Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain

Although cognitive-behavioral therapies (CBT) have been demonstrated to be effective for a variety of chronic pain problems, patients vary in their response and little is known about patient characteristics that predict or moderate treatment effects. Furthermore, although cognitive-behavioral theory posits that changes in patient beliefs and coping mediate the effects of CBT on patient outcomes, little research has systematically tested this. Therefore, we examined mediators, moderators, and predictors of treatment effects in a randomized controlled trial of CBT for chronic temporomandibular disorder (TMD) pain. Pre- to post-treatment changes in pain beliefs (control over pain, disability, and pain signals harm), catastrophizing, and self-efficacy for managing pain mediated the effects of CBT on pain, activity interference, and jaw use limitations at one year. In individual mediator analyses, change in perceived pain control was the mediator that explained the greatest proportion of the total treatment effect on each outcome. Analyzing the mediators as a group, self-efficacy had unique mediating effects beyond those of control and the other mediators. Patients who reported more pain sites, depressive symptoms, non-specific physical problems, rumination, catastrophizing, and stress before treatment had higher activity interference at one year. The effects of CBT generally did not vary according to patient baseline characteristics, suggesting that all patients potentially may be helped by this therapy. The results provide further support for cognitive-behavioral models of chronic pain and point to the potential benefits of interventions to modify specific pain-related beliefs in CBT and in other health care encounters.     

Cognitive-behavioral treatment in unselected rheumatoid arthritis outpatients

OBJECTIVE: This trial was performed to evaluate the efficacy of an adjunctive cognitive-behavioral treatment compared with rheumatological treatment alone in unselected rheumatoid arthritis outpatients. DESIGN: A prospective randomized control design was used. Change in medication during treatment was controlled by matching therapy- and control-group subjects according to this change in medication, sex, age, duration of disease, and functional class. SETTING: A rheumatological outpatient clinic, University of Goettingen, Germany. PATIENTS: Fifty-five consecutive outpatients with a diagnosis of rheumatoid arthritis (age 52.7 years, 74.5% female, duration of disease 9.4 years) finished the study. INTERVENTIONS: Subjects received routine care by the rheumatologists and routine medical treatment. Cognitive-behavioral treatment subjects (n = 19) received adjunctive standardized cognitive-behavioral group treatment with 12 weekly sessions. OUTCOME MEASURES: Outcome measures included disease activity variables, pain variables (pain intensity, affective pain), psychological symptoms, and coping. RESULTS: Subjects mostly demonstrated an increasing disease activity during treatment; change in medication during treatment was necessary in some patients. In the cognitive-behavioral treatment group the course of rheumatoid arthritis seemed less progressive than in the control group. The core effects of cognitive-behavioral treatment pertain more to improved coping, emotional stabilization, and reduced impairment than to reduced pain intensity. Passive, emotion-focused coping, helplessness, depression, anxiety, affective pain, and fluctuation of pain are reduced, "Acceptance of Illness" is improved. CONCLUSIONS: Cognitive-behavioral therapy has proven an effective adjunct to standard treatment of rheumatoid arthritis outpatients. These effects were shown in an unselected sample with increasing disease activity and with comparable changes in medication during treatment. We recommend cognitive-behavioral treatment as an desirable adjunct to standard medical treatment of rheumatoid arthritis.     

Training nursing students in evidence-based techniques for cognitive-behavioral pediatric pain management

This study evaluates the effects of a didactic training program for nursing students involving developmentally appropriate strategies for cognitive-behavioral pain management in children. Junior-level nursing students were assigned to one of two groups: training or control. Pretraining and posttraining knowledge and attitudes toward pain management were assessed. Implementation of cognitive-behavioral strategies was assessed via clinical role-play. Training participants had significantly more knowledge of cognitive-behavioral strategies after the training program versus before it, and they had more knowledge after the training program than did control participants. The training had no effect on attitude. In the role-play, training participants used a higher ratio of cognitive-behavioral strategies and implemented them in a higher quality manner than did control participants. These results suggest that a brief training program in cognitive-behavioral pain management can improve nursing students' knowledge of cognitive-behavioral pain management strategies and ability to implement them.     

