J Phys Ther. 2010;1:49-57.
Cogni ti ve Behavi oral Therapy & Chronic pain
Original ar ticle
Effects of cognitive-behavioral therapy on pain intensity and level of physical activity in Japanese patients with chronic pain- a preliminary quasiexperimental study
Takako Matsubara PT. PhD,* a, b Young-Chang P Arai MD, PhD,a Kazuhiro Shimo PT,a Jun Sato MD, PhD,a Tomoaki Osuga MD,a Makoto Nishihara MD, PhD,a Takahiro Ushida MD, PhD.a INTRODUCTION
ABSTRACT
Physical activity can improve both the physical and psychological conditions of the human body. Several studies have shown that physical activity can decrease pain intensity and pain-related 1-5 However, disabilities. chronic pain patients have not only physical but also psychological dysfunctions such as distorted cognitions, emotions, thoughts, and pain5 behavior. The psychological dysfunction in chronic pain patients can not be improved by physical activity alone, as psychological factors constrain 6 the effect of physical activity. Therefore, cognitivebehavioral therapy (CBT) including physical activity have been developed to improve the psychosocial factors in chronic pain patients. CBT focuses on confirming and modifying distorted cognitions and thoughts that affect persistent pain and pain behaviors, using a psychological approach, i.e. pain education, relaxation,
Introduction: Cognitive-behavioral therapy (CBT) is one of the psychological approaches and focuses on modifying distorted cognitions that affect persistent pain and pain behaviors. CBT involving an activity program could be applied to the treatment of chronic pain with physical and psychological dysfunctions. The aim of the present preliminary experimental study was to investigate the effectiveness of CBT by comparing treatment responders and non-responders by pain levels and physical activity levels in the patients with chronic pain in our multidisciplinary pain center. Methods: CBT was given for 6 months period in 12 patients. They were classified into effective group if they had verbal rating scale (VRS) score reduced by 2 points and into non-effective group if there were no changes in VRS, at 1 month after the beginning of the CBT. Pain intensity and physical activity were assessed by VRS and a three-dimensional accelerometer which were expressed as a total together with each activity intensity level- metabolic equivalents: METs 1-3, mild; METs 4-6, moderate; METs 7-9, heavy activity, and sampled at 1, 3 and 6 month intervals after the CBT. Results: The effective group had lower VRS at 3 and 6 months. They also had higher total physical activity score overall, and mild/moderate activity score was higher at 6 months. The heavy activity score was not different between-groups. VRS was lesser in the effective group at all three levels (1, 3 and 6 months) when compared with before the beginning of the CBT, whereas physical activity levels were similar at all three levels on each group. Conclusion: The study found that mild to moderate physical activity was associated with reductions in VRS in the effective group suggesting beneficial effects of low-load and high amount of physical activity in chronic pain patients attending a CBT intervention program.
Key words: Cognitive-behavioral therapy (CBT), physical activity, pain intensity, METs. Authors’ information: *- Corresponding author.
[email protected] a- Multidisciplinary Pain Center, Aichi Medical University
School of Medicine, 21 Karimata, Nagakutecho, Aichigun, Aichi 480-1195, Japan. b- Faculty of Health Sciences, Department of Rehabilitation
Nihon Fukushi University, Japan.
Key points and pre-publication history of this article is available at the end of the paper.
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cognitive behavioral modification, coping strategies and social skills training. CBT consists of not only psychological approaches but also physical activity, i.e. graded/progressive and submaximal activity, low-load and low-velocity mobilizing activity or activity training. Numerous reports involving a systematic review and randomized controlled trials have provided sufficient evidence of the effectiveness of CBT for chronic pain compared with no treatment or waiting list 1,7-10 But in other control. studies, there has been insufficient evidence of the effectiveness of biopsychosocial and physical rehabilitation versus other 11-14 active therapies. Furthermore, controversy exists regarding the effectiveness of CBT, because there has been only a few convincing evidence for the efficacy of CBT for chronic pain. Our center is the first multidisciplinary pain center established in Japan. There are few reports regarding the effectiveness of CBT for chronic pain in our country, because multidisciplinary pain center has not been developed in our country. In the present preliminary experimental study, we investigated the effectiveness of CBT by comparing treatment responders and non-responders by pain levels and physical activity levels in the patients with chronic pain in our multidisciplinary pain center.
