A Webpage Worth the Read

Those of you who are connected to one of our social media sites know that we tend to post daily on the latest news and research in the field of chronic pain management. We recently came across a description of cognitive behavioral therapy for chronic pain on the web, which we initially thought we’d send out on one of our daily posts. After finding myself reading it for a second time, however, I thought that it was too good to simply send out on social media without more comment than the usual line or two of introduction that we tend to provide.

The webpage is Dr. Christopher Pither’s piece ‘Cognitive Behavioural Approaches to Chronic Pain.’ It’s part of the Wellcome Trust’s website on pain that originally accompanied an exhibition at the Science Museum in London, entitled ‘Pain: Passion, Compassion and Sensibility.’ The website overall is also well worth reviewing, containing webpages on an eclectic range of topics, including scientific research on pain, therapies for pain, the history of how we have conceptualized and treated pain in the past, and cultural issues surrounding pain. All of it is thought provoking as well as useful information to know.

As indicated, Dr. Pither’s article itself is entitled ‘Cognitive Behavioural Approaches to Chronic Pain.’ It is simply the best and most concise description of cognitive behavioral therapy for chronic pain that I have so far come across on the web.

He opens the piece with a compassionate, yet scientifically accurate, description of how chronic pain develops. He reviews the many and complex variables involved. I especially appreciate how he sticks to what the scientific data tell us while at the same time remaining empathic and non-stigmatizing. The importance of this approach to his writing lies in the scientific data: while painful acute injuries and illnesses occur to all of us, likely at a roughly equal rate across all people, what predicts the transition from acute pain to chronic pain are psychosocial factors. To put it another way, those who are at most risk of developing chronic pain once an acute accident or illness occurs are those whose central nervous systems have been previously up-regulated for psychosocial reasons. Now, of course, these consistent scientific findings do not mean that people with chronic pain are to be blamed for their condition. It is simply to assert a common truth that we all know, if we consider it for a bit, which is that the overall context in which an acute injury or illness occurs matters. If an upper respiratory infection occurs in a person whose immune system is already compromised, then that upper respiratory infection will likely take a much different course than if the same infection occurred in someone whose immune system is not already compromised. Similarly, if an acute painful injury or illness occurs in someone whose nervous system is already up-regulated, then the pain is likely to take a different course then if it occurred in someone whose nervous system is not up-regulated. Namely, the pain has a higher likelihood of continuing past the normal healing process of the original acute injury or illness, thus becoming chronic pain. Dr. Pither acknowledges such a scientific based understanding of the development of chronic pain, but does so with compassion and empathy. For after all, that is what people with chronic pain deserve.

All the stakeholders in the field of chronic pain management needs more of this kind of discussion. Whether we are provider, patient, family member, or policy analyst, we have yet to figure out a way to consistently be able to talk about the real psychosocial aspects of chronic pain without raising the specter of stigma. Indeed, all too often, we try to get rid of stigma by denying all the inherent psychosocial aspects of chronic pain. We do so, though, at our own peril. When we deny a major aspect of a health problem in order to resolve a social problem, like stigma, we are bound to have poor outcomes in the management of that health condition. Imagine the cardiovascular field attempting to successfully manage heart disease if its psychosocial components were off limits to discuss and in fact were denied as unrelated. Whether as patient or provider, the management of heart disease would fail if we couldn’t discuss the role of smoking, lack of exercise, obesity, poor nutrition, depression, and stress. Similarly, in chronic pain management, we are bound to have poor outcomes if we cannot discuss the role of the psychosocial aspects of chronic pain. But, of course, we need to be able to have this discussion without stigmatizing the patient. Typically, in our field, we don’t do a good enough job of walking this fine line. Dr. Pither, however, seems to be able to do it. We should learn from his example.

Dr. Pither also astutely describes the common trajectory of care that patients go through on their way to ending up in a cognitive behavioral based chronic pain rehabilitation program. Because chronic pain is truly a ‘biopsychosocial condition’ that doesn’t fit well into the acute medical model of care, providers tend to refer patients back and forth between the medical side of the healthcare system to the mental health side of the healthcare system with neither being able to help very much. All too often this back and forth care goes on too long. Eventually, as Dr. Pither notes, someone refers patients with chronic pain to a cognitive behavioral based chronic pain rehabilitation program where they begin to get the care that most accurately addresses the true biopsychosocial condition that they have.

