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Cognitive behavioural therapy

Created: 20/9/2005
The factors that predict the development of chronic pain following an acute episode do not relate to any 'biological' factors such as findings on physical examination, or radiological changes, but to what are termed 'psychosocial variables', such as mood, stress and the social situation in which the pain occurs.

When pain persists in spite of medical treatment, as is the case in chronic pain syndromes, the issues become complex. Matters get worse, not solely due to progression of the disease but to the vicious circle the patients find themselves in. A patient who has pain, especially on movement, tends to avoid doing things that provoke their symptoms. They rest but unfortunately this is not a helpful treatment as it leads to secondary stiffness and weakness, causing worsening of the symptom that the individual is trying to avoid.

Inability to function leads to a loss of role and self-esteem with the progressive intrusion of other problems such as financial hardship and strained relationships. Tablets may cause side-effects, pain may prevent sleep, and all of these difficulties cause worry and low mood which worsens the situation yet further.

Cognitive behavioural pain management

Modern cognitive behavioural approaches to pain have developed from a number of linked models, all with some efficacy on their own but gaining from being delivered in combination. They have been shown to be the most logical treatment for individuals suffering from chronic musculoskeletal pain, where the pain is accompanied by disability and psychological distress.

Cognitive behavioural approaches aim to improve the way that an individual manages and copes with their pain, rather than finding a biological solution to the putative pathology. The approach is very much related to problem solving and returning control to the sufferer. Many patients state that the pain rules their lives and cannot see how this can change without a medical cure. However, with appropriate instruction in a range of pacing techniques, cognitive therapy to help identify negative thinking patterns and the development of effective challenges, stretching and exercising to improve physical function, careful planning of tasks and daily activities, and the judicious use of relaxation training, many people find that the treatment enables them to take back control of their lives, to do more and feel better.

Combined approaches

Cognitive behavioural approaches are delivered in a number of settings, with various differing protocols. While the cognitive elements of the programme are usually the province of psychologists, other staff working alongside them, such as physiotherapists and occupational therapists, are required to improve their psychological understanding and skills to enable them to contribute to the treatment package.

For example, an exercise programme run by a physiotherapist will adopt a cognitive approach by ascertaining the person's fears and beliefs about the movement or activity they are undertaking. Frequently, this will demonstrate that the person's caution relates to fear of damage. This will be approached by providing detailed information about the spine and how it functions, alongside a graded approach to movement using the behavioural principles of reward and reinforcement. Such an approach will move the person on both physically and psychologically in a way that coercion alone will never achieve.

The outcome varies greatly between individuals, with some subjects finding the ideas life-changing in their relevance and usability, while others struggle to make even small changes. Studies demonstrate that although there is some diminution in effect with time, most patients never return to their previous levels of distress or disability.

Cognitive approaches have relevance for many other areas of pain management, and indeed other aspects of medicine, in situations where people's behaviour is affected more by what they think and believe than by the extent of pathology.

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