Group Therapy for Chronic Pain



Group Therapy for Chronic Pain


Melissa A. Day

Beverly E. Thorn



Group therapy continues to be an appealing and common method of chronic pain treatment delivery both in clinical and research settings.1 First appearing over three decades ago in the pain management literature, case reports2 and open clinical trials3,4 began reporting on adapted individual treatments applied in small-group settings that explored the patient acceptability of a group format. Since that time, controlled trials have demonstrated the utility, efficacy, and cost-effectiveness of this mode of delivery, and the group format is commonly used in interdisciplinary pain management clinics for helping patients manage heterogeneous chronic painful conditions.

Although there are multiple levels of evidence, and each has advantages and disadvantages, in an evidence-based practice, randomized controlled trials (RCTs) provide stronger support.5 Therefore, the primary findings presented in this chapter are based on evidence emerging from searches of the scientific literature that were performed as recommended within the practice of evidence-based medicine.6 Specifically, the search implemented in the prior edition of this chapter that searched the literature dating back to 1980 until 2007 was extended to identify literature published between 2007 and August 2017. As per the prior edition, combinations of controlled vocabulary terms, keywords, and methodologic filters were used in an effort to identify the highest level of evidence currently available on group treatment of chronic pain. Details of these searches may be found in Appendix 87.1.

These literature searches revealed that RCTs have primarily evaluated five different types of groups: (1) cognitive-behavioral therapy (CBT) groups that focus on teaching pain selfmanagement skills; (2) mindfulness-based interventions (MBIs) including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT); (3) acceptancebased approaches, primarily acceptance and commitment therapy (ACT); (4) education groups; and (5) supportive/expressive groups. Although the evidence has rapidly evolved to add further support to mindfulness and acceptance-based approaches since the last edition of this chapter, the vast majority of wellcontrolled trials of group-delivered treatments for chronic pain continue to be dominated by CBT, which has been shown to be an efficacious treatment of chronic pain; as a result, the focus of this chapter is on group CBT for the management of chronic pain conditions.


Rationale and Basic Considerations of Group Treatment for Pain


EVIDENCE FOR EFFICACY OF GROUP TREATMENT FOR CHRONIC PAIN MANAGEMENT

The highest level of evidence from an evidence-based practice viewpoint is meta-analyses and systematic reviews that quantitatively synthesize the evidence. To our knowledge, no meta-analyses or systematic reviews specifically of group CBT for chronic pain management have been published to date, although reviews of both individual- and group-delivered CBT (combined) have been published.7,8 Our literature search revealed numerous controlled studies (both RCTs and non-RCTs) of cognitive and behavioral approaches that have compared (1) group treatment to individual treatment; (2) group treatment to wait-list controls, to treatment as usual, and to other kinds of group treatment (e.g., relaxation or education/support groups); and (3) behavioral group treatments to group exercise and physical therapy treatments. These are reviewed in the following text, followed by a description of the current evidence for group mindfulness- and acceptance-based approaches.



GROUP COGNITIVE-BEHAVIORAL THERAPY VERSUS WAIT-LIST, TREATMENT AS USUAL, OR OTHER GROUP TREATMENTS

Table 87.2 summarizes the controlled studies that have compared the effects of group-administered CBT to wait-list control conditions, treatment as usual conditions, or other group treatments such as relaxation, education, or supportive/expressive group therapy.18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64 Trials comparing CBT to MBIs and ACT are reported in Tables 87.3 and 87.4, respectively. There are an impressive number of controlled trials that have been carried out by different research groups focusing on different populations of individuals with pain that together establish the efficacy of CBT for chronic pain. Systematic reviews of these trials have been conducted that include both individual and group-delivered CBT formats across pain types and in children and adult populations; due to space limitations, not all of the studies reported in these reviews are included here.7,8,65,66 In most cases, RCTs that compared group CBT to other types of group treatments also included a wait-list condition to control for the natural progression of the chronic pain disorder. In the following text, we highlight findings from select studies reported in Table 87.2 comparing group CBT to other types of group treatment because they have played an important role in identifying the effects of CBT; later in this chapter, we also describe a selection of studies that have examined the mechanisms underlying CBT treatment efficacy.

