Cognitive behaviour therapy for persisting pain

1. Introduction
2. Principles of CBT
3. Assessment
4. Treatment planning/preparation
5. Clinical applications
6. Future development

1. Introduction

1.1. For people with persisting pain and disability, unless something specific and treatable has been overlooked, curative treatment is very unlikely and its very pursuit may not be risk-free (1, 2, 3).


1.2. Specific interventions aimed at pain relief, improved sleep or mood can help, but they may not be sufficient to achieve significant functional gains as well, especially in the more distressed and disabled cases (4, 5, 6).


1.3. Cognitive behavioural (CBT) pain management programs provide an additional option for limiting the impact of pain on the patient and assisting them to resume normal functional activities (7, 8). [Level I]


1.4. There is strong evidence that the impact of persisting pain on a patient is       influenced by psychological and social/environmental variables, in addition to their underlying medical condition (9, 10, 11). [Level I]


1.5. Psychological risk factors for disability in chronic pain patients include: fear (of pain and/or re-injury); unhelpful beliefs; avoidance of activities expected to be painful; reliance on passive treatment modalities (high medication use, passive physical therapies); ‘catastrophic’ (overly alarmist) responses to pain; depressed mood (sense of hopelessness); and high use of poor coping strategies (eg. poor activity pacing).


1.6. Social/environmental risk factors include: highly nurturing spouse or significant others, including health professionals (who may inadvertently reinforce a patient’s disability by being too solicitous); hostile spouse/significant other (may undermine attempts to recover); presence of workers or accident compensation claim; unhelpful employers (no flexibility for assisting return to work); being unemployed.


1.7. CBT approaches to pain management are based on the evidence that persisting pain (and its associated problems) is best understood within a bio-psycho-social framework.  Clinically, this requires a thorough assessment of medical (somatic) aspects of each patient, as well as careful assessment of psycho-social contributors to the patient’s difficulties. The assessment findings provide the basis for the CBT intervention that may be targeted at multiple contributing factors (12).


2. Principles of CBT 

2.1. CBT is based on a number of empirically developed principles derived from the scientific study of behaviour and cognitions. Of particular relevance has been the study of learning (conditioning), cognitive processes, social interactions, and more recently, applications of interventions based on this literature to mental and physical illnesses in clinical settings (10, 13-15).


2.2. CBT interventions do not have a standardised content like a drug, but they share common features and a set of operating principles that enable the clinicians to tailor their interactions according the assessed contributing factors to a patient’s pain problems and goals sought.


2.3. The effectiveness of CBT depends upon how well it is applied, the skills of the health professionals involved, the match between content and assessed needs, and the degree to which the patient’s environment supports the approach.


2.4. Training is required to achieve competence in the skills entailed in CBT.  Application of CBT by untrained practitioners risks sub-optimal outcomes and loss of confidence by patients in the approach which can undermine subsequent attempts by others to revisit it.


3. Assessment


3.1 Cognitive-behavioural interventions should be devised only after an appropriate assessment of the patient’s presenting problem(s) and associated contributing factors (somatic and psychosocial).


3.2 In some cases, assessment of psychosocial contributors will require specialised skills, like those possessed by a clinical psychologist or psychiatrist with expertise in pain management.


3.3 All those involved in the assessment should meet soon after the assessment to review the findings, develop a formulation of the case (identifying presenting problems and factors contributing to them), and then develop a management plan to be discussed with the patient. The plan should include agreed goals negotiated with the patient.


3.4 Goals should be couched in terms of what is observable or measurable (eg. return to specific duties at work, or driving car for one hour), rather than less specific entities (eg. ‘to get my life back’).


4. Treatment planning/preparation


4.1 Usually, a CBT program will be employed once attempts at curative treatments have been tried (without success) and/or rejected.


4.2 If CBT is to be implemented with other treatments, the timing and manner of their implementation must be planned. Thus, if invasive procedures are proposed as well, it would normally be preferable that these precede the CBT (which is aimed at pain management rather than pain relief) (16). The two models of intervention (pain reduction vs pain management) can be applied simultaneously but it requires selection of the appropriate patient (ideally one who already accepts and practises some helpful self-management strategies) (17).


4.2 Prior to the program, and after the assessment, clinicians should meet with the patient to confirm their goals for the program and to clarify their motivations for achieving them. The goals must be personally relevant to the patient and they should believe they will benefit by achieving them. Likely obstacles to change should be identified and possible responses or options for dealing with them should be devised jointly.


4.3 Consistency in management approach across disciplines is critical. All those involved in the treatment (and rehabilitation) of a patient entering a CBT program should be made aware of the approach being taken, the expected outcomes and their expected roles prior to and following the program. Ideally, their agreement and support should be obtained and this should be conveyed to the patient.