Effect on Health Care Costs for Adolescents Receiving Adjunctive Internet-Delivered Cognitive-Behavioral Therapy: Results of a Randomized Controlled Trial

The economic burden of pediatric chronic pain is high, with an estimated annual cost of $19.5 billion. Little is known about whether psychological treatment for pediatric chronic pain can alter health care utilization for youth. The primary aim of this secondary data analysis was to evaluate the effect of adjunctive internet cognitive-behavioral therapy intervention or adjunctive internet education on health care-related economic costs in a cohort of adolescents with chronic pain recruited from interdisciplinary pain clinics across the United States. For the full sample, health care expenditures significantly decreased from the year before the intervention to the year after the intervention. Results indicated that the rate of change in health care costs over time was not significantly different between the internet cognitive-behavioral therapy intervention and adjunctive internet education groups. Further research is needed to replicate these findings and determine patterns and drivers of health care costs for youth with chronic pain evaluated in interdisciplinary pain clinics and whether psychological treatments can alter these patterns. This trial was registered at clinicaltrials.gov (identifier NCT01316471).

Psychosocial therapies for neck pain

The biopsychosocial approach provides the necessary framework for understanding and treating chronic pain. Through education, cognitive-behavioral therapy, relaxation training, and active adaptation, the biopsychosocial approach allows patients to learn to control their internal environments (pain-related thoughts and emotions) and to influence their responses to the external environment (physical condition, work, significant others, and other stresses). This education-based model of therapy combines naturally with the medical model and medical care.     

Cognitive-behavioral issues in the treatment and management of chronic daily headache

Chronic daily headache is a heterogeneous group of daily or near-daily headaches that afflicts close to 5% of the general population and accounts for close to 35% to 40% of patients at headache centers. First-line drug or cognitive-behavioral therapies administered alone have minimal impact on reducing the frequency or severity of headaches. However, combined drug and cognitive-behavioral therapy shows promise in providing the most benefit for this often intractable condition. Cognitive-behavioral therapies focus on preventing mild pain from becoming disabling pain, improving headacherelated disability, affective distress, and quality of life, and reducing overreliance on medication. For cognitive-behavioral therapies to be effective, it is important to address complicating factors, including medication overuse, psychiatric comorbidity, stress and poor coping, and sleep disturbance.     

CHRONIC PAIN AND THE FAMILY: THEORY-DRIVEN TREATMENT APPROACHES

The chronic pain experience is the product of a complex interaction of many factors including biological, social, psychological, environmental, and familial. The presence of chronic pain can impact the family system with significant, negative consequences; the family may also be responsible, in part, for maintaining and perpetuating pain problems. The need to examine the family dimension of the chronic pain experience and offer family/couple therapy, should it be indicated, is vital to comprehensive pain management. Operant behavioral, cognitive-behavioral, and structural family therapy approaches are advocated for such families, along with a clear need for controlled evaluations of these approaches.     

Cognitive and cognitive-behavioral methods for pain control: a selective review

The literature on cognitive and cognitive-behavioral methods for pain control is selectively reviewed, with particular focus on controlled studies. Such methods include the provision of preparatory information, cognitive coping skills or strategies, the provision of preparatory information plus some form of coping skills instructions or training, prepared childbirth techniques, multifaceted cognitive-behavioral treatment regimens, and stress-inoculation training. Overall, the scientific evidence for the efficacy of cognitive and cognitive-behavioral methods for clinical pain attenuation is somewhat meager, although some encouraging but still tentative results have been obtained. There has been much work on the psychological elements involved in such strategies in the laboratory but there is still little sound information on their use for clinical pain. Several issues emerging from the literature review are discussed, with the need for further controlled evaluations being obvious.     