METHODS Study design: This preliminary quasiexperimental study was a nonrandomized, single-blind, clinical trial and with six-month follow-up. The ethics committee approval was obtained from Aichi Medical University. Written informed consent was obtained from each patient. Patients: Twelve out-patients (2 male and 10 female, mean (SD) of age 54.7 (18.3) years) suffering from a variety of chronic non-cancer pain conditions, such as neuropathic pain (1 male and 2 female), osteoarthritis (1 male and 1 female), whiplash associated disorder (WAD) (4 female), low back pain (2 female), fibromyalgia (1 female), were recruited to the CBT by consecutive sampling for treatment of chronic pain in Multidisciplinary Pain Center in our university. Intervention: In the present preliminary experimental study, the activity program of CBT was operant behavioral activity training and mild activity. Operant behavioral training focuses on withdrawal of positive attention for pain behaviors while increasing reinforcement of well behaviors such as activity. This mild activity was guided by the patient’s functional abilities, low-load activity and low-velocity mobilizing techniques; including walking, stair climbing, radio/TV gymnastics and stretching. The activity program was aimed at helping patients to
to reach their individual daily life goals, to increase their activity levels, and to modify distorted cognitions and thoughts. In the initial assessment and following consulting, the patients received education in their pain condition, pain management and risk of activity (e.g. association with overactivity/ disuse and more pain). On the basis of the patients’ accepting, they did individual decision-making, including planning and pacing their activity program and goal setting, together physiotherapist. Pacing is an essential technique for chronic pain management. It is important for chronic pain patients to maintain a fairly even level of activity over the day. They had to maintain to start on easier activities, to take frequent and shot break, to keep their plans and pace, to breakup tasks into small bits, to ask for help with specific tasks, to increase gradually the amount of activity on a realistic build-up rate and to record their plan and progress, for preventing more pain. Procedure: After individual decision-making was identified, the patients started performing their individually set activities for 30 to 120 minutes a day and for 3 to 5 days a week, with activity levels increasing gradually towards the final treatment goals. Their individual activities were continued to perform for 6 months and physical activity amounts and pain intensity levels were
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Figure-1: Schematic flow diagram of participants in our study (CBT- cognitive behavioral therapy; VRS- verbal rating scale) recorded every day all that while. The activity amounts were averaged every month, and then analyzed at 1, 3 and 6 months after the beginning of the recording. Pain intensity was rated using verbal rating scale (VRS), averaged every month, and then sampled for subsequent analysis at 1, 3 and 6 months after the beginning of the recording. At 1 month after the beginning of the CBT, patients were allocated into the effective group when there was VRS decrease of at least 2, and the non-effective group when there was no VRS change or VRS decrease of less than 2. Measurements: Initial assessment Data regarding patients’ demographic characteristics
(age, gender, marital status, Physical activity level occupation) was obtained To quantify the daily during the pre-treatment physical activities of patients 4,16 home, assessment by a trained at a threeinterviewer. In addition, dimensional accelerometrypatients were assessed based electronic activity regarding pain intensity using monitor was used (Figure-1). VRS and pain-related psychological conditions using a questionnaire: Hospital and Anxiety Depression scale (HAD). For the VRS, pain intensity was evaluated on a numerical scale from 0 to 10 (0 = no pain, 10 = worst pain imaginable). HAD is a well Figure-1: Three-dimensional accelerometry-based validated scale for measuring electronic activity monitor the psychological well-being of medical patients and consists of two subscales, the anxiety The monitor consisted of a (HAD-Anx; minimum = 0, built-in tri-axial accelerometer maximum = 21) and the designed to detect refined depression (HAD-Dep; human motion. The patients minimum = 0, maximum = 21) wore the monitor during the subscale, which have each daytime except during waterseven items with rating of based activities and nighttime severity of symptoms from 0 to sleep. Data was able to be 15 3. Co gn itiv e b eh avio r al t he ra py i n c hr o nic pa in
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recorded at 2- minute intervals and to be downloaded to a computer for software analysis. Physical activity was expressed as a total and each level divided by the intensity of the activity: METs 1-3, mild; METs 4-6, moderate; METs 79, heavy activity. Daily diary measurement Patients recorded a brief diary consisting of following components: pain intensity, medication, the kinds of activity performed (e.g. walking, stair climbing, radio/TV gymnastics, stretching, yoga), the activity amounts and/or time by the activity monitor, achievement of activity goal, pain-related special events. The patients were requested to complete the diary each evening before sleep.
Data analysis: Pain intensity and physical activity within the group was analyzed at 1, 3 and 6 months after the CBT using by Friedman repeated measures analysis of variance on ranks, followed StudentNewman-Keuls methods. Each data was analyzed using Man-Whitney test between the groups. P < 0.05 was considered statistically significant. RESULTS One male and five female patients were included in each group. Table 1 demonstrates the baseline (pre-treatment) characteristics of the patients. There were no significant differences in the VRS, HAD-Anx and HAD-Dep between the groups at the pretreatment assessment.
