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1. Introduction
Pain is one of the most annoying phenomena that force people to seek medical attention. People are influenced not only by the stress and discomfort caused by pain but also by other distracting consequences like health care burden, inability to concentrate on routine jobs or family-related issues [1]. According to the International Association for the Study of Pain (IASP), pain can be differentiated into acute and chronic based on intensity and duration. Acute pain is usually caused by a disease or an injury, and lasts for less than three months. On the other hand, chronic pain gets prolonged for a period of minimum three months. This could lead to tissue damage, thereby considered as a disabling factor [2]. Chronic pain is a matter of concern which has been studied and discussed often in the field of psychophysical system and factors that affects pain perception in individuals [3]. Patients having chronic pain also experience different sensorimotor complications, mental and social constraints. Chronic pain reduces an individual’s physical and emotional abilities, and a sense of relief from the pain becomes impossible, the reason that take it in the list of disabilities. Hence the patient always used to be in a state of depression, disappointment and demoralization, which ultimately affect the quality of life of the individual [2, 3]. So multi-dimensional rehabilitation technique seems to be an ideal tool to deal with these type of individuals.
Nowadays, back pain is one of the most prevalent problems, human beings are faced with; since about 80% of people experience it over the course of their lives [4]. Billions of dollars are lost directly by treating the pain or indirectly by the loss of working hours of the people caused due to pain. The estimated overall back pain related expenditure in UK and USA was found to be six billion and 75 to 100 billion respectively. According to an estimation, more than 185 and 116 million working days get lost due to back pain of people in the USA and UK respectively [5]. Low backache is one of the most common pain perceived by patients suffering from chronic pain. It is the second most prevalent fact due to which people visit physicians after having viral rhinitis [6]. Twenty-five percent of patients visiting doctors or pain rehabilitation clinics suffer from chronic low back pain [7]. Living with chronic pain demands immense capacity to endure a considerable amount of emotional stress. Many of the previous studies concluded that chronic pain was not just a symptom, but associated with movement limitations, depression, sleeping problems, loss of appetite and reduction of the overall quality of life. 
Because of the multi-dimensional nature of chronic pain, the current strategy to manage the pain is through rehabilitation therapy. The inter-disciplinary approach includes administration of analgesics along with physical, occupational, behavioral and psychological therapies [8]. The purpose of most of the existing psychological treatments is to improve the quality of life of patients, as well as to reduce pain [8, 9]. Current psychological approaches in chronic pain management include psychological interventions which aim to achieve better self-management of the pain. It also includes management of behavioral changes, acceptance-based interventions and cognitive changes which are also called rehabilitation methods [8]. Psychological interventions that have been frequently used in this field include mental and physical techniques, behavioral approaches, and cognitive-behavioral treatments. Acceptance-based therapies are known as the third wave of cognitive-behavioral treatment. It focuses on enhancing the psychological connection a person used to have with his thoughts and feelings rather than changing the cognitions. Acceptance and Commitment-based Therapy (ACT) is among the most prevalent types of treatment.
The purpose of this therapeutic method is to help patients have more valuable and satisfying life by enhancing their psychological flexibility. This method has six core processes such as acceptance, cognitive diffusion, contact with the present moment, self as context, values and committed actions [8, 10]. In case of chronic pain, this rehabilitation method targets inefficient avoidance and control strategies by nurturing the techniques that increase psychological flexibility [11]. This method can reduce individuals’ chronic pain and improve the quality of life. It also helps them accept their pain and the associated thoughts, thereby, promoting meaningful aspects of life [12, 13]. McCracken et al. (2010) concluded the fact that people those who participate in daily activities despite of having chronic pain experience improved emotional, social and psychological abilities [14]. In addition, research results suggest that ACT is able to reduce depression, anxiety and pain in patients suffering from chronic low backache and enhances the quality of their lives [15, 16].
Chronic low back pain is common in women. The study rationale was rooted on the fact that, no Iranian study as focused on the effect of ACT on the management of chronic pain. Hence, it was an unprecedented effort to check the effect of ACT on female patients suffering from chronic low back pain in Iran.
2. Methods
This study was a semi-experimental research, and its design consisted of pre and post-test with the control group. The study population included women suffering from chronic low back pain who had visited the rehabilitation clinic in the city of Rasht during winter in the year 2016. Available sampling method was used to select 20 of these women and were divided into two groups with 10 subjects in each group (experimental and control). Before the study subjects signed the consent agreement, it was ensured that all the subjects met the inclusion criteria. The inclusion criteria of the subjects as per IASP guide were, aged between 23-34 years, devoid of rheumatism, no past history of spine injury or surgery; have a high school diploma and not under any psychological intervention or consultation. The participants were allowed to get discontinued from the study at any moment as per their wish. The participants were individually informed that participation was confidential and voluntary. The study was approved by the department of psychology, Karaj Branch, Islamic Azad University, Karaj, Iran, (IR.IAU.RASHT.REC.1395.70). 
Questionnaires
Following questionnaires were used to collect the study data.
Demographic Characteristics Questionnaire
Demographic characteristics questionnaire contained personal information such as gender, age, level of education, marital status; duration of diagnosis, type of disease and the subject’s post history.
Quality of Life Questionnaire of the World Health Organization
Quality of life questionnaire of the World Health Organization (26-question) was designed by WHO for measuring the overall quality of life of individuals having chronic low back pain [17]. The quality of life scale of WHO has 26 questions and evaluates four dimensions of the quality life of individuals. The scale used had a five-option Likert scale which included physical health, psychological health, social health and environmental health. The questionnaire was validated for Persian Language speaking subjects. The alpha coefficient reported for the entire scale in Iran was equal to 0.89 [18]. 
McGill Pain Questionnaire Modified (MPQ)
McGill Pain Questionnaire Modified (MPQ) was proposed by Mine et al. (1980) and has a set of 20 phrases. The purpose of this questionnaire was to measure the individual’s pain perception and different dimensions of pain. Four different dimensions of pain are there such as sensory perception, emotional perception, evaluative perception and various kinds of pain) [19]. McGill pain questionnaire has two independent factors, the first factor is sensory pain which describes an individual’s experience of pain and the second one is the emotional pain which describes the emotional consequences of it. 
McGill pain questionnaire modified had three sections, the first section contained 15 verbal descriptions in the two main groups. It contains 11 indexes for the sensory pain and 4 indexes for emotional pain each of which had a special rank (0: No pain; 1: Mild pain; 2: Moderate; and 3: Severe). The second section contains a Visual Analogue Scale which was ranked from 0 to 10 and the patients assessed their own rank based on the severity of pain they experienced from 0 (no pain) to 5 (severe pain) on a graded line. Visual Analogue Scale had a horizontal line graded from 0 (absolute lack of pain) to 10 (unbearable pain). The third section contained Present Pain Intensity (PPI) in the rank from 0 to 5 (0: No pain; 1: Mild; 2: Uncomfortable; 3: Agonizing; 4: Horrifying; and 5: Excruciating). The total pain score of a patient was calculated by considering the scores obtained from various dimensions of pain (Table 1).
Procedure
The method of conduction in this study was as follows. After the samples were selected and randomly divided into two groups (experimental and control groups), the same questionnaires were distributed among the research sample. They were comprehensively explained how to answer the questions in the distributed questionnaires. The participants were reassured that their information will remain anonymous and confidential. After filling out the questionnaires, the participants in the experimental group took part in 8 one-hour sessions of ACT twice a week in addition to their usual treatments. On the other hand, the participants in the control group were kept on the waiting list and received only their usual treatment programs. After these sessions, the participants in both the groups filled out the distributed questionnaires. As mentioned previously, ACT was used as the therapeutic 
 