Chronic pain and the family: theory-driven treatment approaches

The chronic pain experience is the product of a complex interaction of many factors including biological, social, psychological, environmental, and familial. The presence of chronic pain can impact the family system with significant, negative consequences; the family may also be responsible, in part, for maintaining and perpetuating pain problems. The need to examine the family dimension of the chronic pain experience and offer family/couple therapy, should it be indicated, is vital to comprehensive pain management. Operant behavioral, cognitive-behavioral, and structural family therapy approaches are advocated for such families, along with a clear need for controlled evaluations of these approaches.     

How Can We Best Reduce Pain Catastrophizing in Adults With Chronic Noncancer Pain? A Systematic Review and Meta-Analysis

Pain catastrophizing (PC), defined as an exaggerated negative cognitive-affective orientation toward pain, is one of the strongest psychological predictors of pain outcomes. Although regularly included as a process variable in clinical trials, there have been no comprehensive reviews of how it can be modified. Using a registered protocol (PROSPERO 2016 CRD42016042761), we searched MEDLINE, PsychINFO, EMBASE, CINAHL, and CENTRAL up to November 2016 for all randomized controlled trials measuring PC in adults with chronic noncancer pain. Two authors independently screened studies and assessed bias risk using the Cochrane tool. Quality of evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation criteria. We included 79 studies (n?=?9,914), which mostly recruited participants with musculoskeletal pain and had low risk of bias. Meta-analyses (standardized mean difference) showed 9 interventions had efficacy compared with waitlist/usual care or active control, although evidence quality was often low. The best evidence (moderate-high quality) was found for cognitive-behavioral therapy, multimodal treatment, and acceptance and commitment therapy. Effects were generally of medium strength and had questionable clinical significance. When only the 8 studies targeting people with high PC were included, effects were larger and more consistent. Multimodal treatment showed the strongest effects when all studies were considered, whereas cognitive-behavioral therapy had the best evidence among targeted studies.

Psychologic management of cancer pain

Psychologic strategies for the treatment of cancer pain continue to be an important component of multiclimensional treatment programs. These techniques, including relaxation therapy. cognitive-behavioral therapy, biofeedback, and hypnosis have demonstrated efficacy and reduced medical costs. The impact of these techniques is on the sensory aspects of pain and the psychologic distress and maladaptive coping mechanisms people develop in response to pain. Although psychologic techniques have been used for many years, the recent literature is elucidating the pathophysiologic mechanisms of these techniques and better defining the best techniques to use in individual cases to maximize effectiveness.     

Preparing for pain management: a pilot study to enhance engagement.

A significant proportion of individuals fail to engage in cognitive-behavioral treatments for pain. The aim of this pilot study was to develop and evaluate a Preparation for Pain Management Intervention administered before community-based therapy (CBT) pain management workshops. Participants (N = 78) were randomly assigned to a treatment group receiving a 2-session intervention including assessment and feedback based on the Preparation for Pain Management Profile (PPMP) or to a control group receiving assessment (treatment as usual) and an attention placebo interview in place of the feedback session. The interviews were conducted with both groups before patients were offered participation in pain management workshops. Results demonstrate that participants in the treatment group were significantly more likely to attend workshops than were participants in the control group (P < .01). PERSPECTIVE: This paper describes a randomized controlled trial assessing a brief motivational intervention aimed at increasing engagement in community-based pain management workshops.     

Struktur- und Prozessqualit?t multimodaler Schmerztherapie

Multimodal therapy has demonstrated good clinical effectiveness in the treatment of chronic pain syndromes. However, within the German health system a comprehensive and nationwide access to multimodal therapy is not available and further improvement is therefore necessary. In order to analyze the current status of multimodal therapy and specifically its structural and procedural requirements and qualities, a survey was carried out in 37 pain clinics with established multimodal treatment programs. An anonymous questionnaire was used for data collection. Results demonstrated that a substantial accordance was found between all pain clinics concerning requirements for space, facilities and staff. Structured multidisciplinary assessments were carried out by all pain clinics even though the amount of time allocated for this varied widely. The main focus of multimodal therapy in all facilities was based on a common philosophy with a cognitive-behavioral approach to reduce patient helplessness and avoidance behavior and to increase physical and psychosocial activities as well as to strengthen self-efficacy. Some differences in the ways and means to achieve these goals could be demonstrated in the various programs.     

