Individuals with chronic widespread pain, including those with fibromyalgia, pose a particular challenge to treatment, given the modest effectiveness of pharmacological agents for this condition. The growing consensus indicates that the best approach to treatment involves the combination of pharmacological and non-pharmacological interventions. Several non-pharmacological interventions, particularly exercise and cognitive-behavioural therapy (CBT), have garnered good evidence of effectiveness as stand-alone, adjunctive treatments for patients with chronic pain. In this article, evidenced-based, non-pharmacological management techniques for chronic widespread pain are described by using two broad categories, exercise and CBT. The evidence for decreasing pain, improving functioning and changing secondary symptoms is highlighted. Lastly, the methods by which exercise and CBT can be combined for a multi-component approach, which is consistent with the current evidence-based guidelines of several American and European medical societies, are addressed.
Many clinicians (and patients) continue to consider chronic pain as an extended version of acute pain. As a consequence, treatments frequently focus on ‘fixing’ the chronic pain rather than upon its management. Reluctance to abandon the allure of a cure has delayed the broad adoption of combined pharmacological and non-pharmacological management of pain – the standard of care for several other chronic illnesses such as diabetes, cardiovascular disease, hypertension and asthma.
Non-pharmacological interventions do not share the status ascribed to pharmacological approaches. Limited details are provided in most medical school curricula, reimbursement is typically challenging and multi-million-dollar marketing campaigns – common to pharmacological agents – are missing. The term ‘non-pharmacological intervention’ itself defines this set of interventions by what they are ‘not’ rather than by their strengths. The limited profile of non-pharmacological treatment is unfortunate, given that these interventions often have favourable cost–benefit ratios and effect sizes that rival pharmacological interventions in the management of pain .
Non-pharmacological interventions, such as cognitive-behavioural therapy (CBT), education and exercise, have substantial efficacy for the management of chronic pain conditions including low back pain (LBP) , arthritis (e.g., osteoarthritis (OA) and rheumatoid arthritis (RA)), complex regional pain syndrome (CRPS), chronic pelvic pain (CPP) and conditions such as fibromyalgia (FM) and chronic widespread pain (CWP) .
Under the rubric of non-pharmacological interventions lies much variability. For example, exercise studies in CWP have addressed activities ranging from calisthenics to belly dancing. Similarly, ‘CBT’, has included everything from traditional cognitive restructuring and behavioural change strategies to medication scheduling. This article helps to clarify the types of non-pharmacological treatments that have the best evidence for use in CWP.
Exercise
The publication of approximately 80 studies evaluating exercise interventions, multiple review papers, meta-analyses and multiple sets of guidelines leave little doubt that exercise is broadly considered to be an effective treatment for patients with FM and CWP. Exercise may be particularly important for improving the health and functioning of individuals with CWP, given that deconditioning and obesity are commonly observed in these patients. In a recent study, Okifuji and colleagues reported that 47% of their sample was obese, while another 30% was overweight. In their study, obesity was related to greater pain sensitivity, less physical strength and worse sleep . The successful integration of exercise can take different forms. Evidence-based ‘exercise’ can be aerobic or more focussed on increasing strength and flexibility; it can be of high intensity and frequency or involve only adding a few steps each day. Exercise can be land- or water-based, can range from whole-body exercise to cycling and involve structured approaches such as Pilates and Tai Chi. This article offers an overview of evidence-based exercise options for the treatment of CWP with practical suggestions to promote successful implementation of an exercise programme.
Strength training (anaerobic exercise)
Strength training seeks to improve overall muscle strength. It is usually an anaerobic activity focussed on using resistance (e.g., weights, machines and resistance bands) to oppose muscle contraction in order to build muscle mass. Anaerobic exercise tends to require high-intensity activity, over a discrete period of time, which leads to improved performance in short-duration activities. Weight lifting and resistance training, as well as isometric exercises such as yoga and various forms of martial arts, are included in this category of exercise.
