Managing chronic pain through cognitive change and multidisciplinarytreatment program

WILLIAM DOUGLAS, CARL GRAHAM, DUNCAN ANDERSON, & KIM ROGERSON

Pain Clinic, Fremantle Hospital, Fremantle, Western Australia, Australia

AbstractA program for enhancing the management of patients presenting with chronic pain is described, using a prospective controlledcohort study. The participants were 152 outpatients referred to a tertiary centre pain clinic. Intervention consisted of acognitive behavioural program aimed at improving mood, functional capacity, and quality of life. Data from outcomemeasures were obtained before and after treatment and compared with data obtained from 48 waitlisted patients. Multivariateanalysis of variance demonstrated a significant statistical difference between treated patients and controls as a result of theprogram, although clinical improvement was modest.

The cost of chronic pain to the general community is

great in both financial and human terms and is

reflected in a recent prevalence study of chronic pain

in Australia. Blyth et al. (2001) found that 17.1%

(male) and 20% (female) of the national population

suffered from persistent pain on a daily basis for a

minimum of 3 months. In that study, a significant

number of respondents reported some degree of

interference with activities of daily living and a strong

association between chronic pain and high levels of

psychological distress. Other studies (Magni, March-

etti, Moreschi, Merskey, & Luchini, 1993; Von

Korff, Dworkin, & Le Resche, 1988) have confirmed

this relationship between chronic pain and psycho-

logical symptoms using different measures to estab-

lish links between chronic pain and depressive

symptoms, and between specific pain conditions

and anxiety, depression, and somatisation.

As a result of this link between chronic pain and

psychosocial factors, the International Association

for the Study of Pain (IASP) has for a number of

years now, been advocating a biopsychosocial model

for the assessment and treatment of chronic non-

cancer pain (Fields, 1995). As a secondary effect of

chronic pain, patients will typically be at high risk of

developing clinical depression and anxiety. They are

also at risk of losing their employment, using

ineffective coping strategies, developing increased

disability, increasing medication use, and experien-

cing a reduction in general quality of life.

Spinal pain is probably the most common form of

chronic pain presenting in tertiary hospital pain

clinics, but Waddell (1987) has argued that conven-

tional medical treatment for intractable chronic

spinal pain has failed. He argues that the psycholo-

gical factors associated with the maintenance of

chronic pain are significant and must therefore be a

part of any treatment protocol. The conditions

causing chronic pain are typically benign, medically

stable, and do not warrant major invasive treatment.

Despite this fact, many patients with such benign

conditions exhibit extreme levels of illness behaviour

and have marked psychological distress. Pilowsky

(1989) has written extensively about this combina-

tion of factors in terms of ‘‘abnormal illness

behaviour’’. He defines this condition as a maladap-

tive mode of perceiving, understanding, and behav-

ing in relation to one’s health status, despite having

been given an explanation of the illness, and told of

the appropriate course of management. In other

words a patient’s behaviour, emotions, and beliefs

remain unchanged in the face of medical reassur-

ance. Therefore, an important aspect of treatment for

chronic pain patients is reassurance that their

condition is benign and stable, despite fluctuating

levels of pain.

Correspondence: W. Douglas, Pain Clinic, Fremantle Hospital, Alma Street, Fremantle, WA 6160, Australia. Tel.: + 61 8 9431 2427. Fax: + 61 8 9431 3236.

E-mail: bdouglas@westnet.com.au

Australian Psychologist, November 2004; 39(3): 201 – 207

ISSN 0005-0067 print/ISSN 1742-9544 online # The Australian Psychological Society Ltd

Published by Taylor & Francis Ltd

DOI: 10.1080/00050060412331295045

Reassurance is probably one of the most clinically

important and commonly appreciated functions in

medical practice. However Coia and Morley (1998)

have argued that the form of reassurance offered by

doctors is frequently ineffective. They distinguish

between emotional – heuristic changes in patient per-

ception and behaviour, and cognitive – systematic

changes. They argue that the former characterises

the form of persuasion and reassurance most

commonly utilised by doctors, and results in only

transient, if any change. It aims to relieve patient

distress in the immediate circumstances while paying

little attention to disease conviction and underlying

beliefs about disease and its longer term implica-

tions. In contrast, cognitive-systematic change re-

sults in more enduring shift because it aims to alter

patient perception, and establish appropriate

thoughts and beliefs regarding illness and underlying

disease.