Mind-body therapies for the management of pain

This paper reviews the evidence for mind-body therapies (eg, relaxation, meditation, imagery, cognitive-behavioral therapy) in the treatment of pain-related medical conditions and suggests directions for future research in these areas. Based on evidence from randomized controlled trials and in many cases, systematic reviews of the literature, the following recommendations can be made: 1) multi-component mind-body approaches that include some combination of stress management, coping skills training, cognitive restructuring and relaxation therapy may be an appropriate adjunctive treatment for chronic low back pain; 2) multimodal mind-body approaches such as cognitive-behavioral therapy, particularly when combined with an educational/informational component, can be an effective adjunct in the management of rheumatoid and osteoarthritis; 3) relaxation and thermal biofeedback may be considered as a treatment for recurrent migraine while relaxation and muscle biofeedback can be an effective adjunct or stand alone therapy for recurrent tension headache; 4) an array of mind-body therapies (eg, imagery, hypnosis, relaxation) when employed pre-surgically, can improve recovery time and reduce pain following surgical procedures; 5) mind-body approaches may be considered as adjunctive therapies to help ameliorate pain during invasive medical procedures.     

Continued disability and pain after lumbar disc surgery: the role of cognitive-behavioral factors

Cognitive-behavioral factors are considered important in the development of chronic disability and pain in patients with low back pain. In a prospective cohort study of 277 patients undergoing surgery for lumbosacral radicular syndrome, the predictive value of preoperatively measured cognitive-behavioral factors (fear of movement/(re)injury, passive pain coping, and negative outcome expectancies) for disability and pain intensity at 6 weeks and 6 months after surgery was investigated, taking into account the effect of possible confounding variables. Higher levels of cognitive-behavioral factors were found to be associated with a worse outcome at both 6 weeks and 6 months. These associations remained significant after controlling for possible confounding variables (preoperative disability and pain intensity, age, gender, educational level, duration of complaints, neurological deficits, and intake of analgesics) and pain intensity 3 days postoperatively. In multiple regression analyses, the cognitive-behavioral factors independently predicted different outcomes. Fear of movement/(re)injury predicted more disability and more severe pain at 6 weeks and more severe pain at 6 months; passive pain-coping strategies predicted more disability at 6 months; and negative outcome expectancies predicted more disability and more severe pain at both 6 weeks and 6 months. The findings support the potential utility of preoperative screening measures that include cognitive-behavioral factors for predicting surgical outcome, as well as studies to examine the potential benefits of cognitive-behavioral treatment to improve surgical outcome.     

Quick Reference Guide for Clinicians

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline on Management of Cancer Pain , which was developed by a private-sector panel of health care providers and consumers. Selected aspects of evaluating and managing pain in adults with cancer pain are presented. Topics covered include initial assessment, pharmacologic treatment, administration of medications, side effects of medications, adjuvant medications, cognitive-behavioral interventions, and discussion of other more invasive palliative techniques, A flowchart is included that shows the sequence of events in evaluating and managing cancer pain, as well as drug dosing tables and forms to assist the clinician and patient to adequately describe and assess pain.
The Clinical Practice Guideline , a critical synthesis of research and knowledge in the field, is designed to help any clinician working with cancer patients in any setting. The Guideline presents a thorough discussion of ways to manage procedure-induced pain and invasive modalities of pain control therapy, for use when simpler methods do not control pain. It also devotes considerable attention to pain control in special populations, including patients with concurrent medical and substance abuse problems, those with psychiatric problems related to pain and cancer, and members of minority and ethnic groups. Because pain problems in patients with HIV/AIDS are often assessed and treated using the same approaches as those used for cancer pain, HIV/AIDS pain is described as well. Practitioners should review the Clinical Practice Guideline carefully to become familiar with the various options for management of cancer pain and then use the Quick Reference Guide to help them remember the major points in managing cancer pain.     

