CBT and CFT for Chronic Pain, 2021, Hadley and Novitch

Abstract

Purpose of Review
Chronic pain is a widespread public and physical health crisis, as it is one of the most common reasons adults seek medical care and accounts for the largest medical reason for disability in the USA (Glombiewski et al., J Consult Clin Psychol. 86(6):533-545, 2018; Schemer et al., Eur J Pain. 23(3):526-538, 2019). Chronic pain is associated with decreased functional status, opioid dependence and substance abuse disorders, mental health crises, and overall lower perceived quality of life (Korff et al., J Pain. 17(10):1068-1080, 2016). For example, the leading cause of chronic pain and the leading cause of long-term disability is low back pain (LBP) (Bjorck-van Dijken et al. J Rehabil Med. 40:864–9, 2008). Evidence suggests that persistent low back pain (pLBP) is a multidimensional biopsychosocial problem with various contributing factors (Cherkin et al., JAMA. 315(12):1240-1249, 2016). Emotional distress, pain-related fear, and protective movement behaviors are all unhelpful lifestyle factors that previously were more likely to go unaddressed when assessing and treating patient discomfort (Pincus et al., Spine. 38:2118–23, 2013). Those that are not properly assisted with these psychosocial issues are often unlikely to benefit from treatment in the primary care setting and thus are referred to multidisciplinary pain rehabilitation physicians. This itself increases healthcare costs, and treatments can be invasive and have risks of their own. Therefore, less expensive and more accessible management strategies targeting these psychosocial issues should be started to facilitate improvement early. As a biopsychosocial disorder, chronic pain is influenced by a range of factors including lifestyle, mental health status, familial culture, and socioeconomic status. Physicians have moved toward multi-modal pain approaches in order to combat this public health dilemma, ranging from medications with several different mechanisms of action, lifestyle changes, procedural pain control, and psychological interventions (Fashler et al., Pain Res Manag. 2016:5960987, 2016). Part of the rehabilitation process now more and more commonly includes cognitive behavioral and cognitive functional therapy. Cognitive functional therapy (CFT) and cognitive behavioral therapy (CBT) are both multidimensional psychological approaches to combat the mental portion of difficult pain control. While these therapies are quite different in their approach, they lend to the idea that chronic pain can and should be targeted using coping mechanisms, helping patients understand the pathophysiological process of pain, and altering behavior.

Recent Findings
CFT differs from CBT functionally, as instead of improving managing/coping mechanisms of pain control from a solely mental approach, CFT directly points out maladaptive behaviors and actively challenges the patient to change them in a cognitively integrated, progressive overloading functional manner (Bjorck-van Dijken et al. J Rehabil Med. 40:864–9, 2008). This allows CFT to be targeted to each individual patient, with the goal of personalized reconceptualization of the pain response. The end goal is to overcome the barriers that prevent functional status improvement, a healthy lifestyle, and reaching their personal goals.

Summary
Chronic pain is a major public health issue. Cognitive functional therapy (CFT) and cognitive behavioral therapy (CBT) are both multidimensional psychological approaches to combat the mental portion of difficult pain control. While these therapies are quite different in their approach, they lend to the idea that chronic pain can and should be targeted using coping mechanisms, helping patients understand the pathophysiological process of pain, and altering behavior.

Open access, https://link.springer.com/article/10.1007/s11916-021-00948-1

 

For some of these people access to physiotherapy or similar when their pain is at an earlier stage, with appropriate exercises and follow-ups would be far more useful.

Only those with the financial resources are able to access this care.

 

Isn't biopsychosocial inherently multidimensional?...bio+psych+social...mind you the way it's practised in the UK perhaps not.

Absolutely. The right intervention in a timely manner rather than lots of delaying chit chat.

 

But why should physiotherapy or exercise be of any value either?
I don't get that.

 

That would require them having an in-depth understanding of how pain comes to physically operate chronically in people. And as yet I think they have no clue so helping pattients to understand is skating over reality (a little white lie to make them feel confident in the treatment and provider).

One would think that something that is a 'crisis' would demand a little more attention than simple brainwashing.

 

Ok i have pain in my ankle, and when my ankle locks on me, i limp. Usually when i wake up in the morning and take my first steps. I have done physio for 5 years now, and i still have the pain. I am not a drug seeker. I am not fearful of movement and this is not a psycho-social component that travels from my brain all the way to my ankle.

Please please please scientists. Stop the pseudo-science. Do not take the patients for a field trip that is the BPS-F (and the F is for functional or course) Break your own bones and find out for yourself that if you use that one limb that is broken, it’s gonna hurt. If you’re unlucky, you will develop long lasting pain, to no fault of yourself (and by unlucky, it is meant to say that depending on healing, physical trauma, and so on)

 

It might not. I guess it depends on what's going on.

I experience pain as part of ME and in the early days pain and cognitive problems were probably my biggest issues.

I was referred to a private physio, initially to see if learning new breathing techniques would be helpful in addressing IBS (not really).

However, she did immediately pick up on the very high levels of constant pain and the inability to completely relax some muscles. We worked on that and she helped me enormously with pain management techniques that were relevant to me.

Exercise didn't come in to it.

It was more about how to make sure my body was sufficiently supported at rest to enable those muscles to relax and to help identify when & where I was putting unnecessary strain on the body. I am slightly below average height so when sitting in a standard dining chair it is slightly too high and the seat slightly too deep, for example. Sitting in that chair, unless I have a phone book or block under my feet and a cushion at my back, will cost me more in terms of energy used and muscle pain than it might if I were a couple of inches taller.

Whereas I was trying to ignore my pain and just work through it, she taught me to pay attention to it & be conscious of my posture and support.

A really good, open minded physio who adapts according to the patient 's needs can be very helpful.

 

I hate when they throw in opioid dependence. Finding that opioid painkillers help reduce pain levels is not dependence but they use the term to imply addiction and needing the drug for its own sake. Too many people with chronic pain are being classed as addicts with the answer to their problems not being research to find why they are in pain but a referral to an addiction clinic.

When they stopped prescribing coproxomal and people said that they were in bad pain it was airily dismissed as addiction and they would be fine in a few weeks. very cruel.

 

I know the cause of 90% of my own chronic pain. But my medical records have so many omissions, mistakes, obfuscation and lies that nobody would believe me if I told them.