Cognitive Behavioral Therapy and Back Pain

Chronic Pain: The Essential Role of Psychology

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, and described in terms of such damage.” This definition of pain recognizes the subjective emotional experience associated with pain and underscores the fact that psychology is inherent in the definition of pain. To fully treat the experience of pain one must acknowledge the psychological factors, such as emotions, attention, and behavioral reactions, that occur in conjunction with the sensory experience. For example, many individuals become fearful of worsening pain with activity and are overly vigilant to cues of pain. This model of fear-avoidance is theorized to maintain pain and pain-related fear. Patients also may develop unhelpful ways of thinking and responding to the pain experience. For example, pain catastrophizing, defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experiences” is comprised of three domains–helplessness, magnification, and rumination –and is consistently linked to a number of poor pain outcomes, including higher pain sensitivity, disability, opioid use, and development of chronic pain and depression. ^, Lastly, patients living with persistent pain may develop anxiety or depressive disorders that add to the patient’s difficulty in managing pain. These psychological factors will be discussed in further detail in subsequent sections of this chapter.

Key Components and Goals of Treatment for Chronic Pain and Chronic Low Back Pain

The recommended treatment for chronic pain has changed over time as the biological, as well as psychosocial, factors that maintain pain have been elucidated. For most patients, it is not solely the experience of pain that can lead to debilitation, but the combination of biological, psychological, and social factors.

When addressing chronic pain, there is a shift away from pain elimination. Pain reduction is treated as secondary to improving function and decreasing disability, improving mood, and reducing fear avoidance and pain catastrophizing. Historically, opioids were used for the treatment of acute pain and cancer-related pain; however, the past few decades saw an explosion in long-term opioid therapy for chronic noncancer pain. Many factors have been postulated to contribute to the opioid epidemic; however, the combination of increased opioid prescribing with little oversight, aggressive marketing campaigns, and the call to treat pain as “the fifth vital sign” are key variables in the subsequent rise in opioid use disorders and overdose deaths within the United States. Although well-meaning at the outset, long-term opioid therapy now is established as largely ineffective for those experiencing chronic, persistent pain. ^, In an effort to combat the consequences of long-term opioid use, new guidelines and policy changes have shifted to focus evaluation and treatment on biopsychosocial interventions that address not only biomedical factors associated with persistent pain but also psychosocial factors. This change paralleled the emphasis on self-management strategies, including cognitive behavioral therapy (CBT), as a first-line treatment for chronic low back pain. With this shift in treatment came a change in relevant treatment outcomes. Concurrently, guidelines for research and outcome studies were developed with more rigorous and multidimensional components. For example, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommends core outcome domains, including “pain, physical function, emotional functioning, participant rating of improvement, symptoms and adverse events, and participation disposition,” as key treatment pain-related outcomes for clinical trials. ^,

The chronification of acute pain leads to a “chronic pain experience” that encompasses biological, affective, cognitive, and behavioral variables ^, that interact and over time may result in a “pain identity.” Whereas traditional biomedical treatment approaches are likely to be more effective for acute pain, they may be insufficient when dealing with a complex, multifactorial condition such as chronic pain. Biopsychosocial frameworks for chronic pain treatment address the personal, social, and economic burden ^, experienced by those living with chronic pain. Traditional medical models aim to treat pain as a symptom of a disease process; however, the biopsychosocial model addresses not only biological factors that play a role in the experience of pain but also psychosocial stressors. Psychosocial factors, considered to be the strongest predictors of pain-related outcomes ^, must be considered in treatment approaches for chronic pain.

Theoretical Foundation for Cognitive Behavioral Therapy for Pain

CBT is largely recommended as a stand-alone treatment intervention or in conjunction with other treatments for chronic pain due to the lasting effects, longstanding efficacy, and minimal side effects. ^, CBT for pain is guided by the theoretical framework established by Dr. Aaron Beck, the originator of CBT, who postulated that distress (or psychopathology as it was initially developed for) stems from cognitive misinterpretations of the world, self, or others. CBT for pain similarly addresses how one’s thoughts and feelings influence behaviors relate to the experience of pain ( Fig. 74.1 ).

CBT-P is also heavily influenced by the gate control theory of pain, which was the first theory of pain that emphasized the role of psychology. The gate control theory revolutionized pain science by suggesting that the modulation of the dorsal horn in the spine is controlled by a “gate,” ultimately modifying the output of the transmission of cells in the spinal cord. The “gate” is opened and closed through ascending and descending nerve fibers, and ultimately is controlled by the brain. It is proposed that various factors have the ability to open the gate, which ultimately increases the flow of pain signals and pain perception, whereas when the gate is closed, it decreases the flow and intensity of the pain signals. Factors that contribute to an open gate may include poor coping skills, trauma, inactivity, depression, anxiety, stress, pain catastrophizing, and/or pain-related fear. Factors that contribute to a closed gate may include healthy coping, psychophysiological self-regulation, exercise, and engaging in pleasurable activities. The gate control theory offered a greater understanding to the role of cognitive, emotional, and behavioral factors in the experience of pain, and underscored the ability of psychological experiences in changing the flow of pain signals. Further conceptualizations of pain, such as the neuromatrix concept, have expanded upon the gate control theory, addressing some of its limitations such as the underemphasis on the interacting pain areas in the brain and how pain is represented centrally. The neuromatrix theory emphasizes cognitive, affective, and sensory influences on pain. ^, These neural components play a vital role in the brain’s ability to modulate pain responses, as well as contributing to pain perception. This system allows the brain to determine if a sensation experienced is threatening or dangerous.

Additional theoretical influences on the application of CBT to pain include applied learning and behavioral theories. Wilbert Fordyce, a psychologist, considered the role of social experiences and environmental factors in shaping the chronic pain experience. His model of pain included the impact of patients engaging in “pain behaviors” (e.g., guarding or bracing) and how these behaviors become dysfunctional and lead to disability as they are reinforced over time.

Cognitive Behavioral Therapy: In-Depth Application to Chronic Pain

A variety of psychological interventions may be used to address the biopsychosocial correlates of chronic pain, depending upon the patient’s treatment needs. As noted, one of the most prominent and rigorously studied approaches is CBT–a skills-based, time-limited treatment modality. CBT-P centers on the bidirectional relations between all of these factors and pain, with interventions specifically addressing these three components. The common goals for CBT-P are to reduce overall pain, suffering, and disability by improving patient self-management skills. Through this treatment, patients acquire adaptive self-regulatory skills such as cognitive restructuring to extinguish maladaptive thoughts and beliefs, relaxation techniques to improve autonomic control, and activity pacing to approach activities in a safe and sensible manner. ^, CBT-P identifies unhelpful responses to pain and invites patients to address the various opportunities they have to break their cycles of pain (see Fig. 74.1 ). CBT-P uses common treatment components across patients, but there are a variety of skills that may be added or removed based on the patient’s individual needs, and there is an art to its implementation. The skill-based interventions discussed in the next section are a selection of the most commonly utilized, but do not represent all possible options.