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Three Approaches Found Effective for Pain Catastrophizing

March 5, 2018
Meta-analysis indicates patients respond best when treatment incorporates CBT, ACT and multimodal approaches while taking patient preferences into account.

With Robert Schütze, PhD, and Robert J. Gatchel, PhD, ABPP

Cognitive behavior therapy (CBT), acceptance and commitment therapy (ACT) and multimodal treatment that combines CBT and exercise appear to be the most reliable in reducing pain catastrophizing (PC) in individuals with chronic non-cancer pain. The findings1 were published in the Journal of Pain. “While there wasn’t a single gold standard intervention, our meta-analysis found that [these] three interventions had reasonable evidence of effectiveness,” lead author Robert Schütze, PhD, a research fellow and clinical psychologist at Curtin University in Perth, Australia, told Practical Pain Management

Pain catastrophizing (PC) is the tendency of some individuals to magnify how threatening their pain is, dwell on their pain, and feel a sense of hopelessness about their pain. Research has shown an association between PC and decreased quality of life, such as greater disability, pain intensity, depression and anxiety, and missed work. Pain catastrophizing has become a key target of interventions,2-7 though studies, until now, had not identified how best to apply these interventions to patients with chronic pain, where a number of approaches have been evaluated with varying ranges of efficacy.

A Closer Look at the Study Methodology

Researchers identified studies through medical literature databases and by a manual search to conduct a meta-analysis of 79 randomized controlled trials (RCTs) including more than 9,900 patients.1 Only 32 studies specifically reported PC as a primary outcome. The most common measures of PC were the Pain Catastrophizing Scale (PCS) (n = 44) and Coping Strategies Questionnaire(n = 28). Only eight targeted studies used PC as a primary outcome and included cohorts with high baseline catastrophizing (PCS ≥ 24).1

The 17 types of intervention identified in the studies were grouped into four broad categories:

  1. mostly psychological content (n = 48, 60.8%)
  2. mostly physical treatments, such as exercise or acupuncture (n = 7, 8.9%)
  3. multimodal interventions involving physical and psychological content (n = 22, 27.8%) 
  4. purely pharmacological treatments (n = 2, 2.5%).

CBT (n = 28, 35.4%) and multimodal interventions (n = 20, 25.3%) were the most commonly studied, though it should be noted that all multimodal interventions contained a CBT component.1

The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria,8 which allowed the researchers to categorize evidence as high, moderate or low grade. The studies were assessed in groups based on timing of outcome assessment (post-test or follow-up) and type of intervention comparison (waitlist/usual care or active control).1 Among post-test outcomes of interventions compared with waitlist/usual care, the best quality evidence (moderate) was found for CBT, multimodal treatment, exercise, and mindfulness.1

Three Interventions Appear Most Efficacious

Fewer studies assessed follow-up outcomes for an intervention versus waitlist/usual care. CBT and multimodal approaches had a medium effect with moderate quality of evidence. Post-test outcomes from 10 different interventions were compared with active controls in 40 studies of 4,191 participants. However, only ACT and CBT showed moderate efficacy while multimodal treatment showed large efficacy. The quality of evidence was considered to be high for ACT and moderate for CBT and multimodal treatments.1

Follow-up outcomes were compared for six specific interventions as compared to control groups (22 studies, n = 2,653). Only three were deemed efficacious: ACT, CBT, and multimodal treatment. While evidence of a medium effect for ACT was considered to be high quality, moderate-quality evidence for a medium effect of CBT was downgraded because of heterogeneity. Likewise, multimodal treatment was also downgraded due to heterogeneity, yielding moderate-quality evidence for a large effect.1

Both baseline and PC as a primary outcome were found to have consistently moderate treatment effects. “Indeed, in the subgroup analyses of only studies targeting high pain catastrophizing, effect sizes were significantly higher and heterogeneity lower,” the researchers noted, leading them to conclude that “treatments are most likely to produce clinically significant benefits when they are targeted to people with high levels of catastrophizing, and CBT has the best evidence in these cohorts.”

Where Does This Leave Clinicians?

“Clinicians could confidently use either of these interventions (CBT, ACT and multimodal treatment that combines CBT and exercise), ideally matching the intervention to patient presentation and preferences,” said Dr. Schütze. Clinicians should assess a patient’s strengths and vulnerabilities and use treatments based on this assessment. For example, Dr. Schütze suggested that a patient might have specific pain-related beliefs that exaggerate the threat value of pain and therefore may be well suited to interventions that challenge specific cognitions, such as CBT.

Robert J. Gatchel, PhD, ABPP, professor of clinical health psychology and director of the Center of Excellence for the Study of Health & Chronic Illnesses at The University of Texas at Arlington, echoed the importance of assessing patients’ individual needs. “In any biopsychosocial-based interdisciplinary pain management program, it is important to carefully assess psychosocial variables, along with biological factors, in order to individually ‘tailor’ treatment to the specific needs of the particular patient,” he told Practical Pain Management.

Based on the findings from this meta-analysis, Dr. Gatchel said, “This can be accomplished now by including a psychometrically-sound measure of pain catastrophizing in one’s initial assessment protocol, in order to determine if catastrophizing needs to be addressed and modified during the treatment process.”

This work was supported by Spinnaker Health Research Foundation in the form of a Bellberry Medical Research Scholarship awarded to the first author. The authors have no conflicts of interest to declare.

Last updated on: January 15, 2019
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Behavioral Medicine: How to Incorporate CBT Into Pain Management
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