Flexibility training
Stiffness and reduced range of motion are common complaints in patients with CWP. Stretching and bending target increasing in range of motion, decreasing stiffness and/or minimising risk of injury. These programmes include a thorough warm-up period, to loosen muscles, followed by a systematic series of stretching exercises. Participants are usually instructed to stretch each area to the point just before discomfort is experienced and to hold the position for approximately 10–30 s. Following the stretch, the muscles can be ‘shook out’ and the same stretch is usually repeated.
Aerobic exercise
Cardiorespiratory or ‘aerobic’ exercise consists of physical activity performed at a minimum level of moderate intensity over an extended period of time. Aerobic types of activities vary widely and can include walking, running/jogging, cycling, swimming and dancing, as well as flexibility and strength-training activities (e.g., yoga and weight/circuit training) that are performed at a more intense pace for a longer duration. Training machines, such as a stationary cycle, rowing machine or elliptical trainer, are frequently used. Pool-based aerobic exercise programmes offer individuals with pain the added benefits of reduced impact, increased resistance and comfort from immersion in warm water. Moderately intense exercise, 60–70% of age-adjusted maximum heart rate or approximately 110 beats per minute for a 40-year-old, is associated with fitness and fat burning.
Other movement therapies and mixed modality
Not all types of exercise fit neatly into the aforementioned categories. For example, yoga can fit into all three categories, contingent upon the type of yoga and intensity of its practice. Other forms of exercise that fall under the category of movement therapies studied in CWP and/or FM include Tai Chi and Qigong. Lastly, mixed-modality interventions include more than one form of exercise, such as the combination of strength training and aerobic exercise. When mixed-modality interventions are evaluated in research, the intervention is typically considered aerobic if there is an aerobic component. This review conforms to this convention.
Support for efficacy – reducing pain
Early hypotheses regarding the aetiology of CWP conditions, such as FM, centred on muscle pathology ; therefore, exercise interventions were directed at building muscle strength or countering deconditioning . Over time, evidence supporting muscle pathology in CWP conditions has been sparse and, instead, favours more central factors. Thus, while there is support for the efficacy of muscle strength training in the reduction of pain, in general , there is little evidence that these forms of exercise are addressing the specific pathology of CWP. In the case of CWP, mild strength training, as opposed to moderate- or heavy-intensity strength training, is considered best .
Few studies specifically address flexibility (stretching) training for CWP, although a number of effective aerobic exercise programmes include a flexibility-training component (e.g., ref. ). An early study of exercise in FM found aerobic training to be superior to flexibility training for improving fitness, but not for pain or sleep . In a more recent randomised control trial (RCT), aerobic exercise was better than flexibility training for decreasing the number of tender points . Similarly, another RCT reported that aerobic training was superior to flexibility training for increasing fitness and decreasing pain . If yoga is considered to be flexibility training, the evidence of effectiveness increases to a certain degree . For example, a study comparing yoga to a waitlist control reported that their 8-week yoga intervention resulted in less pain and pain catastrophising in FM . Taken together, there is not sufficient evidence, as yet, to conclude that flexibility training by itself is helpful for CWP, but some individuals will benefit from the programme.
The evidence supporting the efficacy of aerobic exercise for improving pain is compelling. Despite early negative trails , more recent RCTs are reporting strong effects for decreasing pain . In a recent meta-analysis evaluating 35 RCTs, Hauser and colleagues reported that aerobic exercise significantly reduced pain in participants with FM with ‘land-based’ and ‘pool-based’ interventions yielding similar positive results . The meta-analysis included studies published up to April 2009. Subsequent to this report, additional studies have also been supportive of aerobic exercise . Another therapy related to aerobic exercise is movement therapy. In a recent, single-blind RCT, Tai Chi was compared with a control condition consisting of education plus stretching . The authors reported significant improvement for the Tai Chi group with regard to both clinicians’ and patients’ assessments of pain severity. Although only a handful of studies have been conducted to date, there is growing evidence that both Tai Chi and Qigong movement therapies may be beneficial for some individuals with CWP .