 

method in this research. This method focuses on enhancing an individual’s psychological connection with his or her thoughts and feelings instead of focusing on changing the cognitions. In the present study, the rehabilitation interventions were planned based on the Vowel’s and Sorrel treatment protocol. In addition, to confirm the content validity of the treatment package and comply it with the research objectives, the text was given to five clinical psychology specialists who were fluent in English and familiar with the topic so as to confirm the 
 

 

accuracy of the translation. Here, it should be noted that the treatment package was completely standard and had been confirmed in foreign clinical psychology institutes and assemblies. Then, the translated text was presented to a few university students in the form of an unofficial class so as to confirm the accuracy of the understanding of the text. After this stage, the treatment package was directly used and the sessions of this package have been briefly explained in Table 2. Considering the goal of the study and to control the effect of the pretest variable, descriptive and inferential statistics have been used in this study. In the descriptive statistics, the mean and standard deviation have been examined, and at the inferential level, due to the conditions of the parametric tests, the correlated t-test and independent t-test were used. SPSS 20 software was used for data analysis.
3. Results
According to the descriptive findings, the mean and standard deviation of the age of the subjects was 40.3±8.2, and the mean and standard deviation of the duration of pain was 6.5±3.4. According to the results presented in Figure 1, the percentage of variances of the components of quality of life in the experimental group had increased compared to that of the control group. All the components of quality of life (psychological health (P<0.001), social health (P<0.001), and environmental health (P<0.001) significantly increased, except for physical health (P<0.38). 
In addition, the results of the present study, as displayed in Figure 2, indicate that there is no significant difference between the control group and the experimental group in pretest (P<0.23). On the other hand, the mean score of pain in the post-test did not show a significant difference. In other words, ACT has a significant impact on the reduction of pain score (P<0.001). 
4. Discussion
The purpose of the present study was to examine the effectiveness of ACT on quality of life, severity and duration of pain in women suffering from chronic low back pain. The results of this study suggest that an effective ACT period has a significant effect on the quality of life of women suffering from chronic low back pain. Our results comply with those of Mason et al. (2004), McCracken et al. (2014) and Turk et al. (1984) [15, 20-22]. For instance, Mason et al. (2008) have shown that accepting low back pain improves the quality of life of those who suffer from chronic low back pain [15]. 
In this study, the ACT approach and all of its six core components were used, and it was concluded that by educating patients, ACT will be able to improve psychological flexibility and, therefore, committed and effective behavioral performance. One of these components is self as a context, which means that the individuals become aware of their thoughts, feelings and inner desires, and they are asked to prevent controlling and avoiding them. Then, cognitive diffusion is encouraged, which means adjusting one’s reaction to their thoughts. In fact, in ACT, thoughts and contents are not validated and/or 
 

