sizes (Cohen’s d) at post-treatment ranged from small to large: pain interference (d=0.64, P<0.001), psychological inflexibility (d=1.43, P<0.001), value progress (d=0.72, P<0.001), value obstruction (d=0.42, P<0.001), physical QoL (d=0.41, P=0.005), mental QoL (d=0.67, P=0.005), insomnia (d=0.31, P<0.001), depressive symptoms (d=0.47, P<0.001), pain intensity (d=0.78, P=0.001) and anxiety (d=0.46, P<0.001). Improvements were sustained at 1-year follow-up. Psychological inflexibility and value progress were found to be potential treatment mechanisms.Conclusions: The results from the present study suggests that iACT was feasible in both the clinical and the self-referred sample. Together with the positive preliminary results on all outcomes, the findings from this feasibility study pave the way for a subsequent large randomized efficacy trial.
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