A number of Australian studies have appeared

reporting outcome of pain management programs

using various combinations of psychological and

physical therapy. Nicholas, Wilson, and Goyan

(1991) compared the effectiveness of cognitive

treatment with behavioural treatment in various

combinations, with and without relaxation training.

All conditions received the same physiotherapy, back

education and exercise program. The combination

of psychological and physical therapy was found to

be superior to physical therapy alone, in terms of

pain intensity, self-rated functional impairment and

pain-related dysfunctional cognitions. These

changes, however, were only weakly maintained at

6- and 12-month follow-up. The same researchers

(Nicholas, Wilson, & Goyan, 1992) studied the

efficacy of group cognitive behavioural treatment by

comparing treatment with controls, where both

groups received the same physiotherapy, back

education and exercise program. The primary

difference between the two groups being that one

received cognitive behaviour therapy while controls

were placed in a discussion group focusing on living

with chronic back pain. The treatment group showed

greater improvement in terms of functional impair-

ment, active coping strategies, self-efficacy beliefs,

and medication use. Flavell, Carrafa, Thomas, and

Disler (1996) reported the outcome of a 6-week (two

6-hr group sessions per week) multidisciplinary pain

management program. The 138 outpatients were

exposed to physical exercise, education, and relaxa-

tion sessions. Outcome was measured by way of the

West Haven –Yale Multidimensional Pain Inventory

(WHYMPI) and a 4-min walk test. Patient pain

ratings remained unchanged as a result of the

program, while there was an increase in self-reported

functional capacity and sense of control. These

changes were maintained at 3-month follow-up.

Moseley (2002) compared the combined effects of

education and physiotherapy with general practi-

tioner (GP)-directed treatment of 57 chronic low-

back-pain patients. Outcome was measured in terms

of subjective pain level and disability rating scale.

Although repeated measures analysis of variance

(ANOVA) showed a significant treatment effect for

both measures in both groups, it was unclear

whether the combined physio/education group was

superior to GP management.

Group-based multidisciplinary programs are not

new, although the extent of Australian publications

in this area is limited. This study attempts to further

develop the body of evidence that demonstrates that

substantial reduction in abnormal illness behaviour

in this population can be best achieved in the context

of a cognitive behavioural program of pain manage-

ment. This paper describes an effective program of

treatment for chronic pain patients, which has a

primary emphasis on maintaining cognitive change,

improving mental state, education, and increasing

general functional capacity.

Methods

Participants

Participants in this study were 187 consecutive

patients attending a public hospital pain manage-

ment program. The Pain Understanding and Man-

agement Program (PUMP), is a multidisciplinary

treatment program for outpatients presenting with

chronic pain (Table I). The age range of patients was

between 18 and 82 years.

Prior to undertaking the program, patients were

assessed medically and psychologically. Medically,

patients were deemed suitable for the program if (a)

pain was so widespread as to make nerve blocks and

other anaesthetic procedures inappropriate; (b)

nerve blocks and other procedures failed to produce

significant relief; or (c) patients requested a non-

invasive form of treatment.

