Is Cognitive Behavioural Therapy (CBT) effective in helping chronic pain

patients manage their pain as part of a multi-disciplinary approach to their

care?
Introduction
Chronic pain is defined by the British Pain Society as: continuous, long-term pain of
more than 12 weeks or after the time that healing would have been thought to have
occurred in pain after trauma or surgery.1 It is a condition influenced by biological,
psychological, and social factors, hence being managed, ideally, by treatments that
addresses not only the physical negative manifestations associated with chronic pain
(such as sleep disturbance), but also its psychological, emotional and social
influences and consequences.2
A survey conducted in 15 European countries and Israel in 2005, concluded that
19% of approximately 46,000 respondents had suffered pain for a period of time of 6
months or more, having also experienced pain in the last month and several times
during the last week.3
Traditional biomedical methods of treating chronic pain have proven unsatisfactory
both from the patients and providers prospective and this encouraged a demand for
effective therapy. Chronic pain that is not adequately treated can often cause the
patient to develop psychological, psychosocial and behavioural problems as well as
progressive physical deterioration with marked interruption of activities of daily living.
4

The Oxford Dictionary of English defines the word multidisciplinary as: Combining
or involving several academic disciplines or professional specializations in an
approach to a topic or problem.5 The objectives of multiple disciplinary approaches
are to resolve real world or complex problems (such as chronic pain) to provide
different perspectives on problems, to create far-reaching research questions, to
develop a consensus in clinical definitions and guidelines, and to provide more
thorough health services.6
Currently there is reasonable amount of evidence that patients with chronic pain who
take part in multidisciplinary pain programs can enhance their psychological and

physical functioning.7 Therefore, it is important to address chronic pain from a

multidisciplinary point of view, taking into consideration all aspects of the patient.
Over the past 60 years, parallel advances in the scientific understanding of pain and
the development of cognitive and behavioural therapies have led to the widespread
application of CBT to chronic pain problems.2
CBT is currently an integration of two originally separate theoretical approaches to
understanding and treating psychological disorders: the behavioural approach and
the cognitive approach. The behavioural approach focuses mainly on observable,
assessable behaviour and omits all mental events. It main focus point is the
interaction of environment and behaviour. The cognitive approach centres on the role
of the mind, and specifically on cognitions as determinants of feelings and
behaviours.8
In practice, cognitive-behavioural treatment programs incorporate the key aspects of
the operant model, the emphasis on contingent relationships between pain
behaviour and social consequences, especially when concerned with family
interactions in chronic pain patients.9 In most cases, these programs intend to equip
patients with the psychological tools needed to adequately meet the challenges of
persistent pain syndromes.10
The aim of this essay is to explore the effectiveness of CBT as part of a
multidisciplinary approach in the management of chronic pain by reviewing, critiquing
and analysing the literature available on the subject.
Literature Review and Critical Analysis
In the past two decades, researchers have aimed to determine the efficacy of
multidisciplinary pain treatment through meta-analytic studies. Flor et al.11 examined
65 studies that evaluated the efficacy of multidisciplinary treatments for chronic low
back pain (CLBP). The authors concluded multidisciplinary treatments for chronic
pain are superior to no therapy, waiting list, and single disciplinary treatments such
as physical therapy. In the majority of the RCTs investigating the efficacy of
multidisciplinary approach for the treatment of chronic pain, CBT is an important
element of the multidisciplinary program.12