While rightly claiming that cognitive behavioral based chronic pain rehabilitation programs are the most effective therapy for chronic pain, Dr. Pither’s writing exhibits the scientific values of humility and constraint (i.e., good science tends to provide conservative interpretations of the data, never making greater claims than what the data reveal). I appreciate such humility and constraint. I think that all too often in healthcare, and in the field of chronic pain management in particular, providers tend to promise more than they can deliver. Don’t get me wrong. I don’t think that the multitudes of well-trained professionals in the field are equivalent to the snake oil salespeople of yester year, intentionally making pitches that they know aren’t true. No, what I am saying is that I think there is a pervasive lack of understanding among the stakeholders in the field of what science tells us are the most effective ways to manage chronic pain. Without such knowledge, providers and the public tend to believe that everything we do — any chronic pain treatment that is commonly provided – is effective. Unintentionally, then, providers of various treatments for pain can tend to go beyond the data and promise substantial pain reduction, if not a cure, when discussing with patients what can reasonably be expected. The sentiment in Dr. Pither’s piece does no such thing. He rightly acknowledges that cognitive behavioral based chronic pain rehabilitation is the most effective treatment, but states, with humility and constraint, that what constitutes the greatest effectiveness in the field of chronic pain management is helping patients to live well despite having chronic pain. We simply do not have cures for chronic pain. Nonetheless, there is hope. People with chronic pain can live well. They just have to learn how and they learn how to do it in cognitive behavioral based chronic pain rehabilitation programs.

Charles Pither, MBBS, FRCA, is a physician and consultant in pain medicine. He practices at RealHealth, London, England.

Please read his piece entitled, ‘Cognitive Behavioural Approaches to Chronic Pain.’ You can find the link to the webpage here.

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Author: Murray J. McAllister, PsyD

Date of last modification: 10-4-2014

CBT and Central Sensitization

A study published this month in Pain produced what is likely some of the most important research findings this year for the field of chronic pain rehabilitation. The study demonstrated that basic CBT interventions can reduce central sensitization (Salomons, et al., 2014).

Countless studies in the past have shown that CBT and CBT-based chronic pain rehabilitation programs are effective in reducing self-reported pain in chronic pain patients. In these studies, we have had to infer that CBT reduces central sensitization: because CBT is effective at reducing chronic pain based on verbal self-report, and because central sensitization is a leading cause of chronic pain, we have inferred that CBT must reduce central sensitization. Now, we have a study that directly demonstrates it.

In their well-designed study, Salomons, et al., are the first to experimentally induce a form of central sensitization in a group of previously pain-free subjects, deliver a CBT intervention, and measure the reduction in central sensitization that results from the CBT intervention. As such, they are the first to demonstrate that CBT reduces central sensitization as measured in the laboratory and not simply rely on inferences based on self-reported pain levels.

The study design

The study consisted of 34 healthy women who did not have pain. Through a series of pain-provoking procedures, the researchers induced secondary hyperalgesia in these healthy women. Secondary hyperalgesia is a type of central sensitization. Central sensitization is largely considered a common, if not the most common, cause of chronic pain. In secondary hyperalgesia, the nerves in the general location of the pain become reactive in an increasingly wider area. As a consequence, it takes less and less stimuli to cause pain in this widening area around the site of the original pain.

Along side this series of pain-provoking procedures, the researchers provided half the group of healthy women with a few basic cognitive behavioral interventions for pain. The CBT intervention consisted of both providing the subjects with information about the sensory, cognitive, and affective aspects of pain and engaging them in cognitive restructuring in order to reduce the stress response that accompanies pain. Cognitive restructuring is an intervention that helps people to make sense of their pain differently, from understanding it as something that is alarming or frightening to understanding the pain as something that is more benign and not harmful or perhaps even beneficial. For the other half of women, they provided a psychotherapy focusing on becoming more assertive in interpersonal communication skills.