As part of the psychological assessment, patients

were required to complete the Zung Depression

Inventory (Main & Waddell, 1984), Roland –Morris

Disability Questionnaire (RM) (Roland & Morris,

1983), and the Medical Outcome Study (MOS) 36-

Item Short Form Health Survey (SF-36) (Ware &

Sherbourne, 1992). The SF-36 usually produces

eight different scales relating to quality of life and

level of disability. However, in this case a summation

of all raw scores was used as a single measure of

change. A visual analogue pain scale (VAS) (Price &

Harkins, 1987), and two subscales from the Coping

Strategies Questionnaire (CSQ) (Rosenstiel &

Keefe, 1983) were used. Studies (Rosenstiel &

Keefe, 1983, Turner & Clancy, 1986) have shown

202 W. Douglas et al.

that the subscales of Catastrophising and Praying

and Hoping are associated with greater pain and

disability levels. It was decided for the sake of brevity

to use only these two subscales of the CSQ. The

Medication Quantification Scale (MQS) (Steedman

et al., 1992) was also used to evaluate medication

consumption. These data were collected on patients

attending the program routinely by way of clinical

audit.

Chronic pain patients describe a degree of

variability in pain level, medication use, and mood

over time. As a result it was deemed necessary to

compare outcome of the treatment group with a

similar group of patients who received no treatment.

A control group of 48 patients was used comprising

consecutive patients on the waiting list for PUMP.

These patients completed the same questionnaires 5

weeks prior to commencing treatment and then

again immediately prior to undertaking treatment,

thereby providing data over a 5-week period when no

treatment was being provided. The subjects partici-

pating in the control group were not included in the

subsequent treatment group. In summary, assess-

ment measures were administered on three occa-

sions (before treatment, after treatment, and at 6-

month follow-up) for the treatment group, and on

two occasions for the control group. Thirty-five

patients failed to complete the program, leaving 56

male and 96 female patients. Table II shows no

significant difference in a comparison of pretreat-

ment scores between the 35 patients who dropped

out of the programme and the 152 who completed

treatment.

Treatment

This treatment was a multidisciplinary program for

patients presenting with chronic pain. It adopted a

cognitive behavioural approach developed in re-

sponse to the increasing body of evidence that pain

extends beyond the sole contribution of sensory

phenomena, to include cognitive, affective, and

behavioural factors (Melzack et al., 1988). This

approach also utilises principles of operant condi-

tioning that encourage patients to question, re-

assess, and acquire greater control over maladaptive

thoughts, feelings, behaviours, and physiological

responses. Specifically, the program included the

following.

1. Graduated exercise, which was conducted by

a physiotherapist and which was aimed at

improving exercise tolerance, range of motion,

and functional capacity. This involved a range

of strengthening and stretching exercises

combined with a brisk walk in a 2-hr session

days per week. The repetitions of exercises

and distance and speed of the walk were

monitored on a daily basis with an emphasis

on gradual increases every few days. Patients

Table I. Patient characteristics

Age (years)

M (SD)

Average years

in pain LBP Cervical Other 43 sites

Treatment group

Male 48.7 (11.6) 8.6 24 3 10 17

Female 50.4 (11.7) 4.6 40 5 53 35

Waitlist group

Male 46.5 (10.4) 7.3 12 0 9 1

Female 49.3 (11.0) 5.4 10 5 3 8

Note. LBP= low back pain.

Table II. Independent sample t tests between treatment and drop-out pretreatment scores

Treatment (n=152) Drop-out (n=35)

Measure (t-test) M SD M SD X

Zung 26.32 12.5 25.98 12.1 ns

RM 11.63 5.1 12.01 4.8 ns

SF-36 81.13 16.4 80.80 17.1 ns

VAS 6.00 1.7 5.9 1.8 ns

CSQ 29.01 11.0 28.50 12.1 ns

MQS 11.64 9.5 11.0 8.4 ns

Note. Zung=Zung Depression Inventory; RM=Roland –Morris Disability Questionnaire; SF-36=MOS 36-Item Short Form Health

Survey; VAS=Visual Analogue Scale; CSQ=Coping Strategies Questionnaire; MQS=Medication Quantification Scale.

Managing chronic pain 203

were also taught to monitor heart rate

following the walk and were provided with

information on their optimal training heart

rate based on age so as to maximise aerobic

capacity. A small difference of emphasis in the

exercise routine was made between those

patients with upper and lower spinal pain.