The primary objective of CBT for pain is to promote the adoption of an active
problem-solving approach to tackling the many challenges associated with the
experience of chronic pain. A shift from helplessness with regard to these challenges
to one of personal responsibility, self-control, and confidence is encouraged. The
cognitive-behavioural approach is informed by the understanding that people
generally do not stop being active because of pain, but because they have become
adjusted to the idea that they are physically disabled. Thus, CBT for chronic pain
involves challenging those beliefs and teaching patients ways of safely reintroducing
enjoyable activities to their lives. This can be a particularly daunting task when
thoughts related to disability have been place for long periods of time.13
There are several key components to CBT for chronic pain, including cognitive
restructuring, training in relaxation techniques, activity pacing and homework
assignments designed to decrease the persons avoidance of activity and
reintroduce a healthier active lifestyle. Since individuals who experience chronic pain
often report decreased activity levels and declines in social role functioning, CBT
also focuses on promoting patients increased activity and productive functioning
using techniques such as home-based exercises, activity programming, and
progressive task assignments.8,13
A comprehensive treatment approach for chronic pain patients includes one or more
of these combined with therapies such as physiotherapy, medication for pain and
patient education. Multidisciplinary approach treatments have been recognize in the
past few decades and now find further expansion.9 It has been evaluated in many
studies and some reviews do exist, but they have their limitations.
The first meta-analysis11 elicited in this literature search included non-controlled
clinical studies. The contemporary reviews and meta-analyses found are restricted to
chronic low back pain,14,15 fibromyalgia (FM)16,17 or investigated behavioural
treatment alone and not multidisciplinary approaches.18,19 Others authors have
included different intervention modalities for FM, such as pharmacological approach.
20

Publications retrieved for the literature review and critical analysis in this essay were
searched using MEDLINE, PEDro, Google Scholar and University of Leicester

librarys data base, combing keywords and other relevant terms including:
multidisciplinary, CBT, cognitive-behavioural therapy, and chronic pain.
Only RCTs were included in this essay. The studies had to involve adult patients with
chronic pain (such as FM and CLBP). At least one study group had to be treated in a
multidisciplinary approach in a group setting. Additionally, CBT had to be part of the
multidisciplinary treatment. Plus, a couple of these aspects had to be covered: pain,
quality of life, disability, emotional strain, coping, physical capacity, consumption of
pain medication or pain behaviour. A follow-up (FUP) of at least 3 months had to
have been supervised. There were no date restrictions for the selection of studies in
this essays literature review and critical analysis.
The first two RCT reviewed aimed to compare patient outcomes of 2 treatments. In
1992, Altmaier et al.21 randomised forty-five low back pain patients to one of the
groups. One group participated in a standard inpatient rehabilitation program for
CLBP, emphasizing education and physical reconditioning, and the other took part in
a psychologically based program which added CBT components such as: operant
conditioning, relaxation, biofeedback, and coping skills training to the standard
program. Measures of functional status were taken before treatment, at the moment
of discharge from the inpatient program, and at a 6-month FUP. Data revealed that
patients improved their overall functioning at discharge and maintained these gains
at the follow-up assessment. Patients benefits, however, were not differentially
affected by treatment group assignment, implying that the psychological treatment
failed to increase the effectiveness obtained by the standard rehabilitation program.
The power analysis in this study revealed that the authors were able to detect a
difference between groups with a power of 0.80, hence having sufficient power to
detect large to moderate treatment effects. These findings suggest that in clinical
practice, the standard treatment is beneficial enough on its own without the
psychological interventions. However, the standard treatment program had a
multidisciplinary approach, using exercise, education, group support and vocational
rehabilitation as therapy instruments, which on their own could be able to address
negative psychological cognitive patterns of chronic pain such as catastrophizing,
overgeneralization, helplessness and selective abstraction within others, thus
questioning the authors group treatment design, where they couldve made it