4.4 As CBT may represent a shift from a more passive, pain-relief-first approach (where something is done to the patient), the shift in focus, and its implications, must be explained to the patient. As with any treatment, the use of CBT should not be presented as ‘the last resort’ for those who have failed standard medical interventions (that risks feelings of abandonment or somehow having ‘less real’ pain). Instead, it may be presented as a logical next step for dealing with a difficult problem with no easy answers. It may be combined with other modalities, but the expectations on the patient and his/her role in the process of treatment must be made clear. The patient must be aware they will be trying to learn ways of functioning despite their pain and that the program will be aimed at assisting them in this.


5. Clinical applications 

5.1 Re-formulation. Early in the program some time must be spent on a ‘reformulation’ or ‘re-conceptualisation’ of the patient’s problem(s) within a biopsychosocial framework (18).


5.2 Format.  Most studies of CBT pain management programs have involved group-based interventions (7, 8), with 5-10 patients at a time. This has benefits in terms of cost-efficiency in use of staff, as well as enhancing the sense of support amongst the participants. However, attending a group program may not be feasible for some, and some patients may be too hostile and disruptive to participate constructively, to the detriment of other patients.


5.3 CBT pain management can also be provided on an individual basis. This may have benefits in terms of ability to individualise the treatment and flexibility in appointment times and service delivery, but to date there is insufficient evidence to evaluate the relative effectiveness of group vs individual applications.


5.4 Sole practitioners may have no practical alternative to individual applications and they may become skilled in incorporating CBT principles in their medical management plan. But time constraints may limit the extent to which they can do this without input from other disciplines, especially with more complex cases.


5.5 Considerable knowledge and skills are required to assess and manage persisting pain effectively, especially in complex cases. The IASP (International Association for the Study of Pain) has recommended core curricula for professional education in this area (19). Training and supervision for those new to the area is strongly recommended (20).


5.6 Required clinical skills for conducting a CBT program include the use of active listening, Socratic reasoning, empathy, educational strategies, and reinforcement principles. Considerable experience in pain assessment and management is also important.


5.7 Minimum staffing for a group program is a clinical psychologist, physiotherapist, and medical practitioner (preferably a pain specialist). Others, such as an occupational therapist, nurse and rehabilitation adviser, may enable fuller coverage of problem areas, depending on available facilities. The staff must have extensive training in ways of working cooperatively, in an integrated manner. Common causes of conflict are professional ‘turf’ and hierarchical decision-making processes. Resolution of these issues is critical (20).


5.8 Content. Typical features of a CBT pain management program include: goal setting, education about pain, applied relaxation training, training in identifying and challenging unhelpful cognitions (beliefs, thought processes), learning more effective problem-solving and pain management strategies (eg. activity pacing, daily planning); programmed exercise and systematic encouragement of activities to address avoidance behaviours and to regain confidence in functioning despite pain; and structured medication withdrawal.


5.9 The form and length of a program depends on patient selection and conditions (12). There is evidence that the more disabled, medication dependent patients are more likely to benefit from a more intensive program (ie.100 - 120 hours, over 3-5 weeks) (8, 21, 22). In less disabled cases (at work; no medication issues; mild distress) briefer programs can suffice (eg. six 2-hour sessions or possibly twelve 1-hour sessions over 6-10 weeks) (23, 24).


5.10 A treatment manual (for the patient) describing the pain management skills and how to use them, plus pain education material can help promote acquisition of skills and maintenance of gains (25).


5.11 Planning for maintenance. With a fluctuating condition like chronic pain, the risk of relapse is ever-present. Patients should be trained to apply a number of strategies to manage fluctuations, ideally in collaboration with their significant others, especially their GP. These include: strategies to deal with high risk situations (eg. episodes of more pain, set-backs in attempts to return to work; offers of further investigations or passive treatments). Working on a management plan with the GP, help with rehabilitation planning, and access to follow-up support from a pain service are recommended (26, 27, 28).


6. Future development 

6.1 Refinement of methods for specific groups, such as those with spinal cord injuries, the elderly, and children, needs more attention.


6.2 Education and training for those wishing to employ CBT methods, in all disciplines, is essential if more consistent management of complex chronic pain problems is to be achieved. This has been recognised by some public authorities (eg. NSW WorkCover), but to date this is rare.



6.3 A continuing challenge is to develop effective ways of employing different treatment modalities (and models) simultaneously with CBT methods.  For example, if a pain relief intervention, whether a drug or device, and a CBT program could be combined it might be possible for a patient to achieve both better pain control and functional gains on a sustainable basis (17).



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