The exercise component was otherwise the

same for all patients, based on the assumption

that an improvement in general physical and

aerobic fitness is a most important objective

with this population.

2. Education, which aimed at increasing aware-

ness of the scientific basis of both the physical

and psychological aspects of pain; the differ-

ences between chronic and acute pain; the

importance of pacing activity, the need for

mood management, and goal setting. To assist

with the educational process, patients were

also presented with a 60-page handbook

covering medical aspects of pain; psycholo-

gical aspects of pain; physiotherapy; pain and

activity; maintaining gains; living with

someone with chronic pain. These compo-

nents of the program were covered in eight

sessions and were delivered by medical,

psychology and physiotherapy staff members.

3. A clinical psychologist, who undertook cogni-

tive behaviour therapy in six sessions over

weeks. In these sessions a rational – emotive

therapy (Bernard & Wolfe, 1993) approach

was adopted, and this was aimed particularly

at identification and modification of inap-

propriate behaviour and unhelpful beliefs;

reducing fear – avoidant behaviour; encoura-

ging acceptance of the possibility that pain

may well flare up at times, and may persist for

the remainder of the patient’s life. Pain control

techniques involving methods of muscle

relaxation were also taught by the clinical

psychologist over four separate sessions.

The program was conducted in groups of approxi-

mately 10 patients per group, over a 4-week period,

involving 3 – 4 hr per day, 5 days per week. No

individual treatment was offered. Patients partici-

pated in a 2-hr session of set exercises at the

commencement of each day followed by 1 – 2 hr of

psychoeducational sessions, which were both didac-

tic and interactive.

Results

The results were initially analysed by way of multi-

variate analysis of variance (MANOVA) between

treatment and control groups. This analysis showed

a significant main effect of time, F(6,193)= 10.35,

p5 .001, and a significant interaction between

group and time, F(6,193) = 8.03, p5 .001. The

interaction is probably the statistic of most interest

because it indicates that the rate of change as a result

of treatment is significantly greater than that of

controls, and confirms a positive overall effect of

treatment. The MANOVA examined results at two

levels of time, namely, before and after treatment.

Table III shows the means and standard deviations

for the various measures at these time-points. There

is a consistent trend in treatment group scores,

suggesting improved outcome for the treatment

group, while control group scores remain more or

less unchanged. Follow-up data on all measures

were also obtained from the treatment group at 6

months, with a t test comparison made between

post-treatment and follow-up scores. Although there

is a slight regressive trend in the cases of the Zung,

SF-36, and the MQS, results showed that there was

no significant difference between these two data sets,

suggesting that post-treatment gains were main-

tained. It is noteworthy in the case of the CSQ that

there was a significant ongoing positive change, and

improvement in mental state throughout the 6

months following treatment.

Within the treatment group, t tests were also

applied to the pre- and post-treatment data, and in

all cases there was found to be significant difference,

suggesting that treatment was effective. However,

when the post-treatment means of both groups were

compared, only three of the six measures were found

to be significant. The treatment group VAS, CSQ

and MQS scores were found to be not significantly

different from those of the untreated group.

Table IV shows a univariate analysis of individual

outcome measures for both main effects of treatment

and interaction between treatment and controls. In

all cases a significant main effect of treatment and

interaction was found.

Discussion

Patients with chronic benign pain frequently present

with a range of mistaken beliefs, exaggerated levels of

fear, and exhibit excessive avoidance behaviour.

Many patients who present at tertiary pain clinics

will go on to experience pain for the rest of their

lives, and at initial presentation they frequently

exhibit symptoms of adjustment disorder, with or

without symptoms of anxiety and depression.

The problem of adjusting to their condition has

often been compounded by a system of medical care

that generally encourages the patient to be passive

participants who offer themselves up for treatment.