By comparing CBT for pain with a non-pain related psychotherapy, they attempted to determine the effectiveness of the CBT itself.

The provision of some form of psychotherapy to both groups is important because it controlled for the effectiveness of non-specific therapeutic factors of psychotherapy. Let me explain. To do so, we need to stray from our original topic a bit.

One of the most consistent findings in the last four decades of psychotherapy outcome research has been that a large percentage of what accounts for the effectiveness of psychotherapies are factors that are common to all psychotherapies. So, whether we are talking about cognitive behavioral therapy for pain or diabetes or depression, or psychodynamic therapy for dysfunctional relationship patterns, or family systems therapy for teenage behavior problems, they all tend to have some things in common, which contributes to what makes them effective. That is to say, despite having some obvious differences, they each share certain factors and these factors are in part what make them all effective.

These factors tend to be characteristics of the relationship between the provider and the patient. We tend to refer to these characteristics in general as the qualities of the ‘therapeutic relationship.’ For example, research consistently finds that, in whatever type of psychotherapy that one pursues, the development of a relationship with an expert provider who takes the time to listen to you and provide mutually respectful, caring, and honest feedback leads people to become motivated to make healthy behavior change – whether it is in learning how to manage pain or diabetes, overcome depression, develop healthy relationships, or change problematic teenage behaviors. In other words, the therapeutic relationship that you have with a healthcare provider is what leads, in part, to making healthy changes that can improve health.

So, in a study aiming to determine how CBT is effective for managing pain, Salomons, et al., needed to make sure that they were measuring what is unique to CBT for pain and not the general effectiveness that all the psychotherapies have in common. To do so, they compared CBT to a psychotherapy that was not for pain, but which would have the general therapeutic factors that are common to all therapies, including the CBT for pain. This study design thus allows the researchers to conclude that if CBT for pain is in fact more effective, then what’s making it more effective are those things that are unique to CBT. In other words, the therapeutic relationship might play a role in both psychotherapies equally, but if one is more effective, such as the CBT, then what’s pushing it over the top are those things that are unique to CBT.

So, let’s get back to what Salomons, et al., found.

Cognitive behavioral therapy and central sensitization

While both groups of study subjects reported less pain intensity, those who underwent CBT reported that the pain they had was less unpleasant and therefore more tolerable. These findings that CBT reduces pain and makes pain more tolerable are largely similar to most clinical trials of CBT for pain.

The more interesting and important finding was that the subjects who received CBT exhibited a 38% reduction in the area of secondary hyperalgesia. Recall that secondary hyperalgesia is a form of central sensitization in which the nerves around the site of pain become more reactive in a widening area. In this increasing area around the original site of pain, less and less stimuli are required to generate pain. Secondary hyperalgesia is thought to be one of the ways an acute injury can transition to chronic pain even after the acute injury has healed. In their study, Salomon, et al., experimentally induced secondary hyperalgesia and subsequently showed that CBT can reduce it.

To my knowledge, no previous study has directly demonstrated a reduction in a form of central sensitization with CBT interventions.

A possible explanation for this finding is that CBT reduces the stress response that occurs with pain. By coming to think about pain differently, the change in thinking corresponds to changes in the neural network of the brain. These changes in the brain might subsequently alter the hormonal and inflammatory responses of the stress response, which subsequently makes the nerves in the peripheral area around the site of the original pain less reactive. As such, the cognitive restructuring corresponds to changes in the brain that reduce the stress response, which lead to downstream reductions in nerve reactivity.

Whatever is the explanation, the findings of Salomons, et al., are important as they can lead us to greater confidence as to why CBT and CBT-based chronic pain rehabilitation programs are effective at reducing chronic pain.

References

Salomons, T. V., Moayedi, M., Erpelding, N., & Davis, K. D. (2014). A brief cognitive-behavioral intervention for pain reduces secondary hyperalgesia. Pain, 155, 1446-1452. doi: 10.1016/j.pain.2014.02.012

Author: Murray J. McAllister, Psy.D.

Date of last modification: 9-2-2014