Cognitive-behavior therapy in the management of chronic, occupational pain of the upper limbs

Forty five subjects who experienced chronic, occupational pain of the upper limbs were randomly assigned to one of three conditions; individual cognitive-behaviour therapy (ICBT), group cognitive-behaviour therapy (GCBT) and WLC. Significant benefits were found for both ICBT and GCBT on measures of anxiety, depression, coping strategies, impact on daily living, pain and distress caused by pain. These gains were not evident in the WLC and were maintained at the 6 month follow-up Minimal difference was found between ICBT and GCBT on measures of pain and psychopathology, although client evaluation ratings at the end of treatment favoured ICBT.     

Cognitive-behaviour therapy for chronic fatigue syndrome: comparison of outcomes within and outside the confines of a randomised controlled trial

Outcomes for cognitive-behaviour therapy (CBT) in randomised controlled trials (RCTs) have rarely been compared to those in routine clinical practice. Taking the case of CBT for chronic fatigue syndrome (CFS), we evaluated the results of a successful RCT against those of the same treatment given in the same setting as part of routine practice. Fatigue and social adjustment scores were compared for patients who received CBT for CFS as part of a RCT (N=30) and patients who received CBT as part of everyday clinical practice (N=384). The results in the RCT were superior to those in routine clinical practice. Between pre-treatment and 6-month follow-up, the RCT showed a larger reduction in fatigue and greater improvement in social adjustment than those in routine treatment. The changes in fatigue scores were similar for both groups during treatment but were greater in the RCT between post-treatment and follow-up. Potential reasons for the superior results of the RCT include patient selection, therapist factors and the use of a manualised treatment protocol. Practitioners need to pay particular attention to relapse prevention and ensuring adequate follow-up in addition to encouraging patients to continue with cognitive-behavioural strategies once treatment has ended.     

Site-specific muscle hyper-reactivity in musicians with occupational upper limb pain.

Fourteen musicians who reported a history of pain in the upper limb associated with the playing of their instruments were compared with a sample of pain-free musicians, matched for age, sex and musical instrument. Four tasks were presented in random order and included neutral, general stressor, personal stressor and pain stressor tasks. Ratings of stressfulness and recordings of skin conductance level confirmed the effectiveness of the experimental manipulations for both subject groups. No differences were found between groups or tasks for frontalis surface electromyograph (EMG) activity. Evidence was found, however, of EMG elevation in flexor and trapezius muscles on the pain side for the pain subjects, in response to the task involving recall of a pain experience. This elevation was not found for the pain-free controls or for other stressor tasks, although some elevation in response to the pain stressor task was found for pain subjects in the trapezius muscles of the non-pain side. The duration of return to baseline of EMG following the pain stressor task was found to be extended in pain subjects for the trapezius, but not for the flexor muscles of the pain side. The findings suggest that site-specific muscle hyper-reactivity may play a role in the development and maintenance of occupational upper limb pain in musicians.     

Acceptance and values-based action in chronic pain: a three-year follow-up analysis of treatment effectiveness and process

Recent developments in CBT emphasize the promotion of psychological flexibility to improve daily functioning for people with a wide range of health conditions. In particular, one of these approaches, Acceptance and Commitment Therapy (ACT), has been studied for treatment of chronic pain. While trials have provided good support for treatment effectiveness through follow-ups of as long as seven months, the longer-term impact is not known. The present study of 108 participants with chronic pain examined outcomes three years after treatment completion and included analyses of two key treatment processes, acceptance of pain and values-based action. Overall, results indicated significant improvements in emotional and physical functioning relative to the start of treatment, as well as good maintenance of treatment gains relative to an earlier follow-up assessment. Effect size statistics were generally medium or large. At the three-year follow-up, 64.8% of patients had reliably improved in at least one key domain. Improvements in acceptance of pain and values-based action were associated with improvements in outcome measures. A “treatment responder” analysis, using variables collected at pre-treatment and shorter term follow-up, failed to identify any salient predictors of response. This study adds to the growing literature supporting the effectiveness of ACT for chronic pain and yields evidence for both statistical and clinical significance of improvements over a three-year period.     