Although this may well be generally appropriate in

the normal course of medical care, such an approach

to treatment with the chronic pain population tends

204 W. Douglas et al.

to prolong dependency on doctors and the medical

system to deliver a cure. With the majority of

patients in this population, cure is an unrealistic

expectation, whereas improving quality of life

through improved adjustment and increasing func-

tional capacity is not unrealistic. If the patient is to

progress in this direction and be successfully

reassured in the long term that their condition is

limited and benign, cognitive – systematic changes

must be pursued. If illness and pain behaviour are to

be successfully modified and patients are to become

more adaptive and functional, then brief and simple

reassurance is probably insufficient.

This pain management program encourages pa-

tients to accept a greater degree of responsibility for

the day-to-day management of their pain, while also

addressing any maladaptive ideas, beliefs, emotions,

and behaviour. The program addresses all aspects of

abnormal illness behaviour, and results suggest that

cognitive behaviour therapy in conjunction with

relaxation training and physiotherapy does produce

significant improvement in patient functioning com-

pared to the absence of such treatment. The results

obtained in this study are generally consistent with

the results reported by other Australian studies

(Flavell et al., 1996; Nicholas et al., 1991, 1992).

Where depression level is concerned, there was some

statistically significant reduction in depression in the

current study, although the effect size was small, and

clearly indicates that the post-treatment level of

depression remains at a moderate level. To improve

outcomes for levels of depression, it may be

necessary to lengthen the period of treatment and

also to focus cognitive behavioural treatment more

specifically of depressive symptoms. As a result of

casual observation we believe that the development

of psychological insight over the course of the

program, may have a direct effect on the reportingTab

leIII.

Meansan

dstan

darddeviationsat

pre-,post-treatmen

tan

dfollow-up

Treatmen

t(n

=152)

Control(n

=48)

Pretreatm

ent

Post-treatmen

tFollow-up

Pretreatm

ent

Post-treatmen

t

Measure

MSD

MSD

MSD

MSD

MSD

Follow-up

Zung

26.32

12.5

21.67*

12.5

22.01

13.3

26.15

10.3

26.25{

10.2

–

RM

11.63

5.1

10.0*

5.9

9.99

6.0

12.13

4.5

12.29{

5.1

–

SF-36

81.13

16.4

91.48*

20.1

90.62

22.4

80.27

16.9

80.25{

16.7

–

VAS

6.00

1.7

5.11*

2.3

5.10

2.3

5.83

1.6

5.73

1.9

–

CSQ

29.01

11.0

25.03*

10.8

21.60

12.3

27.85

15.2

27.33

4.0

–

MQS

11.64

9.5

8.02*

7.8

8.64

9.0

10.85

10.5

10.38

10.1

–

Note.Zung=ZungDep

ressionInventory;RM

=Roland–M

orrisDisab

ilityQuestionnaire;SF-36=M

OS36-Item

ShortForm

HealthSurvey;VAS=Visual

AnalogueScale;CSQ=CopingStrategies

Questionnaire;M

QS=M

edicationQuan

tificationScale.

*Pairedsample

ttestsbetweenpre-an

dpost-treatmen

tdatasignificantp5

.05.

{ Indep

enden

tsample

ttestsbetweentreatm

entan

dco

ntrolpost-treatmen

tdatasignificantp5

.05.

Pairedsample

ttestsbetweenpost-treatmen

tan

dfollow-updatawereallnonsignificant.

Table IV. Univariate tests: Main effects for time, group, and

Time6Group interaction F ratios

F(1,198)

Variable Time Group

Time 6Group

Zung 13.83* 1.35 15.13*

RM 4.41* 2.75 6.70*

SF-36 20.55* 4.80* 20.72*

VAS 8.22* .69 5.14*

CSQ 10.43* .09 6.16*

MQS 24.15* .29 14.19*

Note. Zung=Zung Depression Inventory; RM=Roland –Morris

Disability Questionnaire; SF-36=MOS 36-Item Short Form

Health Survey; VAS=Visual Analogue Scale; CSQ=Coping

Strategies Questionnaire; MQS=Medication Quantification

Scale.

