Chronic low back pain (CLBP) is increasingly prevalent in older adults and often leads to functional disability and depressive symptoms. This 2-arm, double-blinded, pilot cluster RCT, with semi-structured interviews, aimed to evaluate the acceptability, feasibility, and preliminary clinical efficacy of ACT plus exercise training (ACT+Ex) on improving pain-related outcomes, psychological outcomes, and physical fitness in older adults with CLBP at post-treatment and 6-month follow-up. Forty community-dwelling older adults (62-85 years) with CLBP, predominantly female, were randomized to ACT+Ex (n=20) or Education plus exercise program (Edu+Ex) (n=20) for 8 weekly group-based sessions, with assessments at baseline, post-treatment, and 6-month follow-up (primary endpoint). Self-reported outcomes included pain intensity, functional disability (Roland Morris Disability Questionnaires, RMDQ), health-related quality of life (EuroQol-5 Dimensions, EQ-5D-5L), psychological inflexibility (Acceptance and Action Questionnaire-Version 2, AAQ-II), and psychological well-being (Depression Anxiety Stress Scale). Physical fitness was assessed using the functional reach test (FRT), Timed Up and Go test (TUG), 6-minute walk test (6MWT), hand grip strength (HGS), and 30-second sit-to-stand (STS-30) test. This trial achieved high recruitment (23.5 participants per week) and completion rates (92.5%). Exploratory analyses revealed that ACT+Ex significantly improved pain intensity, disability, psychological inflexibility, HRQoL, and physical fitness at post-treatment and 6-month follow-up. Qualitative data identified 3 superordinate themes: previous healthcare experience affecting pain beliefs; acceptance strategies guiding behavioral changes; and facilitators and barriers to treatment compliance. These findings support the need for a definitive RCT and form a valuable basis for future exploration regarding the behavioral mechanisms of ACT in clinical applications. PERSPECTIVE: A multimodal therapy incorporating ACT and exercise promotes positive behavioral changes and its treatment effects are maintained at the 6-month follow-up especially for physical performance.
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| Psychologist |  |
| Physician |  |
Physician rater
Incorporating ACT and exercise into treating elderly patients with chronic low back pain result in a reduction in pain and improvement in function, particularly when traditional approaches prove ineffective. This pilot trial has a small sample size, predominantly female participants, and short-term follow-up. Generalizability to broader populations and to men requires confirmation in larger and diverse cohorts. Group delivery has the potential to enhance mutual support, acceptance, and engagement, which are crucial factors in chronic pain management. Furthermore, it is essential to prioritize the following aspects for effective and sustainable pain management: addressing pain beliefs, reconceptualization, and patient autonomy.
Physician rater
For older adults with chronic low back pain, Acceptance and Commitment Therapy (ACT) combined with exercise in outpatient or community group settings is promising, offering physical and psychological benefits with high feasibility and acceptability. However, attention should be given also to maintenance strategies and addressing pain beliefs (e.g., fear of structural damage). Furthermore, the findings are preliminary: the sample size of the RCT was relatively small and mainly female; the participants were clustered in low-resource settings; and the benefits for emotional symptoms were not sustained in the long term, suggesting that additional follow-up interventions or boosters may be needed.
Physician rater
Small study groups - a pilot study. No significant difference between groups were observed for outcome variables across follow-up assessments.
Physician rater
This is a small pilot study that may lead to more research but is not ready for clinical prime time. The study is too small and too many changes to the protocol during the study. Of note, this is not a cluster RCT (wherein interventions occur in clusters/groups and clusters are randomized) as stated in the abstract.
Physician rater
A small pilot study. No significant difference between groups at follow-ups.
Psychologist rater
The robustness of the findings argues for an RCT, as the authors indicate. Encouraging data that is not unexpected but worthwhile disseminating.
Psychologist rater
As a psychologist with a specialty in pain management, I wonder to what extent neuro-diveristy has on the individual participant's experience with pain.
Dr. Hélène Bertrand (9/15/2025 2:40 PM)
Most low back pain is secondary to sacroiliac joint displacement that can be assessed with physical examination and treated with a two-minute repositioning exercise that has a 90% success rate. This article deals instead with the emotional effects of low back pain: it does not address the cause of the problem. This may explain why the results are not very significant.
, McMaster University