Pain intensity and daily physical activity data were summarized in Table 2. There were no differences between the groups on VRS 1 month after the beginning of the CBT, but VRS was lower at 3 and 6 months after the CBT in the effective group compared with the non-effective group (p < 0.05) (Figure 2). There were also no differences on VRS of the non-effective group at any time after the CBT, however, VRS of the effective group was lower at 1, 3 and 6 months after the CBT compared with pre-treatment control value (p < 0.05) (Figure 2). Total activity at 1, 3 and 6 months, and mild (METs 13) and moderate (METs 4-6) activities at 6 months after the beginning of the CBT were
Table- 1: Age, duration of pain, verbal rating scale (VRS) pain scores, pain-related anxiety (HAD-Anx) and depression (HAD-Dep) at the pre-treatment assessment Effective group
Non-effective group
p-value
Age (year) Duration of pain (months)
70.0 (53-73) 23.5 (12-61)
36.5 (30-80) 27.0 (12-51)
0.020* 0.883
VRS HAD-Anx HAD-Dep
7.8 (5-10) 11.0 (10-12) 8.0 (6-8)
5.0 (2-10) 8.5 (7-10) 12.5 (10-19)
0.225 0.078 0.067
Values are presented as median (range 25%-75%). *- significant at p < .05
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Table- 2: Pain intensity (VRS) and physical activity amounts obtained by threedimensional accelerometer Pain/Activity
Non-effective group
Month
Effective group
0 1 3 6
7.8 (5.0-10.0) 1.6 (0.7-6.2) † 0.7 (0.1-3.6) † 0.7 ( 0-3.4) †
5.0 (2.0-10.0) 5.0 (0.6-8.7) 5.2 (1.1-6.6) 5.1 (1.1-5.9)
0.230 0.262 0.016* 0.010*
1 3 6
1396 (1208-2035) 1344 (1216-2106) 1456 (1393-1989)
922 (598-1430) 799 (391-1460) 634 (591-1209)
0.048* 0.048* 0.004*
Mild (METs 1-3) activity
1 3 6
969 (583-1311) 965 (666-1037) 1001 (782-1457)
584 (457-996) 559 (337-1028) 490 (455-889)
0.068 0.068 0.009*
Moderate (METs 4-6) activity
1 3 6
342 (113-1286) 326 (237-1317) 400 (303-1165)
314 (69-414) 244 (53-414) 138 (55-312)
0.361 0.100 0.017*
Heavy (METs 7-9) activity
1 3 6
16 (2-167) 36 (1-123) 43 (5-57)
12 (1-25) 16 (1-19) 10 (1-30)
0.584 0.584 0.465
Pain VRS
Activity (steps) Total activity
p-value
Values are expressed as median (range) of total, mild (METs 1-3), moderate (METs 4-6), heavy (METs 7-9) activities and VRS per mouth, and sampled at 1, 3 and 6 months after the CBT. VRS at 0 month is presented as median at the pre-treatment assessment. †, significantly different from pre-treatment control value (p < 0.05). *- significant at p < .05 for between-group comparison.
Figure-2: Changes in verbal rating scale (VRS) pain scores. 10
8
VRS
6
4
2
0 pre
1M
3M
6M
■, effective group. □, non-effective group. Values are presented as mean. SD represented with error bars. †, significantly different from pre-treatment data (p < 0.05). *, significantly different from the VRS of the non-effective grossup (p < 0.05).
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Figure-3: Changes in physical activity levels.
*
*
**
**
1400 1200 1000 800 600 400 200 0
1M
3M
1M
6M
(c)
moderate activity (counts)
(b)
mild activity (counts)
2000 1800 1600 1400 1200 1000 800 600 400 200 0
3M
6M
3M
6M
(d) 1000
*
800 600 400 200
120
severe activity (counts)
total activity (counts)
(a)
100 80 60 40 20 0
0 1M
3M
1M
6M
Mean of activity amounts on total (a), mild (METs 1-3) (b), moderate (METs 4-6) (c) and severe (METs 7-9) (d) levels at 1, 3 and 6 months after the beginning of CBT program. ■, effective group. □, non-effective group. Values are presented as mean. SD represented with error bars. *, significantly different from the VRS of the non-effective group (p < 0.05). **, significantly different from the VRS of the non-effective group (p < 0.01).