CBT is a generic term used to describe a complex and multifaceted treatment, and the included treatment components within group CBT protocols vary across studies and research groups. However, the general principles associated with CBT are typically consistent across studies (i.e., that one’s thoughts and feelings influence one’s ability to cope with pain and teaching pain self-management strategies). An overarching component of CBT includes strategies to educate patients about how the brain processes pain and psychological factors affecting pain perception. Furthermore, training in specific pain management skills almost always includes one or more modules on recognizing and modifying maladaptive or distorted pain-related automatic cognitions and beliefs, enhancing cognitive coping, learning relaxation strategies (including one or more types of relaxation techniques such as biofeedback, autogenic relaxation, progressive or passive muscle relaxation, meditation, and/or self-hypnosis), and completing regular homework assignments such as thought records or guided relaxation for skills acquisition. Frequently, but less consistently, CBT includes modules focusing on stress management (sometimes referred to as stress inoculation), paced physical activity, assertive communication, pleasant activity scheduling, and coping self-statements.

Because of the varied approaches that have all been subsumed under the label of CBT in the literature, it has historically been difficult to identify the specific treatment components that account for treatment efficacy, and this continues to be the case. There are a limited number of dismantling studies that have evaluated specific CBT components for pain management. However, controlling for nonspecific treatment effects (e.g., attention from therapist, expectations of health care provider and patient) is an important step toward determining the specific components of treatment efficacy as well as for elucidating specific and shared treatment mechanisms. Comparing patients receiving group treatment for chronic pain to those on a waitlist does not allow for this type of analysis, although wait-lists do control for the natural progression of the disorder over time and potential reactivity associated with self-monitoring or keeping pain diaries (if included as part of the study). The social context in which the treatment is administered is of particular relevance for the study of the active components of group treatment approaches. Therefore, studies comparing one type of group treatment to another type of group “attention control” treatment (e.g., support group) provide better evidence for disentangling the specific versus nonspecific treatment effects of CBT. Furthermore, comparing CBT to other active treatments demonstrates the relative effects and also allows for examination of whether the treatments exert benefit for the reasons proposed by the respective theory.

Although there is strong evidence for CBT delivered in nongroup formats in nonadult populations, most of the group CBT research to date has been conducted within adult populations with chronic back pain, headache, orofacial pain, or arthritis-related pain and to a lesser degree across an array of other pain conditions.67 Systematic reviews of the CBT literature typically collapse across most pain types (indicative that the treatment approach and effects are sufficiently similar across these conditions to do so); however, headache and migraine are usually reviewed separately due to differences in the overall approach as well as history.8 More recently, the treatment of neuropathic pain was isolated within a systematic review and results showed that compared to nociceptive pain, neuropathic pain is particularly recalcitrant to treatment.7 The primary focus here is on adult populations; the specific type of pain investigated in each study is reported in the corresponding Table 87.2.

There continues to be a limited number of studies in which one group treatment for pain has been compared to another. One study in patients with fibromyalgia, for example, compared group education plus CBT versus group education plus group discussion (which controlled for the effects of attention).44












These authors found that both groups showed equal improvements in pain coping and knowledge, and both were superior to a wait-list control condition. An economic evaluation of the treatments resulted in the authors’ suggestion that the extra health care costs associated with the addition of the CBT modules were not warranted based on the outcomes.44,68 It is important to note that the education modules that were offered to all participants included structured physical fitness training after each of 12 sessions, and this behavioral component may have served to increase the overall outcome efficacy of both groups. Furthermore, the discussion modules (attention control) included weekly homework assignments, which is typical of CBT groups but atypical of control conditions. The authors suggest that the homework assignments may have served as a form of graded exposure for the fearful participants, thereby resulting in treatment gains in the control group. It is also important to mention that both treatment groups in the mentioned study used limited therapist time in an effort to reduce treatment costs. It may be that the principles associated with cognitive-behavioral change require some threshold amount of therapeutic intervention in order to be successfully implemented. These findings and others led Vlaeyen and colleagues44 raise the important point that the active components of group treatment need further careful study.








