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assumptions in the treatment of people with chronic pain


Cognitive Behavioral Therapy Pain

When you see as much Chronic Pain as I do, you realize very quickly that there are any number of assumptions taking place in the treatment thereof.  One of those assumptions would be that drug therapy for Chronic Pain is both safe and effective.  We know beyond the shadow of a doubt that this is not true (HERE and HERE).  It harkens back to the old adage: Never ASSUME, because when you ASSUME, you make an ASS of both U and ME.  Today we are going to talk about another assumption that has to do with the treatment of Chronic Pain.

Doctors telling people that their pain is all in their head has been common for a very long time.  There are any numbers of reasons for this.  These would include “pesky” facts such as MRI not being able to image most health problems (HERE), numerous health issues being “FUNCTIONAL” and not pathological (FIBROMYALGIA, NCGS, SYMPATHETIC DOMINANCE, MIGRAINE HEADACHES, and FASCIAL ADHESIONS or DENSIFICATION are prime examples), as well as well-kept secrets like MUPS.  This does not even get into the fact that it prevents the examining / treating physician from having to say, “I’m sorry Mrs. Smith, but I ‘m not really sure why you are having pain.”  Unfortunately, the realization that an increasing number of people’s pain really is in their heads (CENTRAL SENSITIZATION) has only added to the confusion. 

Because doctors are often poor diagnosticians when it comes to problems of the musculoskeletal system (HERE), and know so little about nutrition (HERE), they are often left with little else in their arsenal than their ability to prescribe drugs.  The problem is that the drugs chiefly prescribed for MUSCULOSKELETAL PROBLEMS are palliative and not therapeutic.  This means that they help people feel better, but do absolutely nothing to really help people actually get better.  Examples are abundant — PAIN MEDS, MUSCLE RELAXERS, ANTI-INFLAMMATION DRUGS, CORTICOSTEROID INJECTIONS, and ANTIDEPRESSANTS, being the most common.  Recently, another form of therapy for people dealing with CHRONIC PAIN has become popular — Cognitive Behavioral Therapy or CBT.

CBT is said to be good for helping people with problems such as ANXIETY & DEPRESSION, EATING DISORDERS & OBESITY, SEXUAL DYSFUNCTION, Phobias, Personality Disorders, Psychosis, Schizophrenia, Drug Abuse / Alcoholism / SMOKING, OCD, PTSD, tics and other Repetitive Behavior Disorders, and any number of others, including Chronic Pain.  But what does Cognitive Behavioral Therapy entail?  

According to the Mayo Clinic’s website (Cognitive Behavioral Therapy) “Cognitive behavioral therapy is a common type of mental health counseling (psychotherapy) that helps you become aware of inaccurate or negative thinking, so you can view challenging situations more clearly and respond to them in a more effective way.”   Great definition, but I am more interested in what they are doing.  Mayo comes to the rescue again by telling us that CBT is “short term therapy — about 10 to twenty sessions,” and entails the following…….

  • Identify troubling situations or conditions in your life
  • Become aware of your thoughts, emotions and beliefs about these situations or conditions
  • Identify negative or inaccurate thinking
  • Challenge negative or inaccurate thinking

I must honestly say that not only could all of us benefit from this, I believe that on some level, healthy and successful people are doing this on their own to at least some degree.   All this aside, the question we are asking today is not whether CBT is beneficial for most these problems, but whether it is beneficial for people dealing with Chronic Pain.

Just days ago, the July issue of Spine published a study (Cognitive-Behavioral Treatment for Subacute and Chronic Neck Pain: A Cochrane Review) that provided this answer.  After finding ten studies that met the criteria, the researchers used the Cochrane Collaboration’s tool to not only assess how well the therapy worked, but to determine whether or not the “EVIDENCE” was good or poor for each study analyzed. 

“With regard to chronic neck pain , there was low quality evidence that CBT was better than no treatment for improving pain, disability, and quality of life, while no effect was found on kinesiophobia [fear of movement due to pain].  When comparing CBT to other interventions, no difference was found for pain and disability.  CBT was shown to induce changes on pain and disability for chronic NP only when compared to no treatment.  On subacute NP, benefit was found on pain relief but not on disability when comparing CBT to other interventions. However, none of these effects were clinically meaningful [significant].”

What can I as someone who daily treats people with CHRONIC NECK PAIN come away with from this study?  Firstly, unlike drugs and surgery, CBT does not have the potential to make you worse, or wreck your life.  In other words, as far as I can tell, there’s not downside.  Secondly, never confuse CBT (talk therapy) for the kind of brain exercises that a FUNCTIONAL NEUROLOGIST would prescribe after a HEAD INJURY or CONCUSSION, or for certain “BRAIN-BASED” conditions.  And thirdly, this study looked at people who were having CBT done purely for pain — most specifically, neck pain. If you are having SHOULDER PAIN — who knows; CBT might prove to be the cat’s meow.

The point of today’s post is not to rain on the CBT parade As I showed you, I believe the technique has merit.  It is to show you that when it comes to dealing with Chronic Pain, it can be tough to know — like I showed you THE OTHER DAY — whether or not your pain has become “Centralized”.  And like I showed you the other day as well (and like with CBT) the sort of conservative (non drug / non surgical) care delivered in my clinic, is not only not going to make you worse — there is a strong chance it could provide some REAL BENEFIT.  Doctors telling the patient their pain is in their head because they don’t understand what’s really going on, is not the best option for anyone.  For more about helping yourself with Chronic Pain or Chronic Illness, make sure to take a look at THIS POST.


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