cleaner, for example using in the control group only physical treatment, taking out the
psychological components. In that way, the effects of CBT could be really
differentiated from the standard treatment group.
Even though many studies have demonstrated the short-term effectiveness of
multidisciplinary pain treatment programs, few studies have stated that these
treatments benefits are maintained over time.21 For this reason, in order to explore
long-term CBT efficacy as part of a multidisciplinary program, trials with longer FUPs
were included in this essays section.
After 13 years from the original trial, Patrick et al.22 intended to determine if posttreatment improvements were maintained over a long FUP period. Of the original 45
subjects participating in the previous study,21 only 26 accepted to be included in this
FUP study, using telephone interviews. This type of interview may produce
misunderstanding of the information between the interviewer and the patient. In
addition, the small percent of patients that agreed to participate creates a possibility
of bias in the results because participants balance in allocation couldve differed from
the balance in the original population being studied in the previous study.
Confounding this, the results show that patients maintained treatment benefits in all
areas, including pain intensity and interference, mood, employment and general
health, which might suggest that CBT as part of a multidisciplinary program can be
helpful and beneficial for chronic pain for long periods of time. However, as stated
before, the method for retrieving the data (telephone interview) may create
misunderstanding between interviewer and interviewee, whereas face to face
interviews would be more personal, thus reflecting more legitimate results.
Exploring the same chronic syndrome as both studies reviewed above, Kole-Snijders
et al.23 examined the supplemental value of a cognitive coping skills training when
added to an operant- behavioural treatment for CLBP patients. Authors chose a
randomised controlled design consisting of two measurements before treatment, one
during treatment, one after treatment, and two FUP measurements (6 and 12 months
after termination of treatment). A hundred and fifty nine subjects were randomised
into 3 groups. The operant behavioural treatment with cognitive coping skills training
(OPCO) was compared with an operant program + group discussion (OPDI) and a
waiting-list control (WLC), which received a less protocolized operant program,

missing a number of the other two groups treatment ingredients, such as spouse
training, group program and written contract. The operant behavioural treatment (for
both OPCO and OPDI groups) consisted in PT sessions, occupational therapy (OT)
sessions, psychotherapy sessions and meetings with the rehabilitation team to
discuss progress and provide reinforcement, adding either the cognitive component
or the group discussion. The analyses of the results showed that, compared with
WLC, both the OPCO and the OPDI groups led to less negative affect, higher activity
tolerance, less pain behaviour, and higher pain coping and pain control.
Furthermore, at post treatment the OPCO led to better pain coping and pain control
than the OPDI. Calculation of improvement rates revealed that both active groups
(with the CBT component) had significantly more improved patients than the WLC
group on all the dependent variables. Nevertheless, the results imply that, clinically,
a complete CBT multidisciplinary program is needed to accomplish patients recovery
and general well-being.
Investigating a different chronic pain condition, Cedraschi et al.24 published a study
in 2004 that aimed to evaluate the efficacy of a treatment programme for patients
with fibromyalgia (FM) based on self-management, using water-pool exercises and
education. One hundred and twenty nine patients with FM were randomly allocated
to an immediate 6 week programme or to a WLC group. The main outcomes were
quality of life, functional effects, pain and patient satisfaction. Six months after the
programme was completed, important gains in quality of life and functional effects of
FM were seen in the treatment group as compared with the controls. All important
areas of patient satisfaction presented greater improvement in the treatment than the
control groups. From the results of this study, one may infer that a 6 week treatment
programme, which combines physical activity, education, encouragement of selfmanagement schemes, and improvement of coping skills, arise in statistically
important development in quality of life, functional effects associated with FM, and
patient satisfaction with the therapy provided. Withal, these gains were maintained
for at least 6 months after the programme was over, particularly for factors such as
fatigue, depression, anxiety, and vitality. One can also conclude that a mildly
intensive multidisciplinary programme of rather short duration, with cognitive and
behavioural therapy components, can help patients with FM, which is a complex
condition for whom there is no current specific treatment.

One year after the study discussed above, the same condition was researched by
Lemstra et al.,25 exploring the effectiveness of a multidisciplinary rehabilitation (with
CBT components) treatment of FM in comparison to standard medical care.
Seventy-one subjects were randomised in either the intervention group or the WLC
group. The intervention group consisted of a rheumatologist, physical therapist and
psychologist; with group supervised exercise therapy, educational group lectures
(such as; pain, stress management, relaxation training and dietary lectures) and
massage therapy. The WLC group consisted of standard care provided by the
patients family physician. As authors expected, subjects in the intervention group
had a statistically significant increase in their self-perceived health status while
decreasing their scores in average pain intensity, pain disability index, beck
depression inventory scores, days and hours in pain in comparison to the control
group. This results show that multidisciplinary programs with CBT components are
most likely to produce positive effects on patients diagnosed with FM. Clinically,
people living with FM can be undertreated because of the complexity of their
condition, hence the management of this illness should be addressed from a
multidisciplinary approach including CBT techniques such as relaxation training,
behaviour modification, pacing and group activities.
Lastly, Kp et al.26 aimed to evaluate the effectiveness of a semi-intensive
multidisciplinary rehabilitation for patients with CLBP in an outpatient setting,
comparing multidisciplinary group rehabilitation program (MR) with individual PT
program (IP). The goal of the MR was to restore the physical and occupational
condition of the patients, improve their pain coping skills, and praise them to take
responsibility for the management of their back pain, whereas the purpose of the IP
treatment was to bring relief to back pain and help the patients return to normal daily
activities. The primary outcomes were pain intensity, back specific disability,
subjective working capacity, sick leave due to back pain, healthcare consumption
due to back pain, symptoms of depression, general well-being after given back
rehabilitation, and beliefs of working ability after 2 years. Patients expectations for
treatment benefit were assessed as well. In both groups, the before-and-after
comparison showed improvement in main outcome measures, and the effects were
still maintained at the 2-year follow-up. One must consider that in this study two
potentially effective treatment programs were compared. However, both groups had