Support for efficacy – increasing functioning
In view of the fact that only a few studies have evaluated either strength or flexibility training as individual modalities, it is difficult to determine the specific impact of these exercise modalities on functional status; however, improvements have been associated with interventions involving both strength training and flexibility training . In contrast, numerous RCTs have been conducted in aerobic exercise and have shown significant improvement in functioning . Taken together, there is strong evidence that aerobic exercise programmes, land-based and water-based, improve functioning in patients with CWP.
Support for efficacy – other symptoms and outcomes
Aerobic training for individuals with CWP was associated with increased fitness and aerobic work capacity , significant improvement in the 6-min walk test and better general health . In addition, aerobic training was associated with decreased fatigue , improved sleep , less depression , better cognitive performance , greater self-efficacy and increased feelings of well-being . Furthermore, aerobic exercise conducted in low-cost, community-based settings , as well as in the home , was found to be highly effective for patients with FM.
Due to a paucity of studies, there is far less evidence for other modalities; however, some studies have shown that strength training for CWP patients has been associated with less fatigue and depression , while non-aerobic warm water exercises and education resulted in an improved 6-min walk test, better grip strength, less anxiety and better quality of life . Therefore, more studies are needed to affirm the effectiveness of strength and flexibility training.
Intensity and frequency
Jones and colleagues have recommended that low-intensity, non-repetitive exercise be used for the treatment of FM . This recommendation was based on a review of 46 trials conducted from 1988 to 2005 which demonstrated that the best results were associated with low-intensity programmes that were individualised to patient needs . However, another evidence-based review of the exercise literature was published recently and concluded that insufficient evidence existed to draw a conclusion with regard to the benefit of low-intensity exercise on pain reduction . By contrast, there was robust evidence in favour of light to moderate aerobic exercise for pain. Other findings from the same review suggested that aerobic exercise training should be increased slowly, beginning at levels just below capacity and then increased in duration and intensity until individuals are exercising at low to moderate intensity (i.e., 50–70% of age-adjusted maximum heart rate) for 20–30 min per session 2–3 times per week . Training programmes should have a duration of at least 4 weeks, and education during the early stages of a new exercise programme is crucial. Patients should be cautioned that, if they experience increased symptoms, they should decrease exercise until symptoms improve. Lastly, if there is concern with regard to adverse effects, patients should promptly consult with their physicians . These recommendations are consistent with published guidelines .
Attrition, persistence and motivation
What is the best way to engage chronic pain patients in regular exercise when they are frequently obese, sedentary, depressed, fatigued and experiencing pain? This problem is reflected in the attrition rates observed in RCTs that evaluate exercise in CWP that have been estimated to range from 27% to 90% . Interestingly, in this patient population, fitness gains are not always associated with symptomatic improvement . Therefore, it is highly likely that tailoring the exercise-treatment programme to patients’ needs, preferences and interests is key to deriving benefit and enhancing adherence. The combination of exercise with CBT, which focusses upon patients’ thoughts and beliefs, constiutes an optimal non-pharmacological therapeutic approach to CWP.
Cognitive-behavioural therapy
CBT possesses a strong evidence base that supports its efficacy in the management of chronic pain . The term CBT, refers to a class of interventions, each of which is grounded upon a common theoretical framework. For example, CBT interventionists will utilise a wide variety of skill-sets or modules to produce outcomes. Typically, the choice of modules depends upon the intended target of treatment (pain reduction, functional improvement, mood, etc.). That CBT content can vary depending upon the need of the individual patient is actually a strength of the approach and underscores the flexibility of this therapeutic modality; however, such flexibility has also contributed to some confusion when it is assumed that CBT is a uniform intervention. The next section reviews theoretical underpinnings of CBT with some of the more common skill-sets that are used in the management of chronic pain.
The theory behind CBT
CBT is actually a hybrid of two efficacious forms of therapy: behavioural therapy (BT) and cognitive therapy (CT). BT for chronic pain is grounded in the work of Fordyce’s operant model , as well as in classical conditioning and social learning theory. BT focusses upon aspects of patients’ environments that can lead to the development or maintenance of pain through reinforcement (e.g., avoidance, attention, or pain relief from inactivity).