significantly higher in the effective group than the noneffective group (p < 0.05) (Figure 3), whereas there were no significant differences between the groups on heavy (METs 7-9) activity at any time (Table 2). There were also no differences on each activity level at any time after the CBT. DISCUSSION Our results demonstrate that VRS at 3 and 6 months after the CBT was lower and total activity at all time and mild/moderate activity at 6 months after the CBT was higher in the effective group
than the non-effective group, but there were no significant differences on heavy activity at any time between the two groups. Also, there were no differences on VRS in the noneffective group and on each activity level with in each group at any time after the CBT, however, VRS of the effective group were lower at all time after the CBT than pretreatment control. From the present results, we postulate that even mild and moderate activity could improve chronic pain. Furthermore, these effects of the physical activity remained for the following 6 months in the effective group.
Numerous studies have demonstrated the effectiveness of the CBT in reducing the negative consequences of chronic pain, e.g. reduction of pain intensity distress and pain behavior, and improvement of painrelated disability daily function 1,10,17 and return to work. Furthermore, not only the CBT but also physical activity reduced functional limitations and negative complaints as well as pain intensity in patients with low back 2,3,13 pain. A study reported that physical activity is most effective in the CBT for chronic 4 pain. Also, the effects of
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physical activity could remain for the following 6 months (8) 13 to 2 years. Gradually promoting physical activity is likely to reduce pain and disability in chronic pain 4,5,18 patients, as observed in the present report. Rehabilitation with activity training is related to both pain reduction and general neuromuscular adaptation conditioning, as activity training relieves pain and increases maximal activity in 19 myalgia. On the other hand, prolonged bed rest due to pain is associated with a higher 20 long term disability level. Most patients with chronic low back pain-associated disability have a lower level of aerobic fitness, owing to a decrease in activity during leisure time and 21 work/household chores. A study provides that the relation between physical activity and chronic low back pain is a Ushaped curve i.e. both inactivity and excessive activities present an increased 22 risk for back pain. Side effects in response to an individualized, progressive, sub-maximal activity program were observed in up to 20 % 23 of the subjects. We showed in this preliminary experimental study that the patients who responded positively to the CBT have an increase in mild/moderate activity as well as a reduction in the pain intensity. CBTguided activity program is recommended to keep the activity load below the pain threshold (5) and to use lowload and low-velocity 3,24 activity, in order to prevent sensorimotor incongruence and not to increase pain when using stabilization and
mobilizing activity to reeducate muscle control in the treatment of chronic pain patients. We speculate that the mild program in the CBT could induce not only promotion of physical condition but also improvement of the pain intensity and the pain-related disability in chronic pain patients, and thereby, the mild activity program might be adequate for the CBT of chronic pain. The distorted cognitions influence physical 5,25 The performance. dysfunctional descending pain-inhibitory mechanism is influenced by distorted cognitions, emotions, and 5 behavior like catastrophizing. Increased neuronal activity such as pain catastrophizing, has been observed in people with chronic pain and was correlated with disability. Gradually enhancing physical activity is likely to reduce pain catastrophizing and to achieve a positive rehabilitation outcome for patients with 4,5 chronic pain. That is, the physical activity could influence cognitions, emotions and thoughts. We thus speculate that the physical activity of CBT might have a greater effect on the therapy of chronic pain, thereby being one of the most effective pain management programs. There are several limitations to the present preliminary experimental study that should be mentioned. One of them is that only 12 patients were included. Moreover, we did not compare the same
outcomes with no treatment or waiting list control because the present preliminary experimental study was nonrandomized trial, and this is one of the limitations of this preliminary experimental study. Therefore, we need to do further study in large sample size, better designed trial such as comparison between with and without the application of the CBT. Another limitation is that we did not show the outcomes of the CBT after the completion for a long period. We need further evaluation of a long period outcome of the CBT on the pain intensity and painrelated dysfunction. CONCLUSION Promoting physical activity due to performing the activity program of mild but not heavy level was associated with the reduction of pain intensity, and these effects of activity remained for the following 6 months in the effective group which responded to cognitive behavioral therapy intervention. ACKNOWLEGMENTS The authors wish to acknowledge the patients participated in this study and for their co-operation during evaluation, compliance with treatment and home programme. CONFLICTS OF INTEREST None identified.
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Article pre-publication history: Date of submission- 6th April 2010 Reviewer- P. Senthil Kumar Sent for 1st revision- 12th April 2010 Date of 1st resubmission- 28th April 2010 Reviewer- Prof Anne Soderlund Sent for 2nd revision- 16th May 2010 Date of 2nd resubmission- 4th June 2010 Date of acceptance- 10th June 2010 Date of publication- 25th June 2010 WFIN- JPT-2010-ERN-114-1(2)-49-56.