different treatment goals, from which one may question the veracity of the results
due to the different formulation for the aims of the program. Furthermore, both
groups had a CBT component to the treatment, because professionals delivering the
treatment had CBT training in both cases, thus making it less easy to determine if
the difference between groups was real or not. However, there was no significant
difference in the results between groups, reflecting that authors couldve omitted the
CBT component from one of the groups so a difference couldve been appreciated.
In spite of this, one must consider the fact that using a control group without any
intervention may have caused disappointment within patients, hence creating a
false-positive outcome in favour of the treatment method studied.
Conclusion
As in conclusion of the literature reviewed, CBT orientated multidisciplinary
treatments are effective for chronic pain syndromes. However, its still necessary to
determine the components that are really important and elucidate whether all
patients (with different chronic pain conditions and characteristics, culture, age, etc.)
would benefit from all or some components of the treatment. Additionally, the overall
methodological quality of the trials reviewed in this essay was found to be rather low.
One must take into account that important requirements for a high quality RCT, such
as the double-blinding may be difficult to accomplish in multidisciplinary treatment
investigations. Other requirements for high quality RCTs, like randomisation and
concealment of treatment allocation were poorly reported in the studies reviewed in
this essay. Furthermore, it is important to consider the fact that many of these
studies had small sample sizes, and as a consequence were underpowered and
some effects mightve not been detected.27 As a matter of fact, in one of the studies
reviewed above, several patients withdrew their consent after randomisation, which
the authors replaced with unrandomised subjects. This clearly increases the
possibility of bias in the results because random allocation of the sample is highly
important in a clinical trial. If the investigators fail to use randomisation when it could
be used, it may compromise the credibility of the study.28
Moreover, the majority of the studies reviewed in this essay had CBT components in
both the experimental and control groups, which may create confusion when
interpreting the results, and also, may lessen the value of the evidence found.

Future Recommendations
In the future, substantial additional work is extremely necessary (with larger study
groups and longer follows up periods), to examine further the underlying
mechanisms for the improvements seen with CBT oriented multidisciplinary
programs, hence, providing more insight into the essential elements of these
programmes, so researchers can really estimate the ideal duration and intensity
necessary to achieve sustained improvements in time.
Further studies should compare different methods, settings and lengths of CBT
orientated multidisciplinary chronic pain programs and explore their connection with
patients characteristics in more depth in order to distinguish differential effects. This
might be solved by conducting more multicentre studies, and having high quality
allocation and randomisation systems. Nevertheless, due to the extensive
heterogeneity among outcome measures within the studies reviewed, one could
recommend stronger methodological guidelines and the use of internationally
accepted outcome measures in favour of making studies more comparable with each
other. Not to mention the importance of conducting more trials which include costbenefits analyses in order to observe which of the different CBT orientated
multidisciplinary chronic pain programs are really worth being carried out.
Finally, it is also important to outline that similar studies to the ones previously
reviewed, are needed to demonstrate to governmental health authorities worldwide
the importance of increasing the budget to develop solid CBT orientated
multidisciplinary chronic pain rehabilitation programs to help patients living with
chronic pain syndromes improve their quality of life.

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