CT has its roots in the psychological treatment for depression . In its application to pain management, CT focusses on thoughts, beliefs, expectations and attributions that can lead to overwhelming affect, suffering and additional pain intensity and/or diminished functional status. In CT, patients are trained to gain insight with regard to into how their thoughts, beliefs or expectations influence emotions, pain and functioning. They are then taught how to alter these thoughts and beliefs in a manner that is better aligned with the management of pain.
In the context of pain, BT and CT techniques are often combined to form CBT. For any patient, however, behavioural or cognitive elements may be differentially emphasised. In practice, CBT typically includes three phases: (1) an educational phase, in which patients are introduced to a model for understanding their pain and the role that individuals can play in the management of the condition; (2) a skills training phase; and (3) an application phase, in which patients learn to apply their skills in progressively more challenging real-life situations . The next section describes some of the specific skills that are provided in CBT for pain as well as representative studies supporting the use of these skills for the management of pain.
CBT skill-sets
Education
Education is a vital component of CBT and is typically the first phase of treatment. The purpose of education is to establish rapport with the patient and to help ensure that the patient and the clinician are thinking about pain and their respective roles in pain management from a common perspective. Education typically involves providing the patient with an updated summary of the latest facts that concern the type of pain they are experiencing, the latest approaches to treatment and a theoretical framework for understanding the role of the patient in pain management. Education, by itself, is not considered to be an especially robust approach to treatment because simply learning what needs to change does not ensure that any behavioural action will occur.
The relaxation response
The most commonly used behavioural skill in CBT for pain management is a form of the relaxation response used to diminish autonomic arousal (e.g., through reduced muscle tension, heart rate and breathing) . To learn the response, the individual needs to practise the prescribed techniques repeatedly until his/her body acquires the desired response. There is no consensus as to the best method of teaching the relaxation response, for example, progressive muscle relaxation, visual imagery, hypnosis, biofeedback – all of which are based upon behavioural principles of reinforcement and appear to be useful modalities for learning this response. While relaxation has been found to be efficacious, on its own, for reducing pain in FM , it is also one of most commonly used skills in a multi-component CBT approach to pain management .
Graded activation
Performing tasks can enhance ones’ self-esteem. Thus, on ‘good days’, patients will unwittingly engage in more activity than personal limitations allow and will then suffer several ‘bad days’ of symptom flares, lost productivity and decreased self-esteem. Graded activation or ‘time-contingent pacing’ is a method of pacing that can improve physical functioning while minimising the likelihood of pain flare-ups. This approach has been successfully applied with LBP populations , rheumatological populations , in patients with FM and in patients having chronic fatigue syndrome . The key to success of this strategy is to pace activities based upon time rather than upon subjective experiences of pain or upon the completion of tasks. Active time can be as short as several minutes or as long as several hours depending upon what the patient can initially tolerate without exacerbation. The patient and therapist must work together to develop a plan for steadily increasing the amount of time spent on specified targeted behaviours. Time-based pacing can be used as a complementary skill to help ensure the long-term adoption of exercise regimens, work-related activities and pleasant activities, such as social outings and sporting activities.
Pleasant activity scheduling
Many individuals with chronic pain exclude enjoyment from their lives and leave time for only essential tasks. While this strategy is understandable, and may work well in the context of acute pain, long-term denial of personal pleasures can have devastating effects on mood and motivation, increasing pain and reducing function. Enjoyment of pleasant activities is a natural way to elevate mood and invites confidence in ones’ body to function at a higher level. As considered in CBT, this behavioural change encourages scheduling of pleasant activities into ones’ day with the same priority as a meeting, a doctor’s appointment, or a deadline .
Behavioural methods for improving sleep
Individuals with chronic pain have a number of problems related to getting a good night’s sleep and they include difficulty falling asleep, being awakened by pain or discomfort or, after sleeping, awakening with feelings of being unrefreshed and unrestored. Behavioural strategies for sleep, if used regularly, can help individuals obtain the required restorative sleep with additional benefits in improved mood, better management of pain, less fatigue and improved mental clarity . Some of these skills focus on timing strategies (e.g., having regular sleep routines), sleep behaviours (e.g., attempting to sleep only when in need of sleep) and behavioural avoidance of stimulating activities (e.g., watching action movies, consuming nicotine or caffeine). CBT, which targets sleep, appears to have a direct impact on pain symptoms and on functional interference resulting from non-restorative sleep .