Cognitive-behaviour therapy for marital conflict: refining the concept of attribution

In recent years, the concept of attribution has received increasing attention in the field of cognitive-behavioural marital therapy. Research has found that the attribution dimensions of source, globality, stability, intent and voluntariness are related to marital distress and conflict behaviours. This paper argues that the application of the attribution dimensions has been conceptually problematic, and proposes a distinction between attributions made for a specific conflict episode, a behaviour in an episode and the causal schema for the conflictual relationships. Different reattribution techniques should be employed to target attributional change at appropriate levels of conflict attributions. This proposition is illustrated with a case example.     

MMPI-2 characteristics in a chronic pain population

This study investigated the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) characteristics of 209 chronic pain patients in an inpatient pain treatment program. Patients completed the MMPI-2, Zung Self-Rating Depression Scale, and Oswestry Low Back Pain Disability Questionnaire. Participants in this sample were matched with comparison participants from the MMPI-2 normative sample on the demographic variables gender, age, and ethnicity. Chronic pain patients reported higher levels of general maladjustment and affective distress than did the normative control group, including more anxiety, depressive symptomatology, and somatic complaints. The MMPI-2 basic scales Hypochondriasis, Depression, and Hysteria were the most useful discriminating factors between chronic pain patients and normal controls, and the content scales Health Concerns and Depression showed significant elevations for the chronic pain group. The 1-3/3-1, 1-2/2-1, and 2-3/3-2 code types accounted for more than two thirds of all two-point classifications for the chronic pain group, and four cluster analysis types classified nearly half of all of these protocols.     

Family treatment for chronic pain: State of the art

A variety of family therapy techniques have been used to treat chronic pain. In this paper, an attempt is made to examine those familytherapy methods. It is noted that to date there is virtually a total absence of research to determine the efficacy of family therapy to treat chronic benign pain. From a clinical perspective family therapy must be offered to famiies with chronic pain patients to counteract the negative impact of chronic pain on the entire family system.     

Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review

The number of acceptance- and mindfulness-based interventions for chronic pain, such as acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT), increased in recent years. Therefore an update is warranted of our former systematic review and meta-analysis of studies that reported effects on the mental and physical health of chronic pain patients. Pubmed, EMBASE, PsycInfo and Cochrane were searched for eligible studies. Current meta-analysis only included randomized controlled trials (RCTs). Studies were rated for quality. Mean quality did not improve in recent years. Pooled standardized mean differences using the random-effect model were calculated to represent the average intervention effect and, to perform subgroup analyses. Outcome measures were pain intensity, depression, anxiety, pain interference, disability and quality of life. Included were twenty-five RCTs totaling 1285 patients with chronic pain, in which we compared acceptance- and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Effect sizes ranged from small (on all outcome measures except anxiety and pain interference) to moderate (on anxiety and pain interference) at post-treatment and from small (on pain intensity and disability) to large (on pain interference) at follow-up. ACT showed significantly higher effects on depression and anxiety than MBSR and MBCT. Studies’ quality, attrition rate, type of pain and control group, did not moderate the effects of acceptance- and mindfulness-based interventions. Current acceptance- and mindfulness-based interventions, while not superior to traditional cognitive behavioral treatments, can be good alternatives.     

A collaborative approach in the treatment of chronic pain

The impact of chronic pain on patients and their families can be devastating, with significant disruption and progressive deterioration of many life functions and roles. Typically, chronic pain patients have exhausted all standard medical treatment alternatives without finding relief from the pain. For chronic pain patients and their families, this leads to dependency on the health-care system which leaves patients and their families feeling helpless and hopeless in their struggle to survive their pain experiences. Assessment and treatment of chronic pain requires a comprehensive approach based on a multidimensional conceptualisation of pain that addresses cognitive, affective, behavioural, as well as sensory factors in the pain experience. A cognitive-behavioural treatment programme consisting of (a) a comprehensive multidimensional assessment, (b) a reconceptualisation aspect, (c) a skills acquisition phase, (d) a skills application, maintenance, and generalisation component, and (e) relapse prevention, is outlined. Emphasis is given to the important inter-related roles of the collaborative therapeutic relationship, reconceptualisation of the pain experience, and coping skills training, leading to self-management of life with pain as the ultimate treatment objective.     

Developing a treatment manual for attention management in chronic pain

This article reports the development of a protocol for the therapeutic application of "attention control" for chronic pain. Attention control is the limitation of the impact of pain by switching or retunning attention. An expert systems approach was used to develop the protocol. In the first stage an extensive literature search retrieved published and unpublished accounts of attention control strategies and a draft treatment manual was prepared. In the second stage 6 experts were recruited and they independently read and reviewed the draft manual. They were interviewed using a semi-structured protocol to elicit their views on the draft manual. The manual was then revised to accommodate the information and expertise. In addition to providing expert opinion on the manual the experts also raised issues about the process of change in psychological treatment for chronic pain. These issues were organized into a process model of change in chronic pain.     

