Integrative Pain Managment With Cognitive Behavioral Therapy

Natalie Lewis L.Ac., Doctoral Candidate

          Evidence for Non-Pharma Pain Management Through Cognitive Behavioral Therapy

     During labor and childbirth, women who seek support for a natural birth learn meditation and relaxation techniques to control their fear in order to cope with the pain. They do best when they retrain their thoughts to believe that birth is normal and not a catastrophic injury. Marathon runners succeed not only through intense physical training but through intense cognitive training to override the messages of pain and instead believe in their strength and their bodies to continue running. Researchers studying the benefits of cognitive restructuring to help patients with intense chronic pain find the benefits to last months after the patients were trained to think differently.  Lazaridou et al. performed a randomized controlled trial to study the effects of Cognitive Behavioral Therapy for fibromyalgia patients entitled: Effects of Cognitive Behavioral Therapy (CBT) on Brain Connectivity Supporting Catastrophizing in Fibromyalgia (2017). 

This controlled clinical trial randomly assigned participants to a group that received either Cognitive behavioral therapy or a control group that received Fibromyalgia education. The patients all had fibromyalgia (FM) with a tendency toward high-catastrophizing as assessed initially by both pain and catastrophizing questionnaires as well as functional MRI which measured brain connections. Patients brains were scanned with fMRI before the treatments, after four weeks of four treatments, and six months after the study. Their hypothesis asserted that Cognitive Behavioral Therapy (CBT) positively effects the connectivity in the brains of patients with Fibromyalgia and reduces FM pain characterized by hyperalgesia with catastrophizing. 

      The fMRI was used to observe the brain connectivity of the FM study participants and measure how that connectivity changed after four weeks of treatment and six months after the end of the study. The interesting finding was that the changes in connectivity were observed six months after the four weeks of CBT, not immediately after the four weeks. Further research, the authors believe, would require smaller sample sizes to predict the benefits of CBT for FM patients. While the fMRI observed several parts of the study participants’ brains,  the CBT treated group that showed improvement in the “reduced resting state connectivity between S1 and anterior/medial insula at posttreatment” (Lazaridou 2017).

Researchers enrolled only high-catastrophizing patients and found that the cognitive skills taught through CBT were more effective for catastrophizing than for depression. Other similar research helped the researches focus on catastrophizing as the most likely to benefit from CBT.

     The treatment group received CBT with the goal of reducing catastrophizing behavior, with homework and direct strategies to redirect their behaviors, beliefs and attitudes. The hypothesis included a belief that catastrophizing increased FM while CBT reduced FM by focusing on the reduction of catastrophizing, a dysfunctional set of cognitive emotional processing. The overall hypothesis sought to reveal the benefit of cognitive behavioral therapy with an emphasis on reducing catastrophizing to reduce pain and change the brain connectivity that plays a role in FM. 

     Researchers employed different measurements for their baseline questionnaire versus their outcome measurements. One of the benefits of a randomized clinical trial is the flexibility researchers have to make changes to the study based on the findings along the way. For baseline evaluations, Lazaridou et al. used several questionnaires including the Widespread Pain Index, the Symptom Severity Questionnaire and the Short form 36 health survey (SF-36). The SF-36 includes 36 questions assessing health-related quality of life while the Visual Analog Scale for Fatigue measures fatigue. Brain fMRI scans were also taken. After the four weeks of CBT, researchers used Outcome measures (assessed at baseline, post-treatment, and 6-month follow-up)—The Brief Pain Inventory is an instrument that measures pain severity for FM patients. The Beck Depression Inventory is a general measure of depressive symptomatology. The Pain Catastrophizing Scale is a self-reporting measure of catastrophic thinking associated with pain.

The follow up tests helped researchers identify outliers and cluster groups to increase precision in their analysis of the results.

    Catastrophizing affects pain, according to the article; catastrophizing thoughts about pain includes magnification, rumination and helplessness. Researchers indicate the presence of a “default mode network” which is apparently identified by the fMRI. After the CBT patients with less self-reported pain have a reduction in the functional connectivity between S1 and insula cortex regions of the brain. Researchers indicate catastrophizing is an important factor to address in order to reduce FM pain through CBT. In addition to relaxation, strategies such as visual imagery, thought challenging, and distraction were utilized to retrain the CBT group (2017 Lizaridou et al.). Researchers indicate that the thoughts about pain may precede the perception of pain and influence how long pain lasts. The CBT cognitive restructuring was used to help patients recognize the relationships between thoughts, feelings and behaviors. Patients learned to identify, evaluate, and challenge negative thoughts and to diminish the degree of catastrophizing about their pain.