Cognitive difficulties
Individuals with chronic pain will often report difficulties with memory, concentration and mental clarity . The cause of cognitive difficulties in chronic pain is not well understood but is likely to be associated with the lack of restorative sleep and the distracting nature of persistent pain on information processing . Behavioural approaches to stress reduction, such as inducing the relaxation response, and structured rehearsal methods for improving memory (e.g., repetition and developing associations) can provide benefit; but this remains an area where more study is needed.
Problem-solving strategies
Individuals with chronic pain face interpersonal and functional challenges that rarely affect healthy individuals. Programmatic problem-solving strategies can be taught to patients by helping them to break large problems down into solvable pieces . What is taught in therapy is a strategy for solving problems rather than specific solutions; thus, patients learn a strategy that can be carried into the future as new problems arise. Support for the use of problem solving in the context of CWP is derived from several studies demonstrating that improvements in the ability to deal with life’s problems are associated with reduced pain .
Cognitive restructuring and reframing
Behavioural solutions to problems reflect the beliefs held with regard to the nature of the problem and beliefs about one’s personal ability to effectively execute solutions. Strong convictions in one’s helplessness, the futility of trying to control illness or the inability to contribute meaningfully in life tasks are examples of learned, automatic, thinking patterns that can impede successful adaptation. Cognitive restructuring is a cognitive skill that is used to challenge the rationality of negative automatic thoughts and seeks to instill alternative thinking that is capable of promoting greater functioning and well-being. Cognitive restructuring invites individuals to explore the origin of learned automatic thinking patterns that contribute to maladaptive behavioural responses. With practice, new thinking patterns can replace old ones that are more consistent with well-being and pain control. This form of CT has been associated with improvements in pain .
Coping skills training
Coping skills training (CST) refers to a set of CBT skills that are aimed directly at reducing the experience of pain (e.g., distraction, reinterpreting the sensation of pain and ignoring the pain) . These skills have been studied as stand-alone interventions or as part of a multi-component approach. The use of CST has been associated with improvements in pain , sleep , improvements in functional status and improved mental health .
Interpersonal skills
Individuals with CWP often experience challenges in their dealings with other people. For example, spouses may become frustrated with the pain and the limited functionality of the patient. Employers may become less sympathetic over time and busy physicians may not have sufficient time to hear the many important details that a patient wishes to communicate. Assertiveness training or other forms of more effectively engaging in interpersonal processes are often taught in the context of CBT to help improve one’s self-efficacy to garner the support of others as well as to improve symptoms of pain directly .
Methods of CBT service delivery
CBT is commonly delivered either in a one-to-one format between a trained therapist and a single patient or with a therapist in a group setting. The duration of therapy is typically brief and involves between 6 and 12 sessions, with booster sessions being used to reinforce change over a longer term. Given the potential difficulties in accessing trained therapists or difficulties in travelling long distances to receive therapy, alternatives to traditional face-to-face delivery methods have been explored. For example, the delivery of CST can be accomplished over the telephone , CBT skills can be taught and supported by lay coaches and therapist-less websites can provide patients with the content of cognitive and behavioural approaches with significant impact upon symptoms .
Cognitive-behavioural therapy
CBT possesses a strong evidence base that supports its efficacy in the management of chronic pain . The term CBT, refers to a class of interventions, each of which is grounded upon a common theoretical framework. For example, CBT interventionists will utilise a wide variety of skill-sets or modules to produce outcomes. Typically, the choice of modules depends upon the intended target of treatment (pain reduction, functional improvement, mood, etc.). That CBT content can vary depending upon the need of the individual patient is actually a strength of the approach and underscores the flexibility of this therapeutic modality; however, such flexibility has also contributed to some confusion when it is assumed that CBT is a uniform intervention. The next section reviews theoretical underpinnings of CBT with some of the more common skill-sets that are used in the management of chronic pain.