Anger intervention

This article compares and contrasts psychoanalytic and cognitive-behavioral approaches to anger intervention. Related research is discussed and a cognitive-behavioral model of anger intervention is presented. The model views anger as an affective stress reaction consisting of four factors: physiological arousal, antagonistic cognitions, environmental stimuli, and behavioral reactions. The article also examines occupational therapy assessment and treatment goals on the basis of the cognitive-behavioral model and recommends stress management activities and techniques for helping clients control the factors that mediate their anger.     

Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain.

This study was designed to investigate the relative efficacy of cognitive-behavioral group treatment, including relaxation training, in comparison with a control condition in a sample of 20 outpatients with chronic low back pain. Subjects in both conditions also received the same physiotherapy back-education and exercise program. The control condition included a control for the attention of the therapist in the cognitive-behavioral treatment. The combined psychological treatment and physiotherapy condition displayed significantly greater improvement than the attention-control and physiotherapy condition at post-treatment on measures of other-rated functional impairment, use of active coping strategies, self-efficacy beliefs, and medication use. These differences were maintained at 6 month follow-up on use of active coping strategies and, to a lesser degree, on self-efficacy beliefs and other-rated functional impairment.     

Cognitive Change Across Cognitive-Behavioral and Light Therapy Treatments for Seasonal Affective Disorder: What Accounts for Clinical Status the Next Winter?

Efficacious treatments for seasonal affective disorder include light therapy and a seasonal affective disorder-tailored form of cognitive-behavioral therapy. Using data from a parent clinical trial, these secondary analyses examined the relationship between cognitive change over treatment with cognitive-behavioral therapy, light therapy, or combination treatment and mood outcomes the next winter. Sixty-nine participants were randomly assigned to 6-weeks of cognitive-behavioral therapy, light therapy, or combination treatment. Cognitive constructs (i.e., dysfunctional attitudes, negative automatic thoughts, and rumination) were assessed at pre- and post-treatment. Dysfunctional attitudes, negative automatic thoughts, and rumination improved over acute treatment, regardless of modality; however, in participants randomized to solo cognitive-behavioral therapy, a greater degree of improvement in dysfunctional attitudes and automatic thoughts was uniquely associated with less severe depressive symptoms the next winter. Change in maladaptive thoughts during acute treatment appears mechanistic of solo cognitive-behavioral therapy’s enduring effects the next winter, but is simply a consequence of diminished depression in light therapy and combination treatment.     

Reduced work capacity after lumbar disc surgery: the role of cognitive-behavioral and work-related risk factors

A significant number of patients who have had surgery for lumbosacral radicular syndrome still have a reduced work capacity several months later. In a prospective cohort study of 182 people who underwent lumbar disc surgery, we determined the predictive value of preoperatively measured cognitive-behavioral and work-related factors on work capacity 6 months after surgery. Logistic regression analyses indicated that these factors independently predicted work capacity 6 months after surgery. Specifically, fear of movement/(re)injury, more passive pain coping, and higher physical work-load predicted reduced work capacity in multiple logistic regression analyses, taking into account the role of a wide range of control variables including demographic variables, preoperative disability and pain intensity, neurological deficits, intake of analgesics, duration of complaints, and pain intensity 3 days postoperatively. The study supports the need to develop and evaluate preoperative risk screening measures that include both cognitive-behavioral and work-related factors and to evaluate the effectiveness of cognitive-behavioral and work-related interventions in patients at risk of reduced work capacity after surgery for LRS.