Repression predicts outcome following multidisciplinary treatment of chronic pain.

This study examined whether repression predicts outcome following multidisciplinary treatment for chronic pain and whether links between anxiety and outcome are obscured by repressors. Ninety-three chronic pain patients completed a 4-week pain program. Lifting capacity, walking endurance, depression, pain severity, and activity were measured at pre- and posttreatment. Low-anxious, repressor, high-anxious, and defensive/high-anxious groups were formed from median splits of Anxiety Content (ACS) and Lie scales of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). Significant ACS x Lie interactions were found for lifting capacity, depression, and pain severity changes. Planned comparisons showed that both repressors and high-anxious patients performed poorly on lifting capacity; repressors alone recovered poorly on depression and pain severity. Results imply that repression may interfere with the process and outcome of pain programs.     

MMPI-2 subgroups in a sample of chronic pain patients

MMPI-2 scores of 307 female and 161 male chronic pain patients were analyzed by gender using a multivariate clustering method. Two subgroups were found for both sexes replicating previous results. The major subgroup corresponded to the classical "Conversion V" and the minor corresponded to the "Generally elevated" profile. The results also indicated a satisfactory internal consistency and a high discriminant validity of the Swedish version of the MMPI-2.     

Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase

The concept of acceptance is receiving increased attention as an alternate approach to the suffering that is often associated with persistent and disabling pain. This approach differs from established treatments in that it does not principally focus on reducing pain, but on reducing the distressing and disabling influences of pain as they concern important areas in patients' lives. The present analyses represent a preliminary evaluation of an acceptance-based approach to chronic pain within an interdisciplinary treatment program. One hundred and eight patients with complex chronic pain conditions completed treatment and provided data for the current study. Treatment was conducted in a 3- or 4-week residential or hospital-based format. It included a number of exposure-based, experiential, and other behavior change methods focused on increasing (a) engagement in daily activity regardless of pain and (b) willingness to have pain present without responding to it. Significant improvements in emotional, social, and physical functioning, and healthcare use were demonstrated following treatment. The majority of improvements continued at 3-months post-treatment. Improvements in most outcomes during treatment were correlated with increases in acceptance, supporting the proposed process of treatment.     

Follow-up results of a cognitive-behavioural treatment for chronic pain in a primary care setting

Abstract

An outpatient cognitive-behavioural treatment programme for pain control was administered to chronic pain patients in three primary care practices with a medical psychologist as a group therapist. The patients suffered from headaches, migraines, cervical pain, shoulder-arm pain, and low back pain. A matched sample of patients with the same disorders served as a waiting-list control group. The programme consisted of training in progressive muscle relaxation, several attention related techniques, and cognitive restructuring as well as reinforcing non-pain behaviour, and aimed at an improvement of self-control strategies. At the six month follow-up, the treated subjects showed improvements in their average scores of anxiety, depression and bodily symptoms compared with the untreated controls. Pain intensity was reduced by 34% in those subjects (9 out of 25) who were most adherent to the treatment regimen. Our results indicate a long-term improvement in well-being as a consequence of the treatment. This was confirmed by the ratings of the physicians and by the reduced number of patient-physician contacts three months post treatment as compared to the controls. Treatment adherence seems to be a most important agent in maintaining long-term reductions of pain intensity.     

Predicting outcome of chronic pain treatment via a modified self-efficacy scale

This study utilized a modified self-efficacy scale and examined the relationship of perceived self-efficacy to treatment outcome in a chronic, intractable, benign pain population (N = 62). In two separate studies a self-efficacy scale was given to inpatients in a combined cognitive-behavioral and medical treatment program. The scale categories consisted of (1) walking distance, (2) lifting ability, (3) pain coping, (4) working ability, and (5) social and recreational engagement. Self-efficacy beliefs were found to be associated with the level of functioning of these patients and their response to treatment. Patients with higher self-efficacy scores following treatment rated themselves as more improved and demonstrated better overall functioning with greater reductions in chronic illness behavior at followup. These observations support the merits of self-efficacy measures as predictors of treatment outcome in chronic pain patients.