The theory behind CBT
CBT is actually a hybrid of two efficacious forms of therapy: behavioural therapy (BT) and cognitive therapy (CT). BT for chronic pain is grounded in the work of Fordyce’s operant model , as well as in classical conditioning and social learning theory. BT focusses upon aspects of patients’ environments that can lead to the development or maintenance of pain through reinforcement (e.g., avoidance, attention, or pain relief from inactivity).
CT has its roots in the psychological treatment for depression . In its application to pain management, CT focusses on thoughts, beliefs, expectations and attributions that can lead to overwhelming affect, suffering and additional pain intensity and/or diminished functional status. In CT, patients are trained to gain insight with regard to into how their thoughts, beliefs or expectations influence emotions, pain and functioning. They are then taught how to alter these thoughts and beliefs in a manner that is better aligned with the management of pain.
In the context of pain, BT and CT techniques are often combined to form CBT. For any patient, however, behavioural or cognitive elements may be differentially emphasised. In practice, CBT typically includes three phases: (1) an educational phase, in which patients are introduced to a model for understanding their pain and the role that individuals can play in the management of the condition; (2) a skills training phase; and (3) an application phase, in which patients learn to apply their skills in progressively more challenging real-life situations . The next section describes some of the specific skills that are provided in CBT for pain as well as representative studies supporting the use of these skills for the management of pain.
CBT skill-sets
Education
Education is a vital component of CBT and is typically the first phase of treatment. The purpose of education is to establish rapport with the patient and to help ensure that the patient and the clinician are thinking about pain and their respective roles in pain management from a common perspective. Education typically involves providing the patient with an updated summary of the latest facts that concern the type of pain they are experiencing, the latest approaches to treatment and a theoretical framework for understanding the role of the patient in pain management. Education, by itself, is not considered to be an especially robust approach to treatment because simply learning what needs to change does not ensure that any behavioural action will occur.
The relaxation response
The most commonly used behavioural skill in CBT for pain management is a form of the relaxation response used to diminish autonomic arousal (e.g., through reduced muscle tension, heart rate and breathing) . To learn the response, the individual needs to practise the prescribed techniques repeatedly until his/her body acquires the desired response. There is no consensus as to the best method of teaching the relaxation response, for example, progressive muscle relaxation, visual imagery, hypnosis, biofeedback – all of which are based upon behavioural principles of reinforcement and appear to be useful modalities for learning this response. While relaxation has been found to be efficacious, on its own, for reducing pain in FM , it is also one of most commonly used skills in a multi-component CBT approach to pain management .
Graded activation
Performing tasks can enhance ones’ self-esteem. Thus, on ‘good days’, patients will unwittingly engage in more activity than personal limitations allow and will then suffer several ‘bad days’ of symptom flares, lost productivity and decreased self-esteem. Graded activation or ‘time-contingent pacing’ is a method of pacing that can improve physical functioning while minimising the likelihood of pain flare-ups. This approach has been successfully applied with LBP populations , rheumatological populations , in patients with FM and in patients having chronic fatigue syndrome . The key to success of this strategy is to pace activities based upon time rather than upon subjective experiences of pain or upon the completion of tasks. Active time can be as short as several minutes or as long as several hours depending upon what the patient can initially tolerate without exacerbation. The patient and therapist must work together to develop a plan for steadily increasing the amount of time spent on specified targeted behaviours. Time-based pacing can be used as a complementary skill to help ensure the long-term adoption of exercise regimens, work-related activities and pleasant activities, such as social outings and sporting activities.
Pleasant activity scheduling
Many individuals with chronic pain exclude enjoyment from their lives and leave time for only essential tasks. While this strategy is understandable, and may work well in the context of acute pain, long-term denial of personal pleasures can have devastating effects on mood and motivation, increasing pain and reducing function. Enjoyment of pleasant activities is a natural way to elevate mood and invites confidence in ones’ body to function at a higher level. As considered in CBT, this behavioural change encourages scheduling of pleasant activities into ones’ day with the same priority as a meeting, a doctor’s appointment, or a deadline .