*Significant p5 .05.

Managing chronic pain 205

of psychological state. As psychological insight

improves, patients are increasingly likely to notice

and admit to psychological factors affecting their

experience of pain and related disability. The effect

of this may be to have underreported the presence of

symptoms at preprogram assessment and thereby

reduce the sensitivity of self-report scales to detect

the psychological changes that are occurring. Statis-

tically, this causes a reduction in the effect size

present and, potentially, could increase the chances

of Type II errors in outcome research. This

deficiency might be addressed, in part, by the

inclusion of behavioural and physiological measures

of change in the batteries used to assess patients.

Disability as rated by a disability rating scale

showed a small but significant reduction. Sub-

jective perception of pain as measured by the VAS,

showed some significant statistical decrease,

although the clinical significance seems to be

negligible. This is also a finding that is consistent

with other studies (Nicholas et al., 1991). Given

that many patients participating in this program

have pain arising from substantial physical injury, it

maybe reasonable to expect that only modest gains

will be made in pain perception as a result of

improvement in physical fitness. Another factor

accounting for this lack of clinically significant

change in pain rating may also be that depression

levels remain in the mild to moderate range.

Cognitively, depressed patients are going to show

a tendency to magnify their difficulties and this

may contribute to the finding that subjective pain

perception remains at a moderate level. However,

many clinicians working in the area of chronic pain

management regard improvements in the patient’s

capacity to cope with pain as more important than

the pain level itself.

General quality of life, as measured by the SF-

36, was elevated, reflecting a positive trend.

Although the pre- and post-treatment CSQ results

reflected improvement in terms of reduction in

unhelpful strategies of pain coping, significant

treatment effect was not supported by the t-test

comparison between treatment and controls at the

post-treatment stage. Similarly, the pre- and post-

treatment MQS scores show a substantial reduc-

tion in the consumption of medication following

the program, but again, treatment was not found

to be significantly different from controls at the

post-treatment stage.

The magnitude of change in pre- to post-measure

comparison in some cases is not great. We suspect

that this is in part the result of not selecting out

patients according to prescribed criteria. Some pain

management programs (Main & Spanswick, 2000;

Nicholas et al., 1991) select out patients who may

still be considering further medical treatment; or

those outside certain age limits; or those who may

have psychiatric comorbidity. By removing challen-

ging patients on the grounds of a predicted resistance

to change, it is reasonable to expect a greater

magnitude of group change. Our stance on this

issue is supported by regularly observed clinical

improvements in a number of patients who would

have been excluded by some other programs.

Given a tendency toward treatment failure and the

high levels of ongoing health system utilisation in this

population, it is of particular importance that

treatment gains are maintained, including any

reduction of overall pain levels. In terms of the

reduction of ineffective cognitive strategies it is

interesting to note that the CSQ showed improve-

ment over time following the completion of the

program. At 6-month follow-up, CSQ scores were

found to be within the normal range and it maybe

assumed that the program managed to deliver the

more enduring form of reassurance or persuasion,

resulting in cognitive – systematic changes in disease

conviction and associated beliefs.

There are some limitations with a study such as

this, in comparison with prospective study. The

authors recognise that use of a waitlisted control

group instead of a placebo control, and lack of

randomisation in group allocation are weaknesses of

this study. However, these data are derived from an

attempt to audit clinical treatment, and nevertheless

represent some useful findings. We also recognise

that there may be some lack of precision in mixing

together a group of patients with various pain sites.

However, many clinicians within both medicine and

psychology who are working in the pain area, believe

that the psychosocial and behavioural problems

experienced by chronic pain patients tend to be the

same irrespective of pain site.

Acknowledgement

The authors acknowledge the helpful comments of

Peter Drummond, Murdoch University, on an

earlier draft of this paper.

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Managing chronic pain 207