     Implications, based on the study’s conclusions, for treating fibromyalgia patients are powerful for self-management of FM. Patients continued to practice the cognitive skills they learned beyond their four weeks of treatment. This empowered the patients to continue actively treating themselves. This self-treatment is inspiring. Patients demonstrated the responsibility and the ability to maintain their improved mental health and use the skills without a dependence on drugs or endless therapy.

     Questions that remained unanswered by the study’s findings include not counting how often patients used the skills they learned in the follow up or which skills were indeed used. This would be very difficult to assess because patients were taught multiple skills and strategies at the same time. It would be very difficult to tease out which skills were more helpful and which were less helpful. This study did not compare the effects of CBT with meditation or exercise in the treatment of FM with catastrophizing, despite the evidence that they also help.

     The study did not examine how hyperalgesia is not only an increased sensitivity to pain but also pain caused by damage to nociceptors or peripheral nerves that cause hypersensitivity to stimulus. The authors used self-reporting questionnaires that in and of themselves show improvement six months after the CBT ended. And the fMRIs show changes in the brain’s connectivity but there remains no conclusion as to whether the patient has just been trained to perceive their pain differently (choose to be less upset about it), or if the nociceptors are actually healed. Is the patient’s pain messaging overridden by the brain’s ability to refocus or not focus as the case may be? Or was the pain actually healed by the patient’s thoughts about the pain? Is it just the messaging of pain that is obstructed or does the new messaging heal the tissue? And further, there is no mention of nociceptors healing or peripheral nerves healing in the study. Rather than fMRI of the painful soft tissue in the body or the painful nerves in the body, the researchers took images of the brain, the part of the body that perceives pain or receives messages about pain elsewhere. This could lead the reader to the conclusion that the pain is “all [if not partially] in their heads”. I see how catastrophizing leads to more emotional pain which, researchers believe, compounds the physical pain. This is not a new idea. I was told fifteen years ago that there is pain and then there is how we interpret the pain and that interpretation makes a  difference in suffering. Independent of catastrophizing, patients do experience significant physical pain from injuries, trauma, disease, surgeries etc. Results from this study emphasize that how we think about our pain, or the stories we tell ourselves about what our pain means (ie fear of job loss or inability to care for loved ones) can either reduce or exacerbate our pain. 

     Clinically, I am encouraged by the results of this study. The evidence that Cognitive Behavioral Therapy reduces pain for catastrophizing FM patients may reduce the prevalence of FM and of opioid addiction. I am hopeful that fMRI will not be necessary, however, because it has risks associated with radiation exposure and it is expensive. The CBT skills and strategies used to help patients reduce their catastrophizing behavior include: “active, structured techniques to alter distorted thoughts, with a focus on acquiring and practicing cognitive and emotion-regulation skills. CBT was based on self-management. This required that patients recognize their own catastrophizing behavior “using techniques such as relaxation, visual imagery, thought challenging, and distraction. CBT prominently emphasized ‘in-vivo practice’ during each session, and featured home practice using written exercises”(Lazaridou 2017). In particular, cognitive restructuring was used to help patients recognize the relationships between thoughts, feelings and behaviors. Patients learned to identify, evaluate, and challenge negative thoughts and to diminish the degree of catastrophizing about pain. The control group was provided information about fibromyalgia and educated about chronic pain. The control group received no training or homework assignments about how to change their thoughts or behavior. The control group was educated about the FM condition but not trained how to reduce their catastrophizing (Lizaridou 2017). 

      I was pleased to see the evidence of a non-pharmalogical option in the treatment of fibromyalgia patients. And I was also happy that the treatment was based on a self-management paradigm and required only four weeks with a therapist. Patients were taught how to continue to manage their behavior and hence manage their pain independently. Reading this study has helped me professionally with every client I have treated this past week. Every one of them appreciated the reminder that our thoughts have tremendous power over how we feel.

                                                              Work Cited

Lazaridou, A., Kim, J., Cahalan,C.,  Loggia, M., Franceschelli, O., Berna1, C.,  Schur, P., 

       Napadow,V.,  & Edwards,R. (2017). Effects of Cognitive-Behavioral Therapy (CBT) on 

       brain connectivity supporting catastrophizing in fibromyalgia. Clin J Pain. 33(3): 215–221.

 


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