REFERENCES 1. Scascighini L, Toma V, DoberSpielmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatol. 2008;47:670-678. 2. Smeets RJ, Vlaeyen JW, Hidding A, Kester AD, van der Heijden GJ, van Geel AC, Knottnerus JA. Active rehabilitation for chronic low back pain: cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial. BMC Musculoskelet Disord. 2006;20:7. 3. Smeets RJ, Beelen S, Goossens ME, Schouten EG, Knottnerus JA, Vlaeyen JW. Treatment expectancy and credibility are associated with the outcome of both physical and cognitivebehavioral treatment in chronic low back pain. Clin J Pain. 2008;24:305-315. 4. de Jong JR, Vangronsveld K, Peters ML, Goossens ME, Onghena P, Bulté I, Vlaeyen JW. Reduction of pain-related fear and disability in post-traumatic neck pain: a replicated single-case experimental study of exposure in vivo. J Pain. 2008;9:1123-1134. 5. Nijs J, Van Oosterwijck J, De Hertogh W. Rehabilitation of chronic whiplash: treatment of cervical dysfunctions or chronic pain syndrome? Clin Rheumatol. 2009;28:243-251. 6. Moseley GL, Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain. 2004;8:39-45. 7. Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:113.
18. Borsbo B, Peolsson M, Gerdle B. Catastrophizing, depression, and pain: correlation with and influence on quality of life and health-a study of chronic whiplash-associated disorders. J Rehabil Med. 2008;40:562-569.
8. Reid MC, Otis J, Barry LC, Kerns RD. Cognitive-behavioral therapy for chronic low back pain in older persons: a preliminary study. Pain Med. 2003;4:223-230. 9. Wong M, Rietzschel J, Mulherin D, David C. Evaluation of a multidisciplinary outpatient pain management programme based at a community hospital. Musculoskeletal Care. 2009;7:106-120.
19. Andersen LL, Andersen CH, Zebis MK, Nielsen PK, Søgaard K, Sjøgaard G. Effect of physical training on function of chronically painful muscles: a randomized controlled trial. J Appl Physiol. 2008;105:1796-1801.
10. Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 2001;322:1511-1516. 11. Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Metaanalysis: exercise therapy for nonspecific low back pain. Ann Intern Med. 2005;142:765-775. 12. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain. 2004;107:176-190.
20. Verbunt JA, Sieben J, Vlaeyen JWS, Portegijs P, Knottnerus JA. A new episode of low back pain: Who relies on bed rest? Eur J Pain. 2008;12: 508-516. 21. Smeets RJ, van Geel KD, Verbunt JA. Is the fear avoidance model associated with the reduced level of aerobic fitness in patients with chronic low back pain? Arch Phys Med Rehabil. 2009;90:109-117. 22. Heneweer H, Vanhees L, Picavet HS. Physical activity and low back pain: a U-shaped relation? Pain. 2009;143:21-25.
13. Kääpä EH, Frantsi K, Sarna S, Malmivaara A. Multidisciplinary group rehabilitation versus individual physiotherapy for chronic nonspecific low back pain: a randomized trial. Spine. 2006;31:371-376. 14. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. Cochrane Database Syst Rev. 2003;(2):CD002194. 15. Wong M, Rietzschel J, Mulherin D, David C. Evaluation of a multidisciplinary outpatient pain management programme based at a community hospital. Musculoskelet Care. 2009;7:106-120.
23. Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas M. Randomized controlled trial of exercise for chronic whiplash-associated disorders. Pain. 2007;128:59-68. 24. Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? A preliminary RCT. Pain. 2007;129:28-34.
16. Verbunt JA, Huijnen IP, Köke A. Assessment of physical activity in daily life in patients with musculoskeletal pain. Eur J Pain. 2008;13:231-242. 17. Norlund, Ropponen A, Alexanderson K. Multidisciplinary interventions: review of studies of return to work after rehabilitation for low back pain. J Rehabil Med. 2009;41:115-121.
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Key points: Past- Cognitive behavioral therapy using behavioral graded activity training was shown to be beneficial in chronic pain population. Present- Cognitive behavioral therapy was administered in Japanese chronic pain patients attending a multidisciplinary pain clinic and the patients were then sub-grouped into responders and non-responders of which responders had high levels of physical activity measured by accelerometry. Future- Physical therapists have a global role to play in multidisciplinary chronic pain programs where inclusion of behavioral graded activity training as part of cognitive behavioral therapy. Future large scale studies in this area are warranted.
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