 

thoughts are not challenged; only the performances are challenged in this approach. Another component is acceptance, which means accepting a situation that cannot be avoided; for example, experiencing pain. 
Another component is being in contact with the present moment and being aware of what’s going on at the moment instead of focusing on the past or what might happen in the future. Another component is specification of one’s values and ultimately committed and effective performance in compliance with the predetermined objectives. All of these components and processes contribute to the psychological flexibility of individuals and improve the quality of their lives [19]. In this respect, some studies have shown that a mind consciousness program based on stress reduction is effective on improving the total score of quality of life, mental, spiritual, emotional, and physical well-being [23, 24]. 
On the other hand, this finding does not comply with the findings of Andersson et al. (2004) [25] and Hayes et al. (2011) [11]. For example, using this therapeutic method on patients suffering from sensorimotor defects can be helpful in terms of achieving another opportunity for assessing the physiological reactions of their bodies and acquiring the ability to control these involuntary reactions [25]. Dissimilarity of the results of these studies with the present study is probably due to the gender and age of the subjects and the method used in the research. 
According to the research results, chronic low back pain affects patients’ sleeping, emotional and psychological status, social relations and other aspects of quality of life [26]. Given the relationship between psychological factors and chronic low back pain, the negative psychological and social effects of chronic low back pain cannot be determined by using other medical models alone and focusing only on the physical dimension. Hence, it is necessary to pay attention to psychological interventions and approaches [27]. Over the past ten years, cognitive-behavioral therapy is the most common psychological approach in treating chronic pain that directly focuses on changing thoughts and emotions associated with pain and other disturbing and stressful conditions in addition to behavioral interventions. Many studies have shown that in the best situation, the success of the aforementioned approach was not considerable. In contrast, some other studies have shown that among the third wave treatments, ACT improves psychological flexibility, reduces chronic pain, and enhances quality of life. The purpose of this rehabilitation method is to help patients have a more valuable and satisfying life by enhancing psychological flexibility [15, 16]. 
The results of the present study suggest that therapeutic commitment and acceptance is effective in reducing severity and duration of pain in women suffering from chronic low back pain. This result complies with the results obtained by Veehof et al. (2016), Veehof et al. (2011) and Breivik et al. [28-30]. Veehof et al. (2016) have shown that accepting back pain improves quality of life of individuals suffering from chronic low back pain [30]. Breivik et al. (2006) have also shown that a mind consciousness program based on stress reduction is effective in improving the total score of quality of life, mental, spiritual, emotional and physical well-being. In addition, Chisholm et al. (2016), in their study, concluded that ACT affects mental distress, anxiety, depression, stress and enhancement of quality of life [28]. The results of the study of Veehof et al. (2011) suggest that ACT interventions improve health and reduce mental pressures by changing psychological flexibility and paying conscious attention to the symptoms of anxiety [29]. 
Wicksell et al. (2009) reported that flexibility throughout the interventions reduces symptoms of depression and anxiety [31]. Moreover, this study shows that ACT affects anxiety-related disorders [15, 16]. The results of the studies of Tamannaeifar et al. (2014) have suggested that ACT has been effective in reducing the pain experienced by women suffering from chronic headaches [32]. Furthermore, Mohabbat et al. (2015) reported that ACT has significantly increased the quality of life of participants in the experimental group and their physical and mental health subscales in comparison with those in the control group [33]. 
5. Conclusion
The results of this study have shown that ACT can reduce the severity and duration of pain and increase the quality of life of women suffering from chronic low back pain. The findings of this research are indicative of the necessity of creating a connection between various branches of sciences to solve the problems associated with various physical, psychological and social aspects. Such therapeutic methods make the patients’ lives more meaningful, improve the quality of their lives, and reduce the costs of rehabilitation and treatment. Further, these therapeutic methods can be used in rehabilitation clinics and psychological services centers in order to solve the psychological problems of patients suffering from chronic pains.
Acknowledgments 
This paper was abstracted from the first author's PhD thesis in the Department of Psychology, Karaj Branch, Islamic Azad University, Karaj, Iran. The authors would like to thank all people who participated in this study. 
Conflict of Interest
The authors declared no conflicts of interest.


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