Cognitive Behavioral Therapy Aids Long-Term Pain Management

Kate Johnson

February 13, 2012

February 12, 2012 (Miami Beach, Florida) — The benefits of adding cognitive behavioral therapy (CBT) to a chronic pain management protocol are evident in patients up to 3 years after the end of treatment, according to research.

"In our program, we don't use analgesic drugs, strong opioids, or anything," Magnus Olason, MD, from the Chronic Pain Division at Reykjalundur Rehabilitation Center in Iceland, told Medscape Medical News. Instead, he said, "we wean patients off them, and we try to teach patients relapse control: how to deal with the pain, if it gets worse, without taking drugs again."

The findings were presented here at the 6th World Congress of the World Institute of Pain.

Chronic Pain

The new study followed-up 113 patients (64% women), mean age 38 years, who had been through a 6-week pain management program to deal with noncancerous, musculoskeletal pain.

"These were chronic pain patients, almost half have had pain for more than 5 years, over 40% had low back pain, and they were on pain relievers, nonsteroidal anti-inflammatory drugs, antidepressants, relaxants," Dr. Olason said.

All patients were screened to assess whether they needed CBT, based on their scores on the Beck Anxiety Inventory, the Beck Depression Inventory (BDI-II), the Fear and Avoidance Beliefs Questionnaire, and the Pain Catastrophizing Scale. Quality of life (QOL) was also measured with the short-form 36 health survey questionnaire.

Patients were divided into groups based on these scores: those who did not need CBT (n = 34), and who therefore were put into the non-CBT pain management program; , and those who were eligible for CBT (n = 79) who were subsequently randomly assigned to either the non-CBT program or a CBT program that consisted of 12 individual manual-based sessions delivered by trained therapists.

The non-CBT program focused primarily on physical rehabilitation and exercise.

Baseline scores were measured 6 weeks before entry into the program, and again at the start of the program, and these scores were compared with scores at the end of the 6-week program, as well as 1 and 3 years after treatment.

The study showed that compared with their baseline scores, all patients showed similar statistically significant reductions in pain, catastrophizing, anxiety, and depression (P < .001), both at the end of treatment as well as at the 1-year follow-up.

Similarly, both non-CBT groups and the CBT group showed significant improvements in QOL, social functioning, and return to work.

However, at the 3-year follow-up, a statistically significant difference emerged between the groups, with the CBT group having maintained a meaningful and clinical improvement in BDI scores, and both non-CBT groups having reverted to baseline levels.

Pain and catastrophizing improvements were maintained in the CBT group, but had reverted to baseline in the non-CBT groups.

Mounting Evidence

Asked to comment, Magdalena Naylor, MD, PhD, professor of psychiatry and director of the Clinical Neuroscience Research Unit at the University of Vermont's MindBody Medicine Clinic in Burlington, said there is mounting evidence that CBT can partially reverse abnormal brain anatomy associated with chronic pain, which would explain the persistence of improvements in the CBT group alone.

She said her group's work with functional magnetic resonance imaging shows that CBT can alter dysfunctional neural circuitry associated with chronic pain, improving both coping and perception of pain, regardless of baseline depressive or anxiety symptoms.

"Our neuroimaging study documented that the gray matter atrophy associated with chronic pain can be reversed by an 11-week group CBT," she told Medscape Medical News. "We propose that increased gray matter volume in the prefrontal cortex reflects greater top-down control over pain, while changes in pregenual cingulate and somatosensory cortices reflect changes in the perception of noxious signals."

The study was supported by the Icelandic Center for Research. Dr. Olason and Dr. Naylor have disclosed no relevant financial relationships.

6th World Congress of the World Institute of Pain: Abstract 260. Presented February 5, 2012.

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