Behavioural methods for improving sleep
Individuals with chronic pain have a number of problems related to getting a good night’s sleep and they include difficulty falling asleep, being awakened by pain or discomfort or, after sleeping, awakening with feelings of being unrefreshed and unrestored. Behavioural strategies for sleep, if used regularly, can help individuals obtain the required restorative sleep with additional benefits in improved mood, better management of pain, less fatigue and improved mental clarity . Some of these skills focus on timing strategies (e.g., having regular sleep routines), sleep behaviours (e.g., attempting to sleep only when in need of sleep) and behavioural avoidance of stimulating activities (e.g., watching action movies, consuming nicotine or caffeine). CBT, which targets sleep, appears to have a direct impact on pain symptoms and on functional interference resulting from non-restorative sleep .
Cognitive difficulties
Individuals with chronic pain will often report difficulties with memory, concentration and mental clarity . The cause of cognitive difficulties in chronic pain is not well understood but is likely to be associated with the lack of restorative sleep and the distracting nature of persistent pain on information processing . Behavioural approaches to stress reduction, such as inducing the relaxation response, and structured rehearsal methods for improving memory (e.g., repetition and developing associations) can provide benefit; but this remains an area where more study is needed.
Problem-solving strategies
Individuals with chronic pain face interpersonal and functional challenges that rarely affect healthy individuals. Programmatic problem-solving strategies can be taught to patients by helping them to break large problems down into solvable pieces . What is taught in therapy is a strategy for solving problems rather than specific solutions; thus, patients learn a strategy that can be carried into the future as new problems arise. Support for the use of problem solving in the context of CWP is derived from several studies demonstrating that improvements in the ability to deal with life’s problems are associated with reduced pain .
Cognitive restructuring and reframing
Behavioural solutions to problems reflect the beliefs held with regard to the nature of the problem and beliefs about one’s personal ability to effectively execute solutions. Strong convictions in one’s helplessness, the futility of trying to control illness or the inability to contribute meaningfully in life tasks are examples of learned, automatic, thinking patterns that can impede successful adaptation. Cognitive restructuring is a cognitive skill that is used to challenge the rationality of negative automatic thoughts and seeks to instill alternative thinking that is capable of promoting greater functioning and well-being. Cognitive restructuring invites individuals to explore the origin of learned automatic thinking patterns that contribute to maladaptive behavioural responses. With practice, new thinking patterns can replace old ones that are more consistent with well-being and pain control. This form of CT has been associated with improvements in pain .
Coping skills training
Coping skills training (CST) refers to a set of CBT skills that are aimed directly at reducing the experience of pain (e.g., distraction, reinterpreting the sensation of pain and ignoring the pain) . These skills have been studied as stand-alone interventions or as part of a multi-component approach. The use of CST has been associated with improvements in pain , sleep , improvements in functional status and improved mental health .
Interpersonal skills
Individuals with CWP often experience challenges in their dealings with other people. For example, spouses may become frustrated with the pain and the limited functionality of the patient. Employers may become less sympathetic over time and busy physicians may not have sufficient time to hear the many important details that a patient wishes to communicate. Assertiveness training or other forms of more effectively engaging in interpersonal processes are often taught in the context of CBT to help improve one’s self-efficacy to garner the support of others as well as to improve symptoms of pain directly .
Methods of CBT service delivery
CBT is commonly delivered either in a one-to-one format between a trained therapist and a single patient or with a therapist in a group setting. The duration of therapy is typically brief and involves between 6 and 12 sessions, with booster sessions being used to reinforce change over a longer term. Given the potential difficulties in accessing trained therapists or difficulties in travelling long distances to receive therapy, alternatives to traditional face-to-face delivery methods have been explored. For example, the delivery of CST can be accomplished over the telephone , CBT skills can be taught and supported by lay coaches and therapist-less websites can provide patients with the content of cognitive and behavioural approaches with significant impact upon symptoms .
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