TABLE 87.2 Group Cognitive and Behavioral Therapy Studies































































































































































































































































































































































































































































































































Authors


N


Study


Treatment Type


Treatment Components


Duration


Outcome Measures


Results


Limitations


Follow up (f/u)


Thorn et al.18


290 with mixed chronic pain


RCT


Literacy-adapted CBT (n = 95) vs EDU (education) (n = 97) vs. treatment as usual (TAU) (n = 98)


CBT: psychoeducation, cognitive restructuring, activity pacing, relaxation, motivational reinforcement


EDU: pain-related information provided, no specific skills-building exercises


Ten 1.5-h weekly sessions


Brief Pain Inventory intensity and interference, Patient Health Questionnaire-9


CBT = EDU at posttreatment, both > TAU on pain intensity and physical function; gains in intensity maintained at f/u for EDU but not CBT, gains in physical function maintained for both CBT and EDU. No significant changes in depression.


Participants were recruited from a single health care system, so a self-selection bias was possible.


6 mo


Helminen et al.19


111 with knee osteoarthritis, aged 35-75 y


RCT


CBT (n = 55) vs. medical TAU (n = 56)


CBT: psychoeducation on pain, problemsolving skills, relaxation, scheduling activities, cognitive appraisals and beliefs, assertiveness training


Six 2-h weekly sessions


Western Ontario and McMaster Universities Osteoarthritis Index Pain Scale, Pain Self-Efficacy Questionnaire, RAND-36 emotional well-being, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia (TSK), Beck Depression Inventory (BDI)


CBT = TAU on pain and function; CBT > TAU on well-being, TAU > CBT on self-efficacy. No significant differences at f/u.


Lack of fidelity monitoring, low recruitment to enrollment rate; baseline self-efficacy was high at baseline for both groups.


3 mo 12 mo


Linden et al.20


103 with chronic low back pain


RCT


CBT (n = 53) vs. unspecified occupational therapy (OT; n = 50)


All participants treated for 21 d in an inpatient interdisciplinary rehabilitation unit. In addition:


CBT group: gate control theory, stress reduction, problem solving, self-monitoring, cognitive restructuring, reducing avoidance, increasing activities, relaxation


OT: additional OT sessions, playing games, motivated to engage in activities


Six 90-min sessions (3/wk)


Symptom Checklist-90, Rating of Health Locus of Control Attributions, Fear Avoidance Belief Questionnaire, VAS pain


All outcomes significantly improved in both groups; CBT > OT on pain and fear avoidance beliefs.


Lack of fidelity monitoring; effect of CBT in isolation from other interdisciplinary treatments not established; no f/u



Seminowicz et al.21


13 with mixed chronic pain vs. 13 healthy and age-matched controls (baseline only)


Nonrandomized trial


CBT (n = 13)


Self-regulatory skills such as relaxation, cognitive coping strategies such as cognitive restructuring, attention diversion methods, activity pacing, scheduling pleasant events, exercise, methods for enhancing social support


Eleven 1.5-h weekly sessions


Structural neuroplasticity (i.e., gray matter, GM), McGill Pain Questionnaire-Short-Form, Treatment Outcomes in Pain Survey, Short-Form Health Survey (SF-36), BDI, Coping Strategies Questionnaire


Increased GM post-CBT in the bilateral dorsolateral prefrontal, posterior parietal, subgenual anterior cingulate/orbitofrontal, and sensorimotor cortices as well as hippocampus; reduced GM in supplementary motor area. Most increases in GM became significantly greater than GM in controls. CBT-related reductions in pain catastrophizing and increases in pain control were correlated with several of these regional GM changes.


Small sample size; no comparison or randomization; lack of f/u



Slavin-Spenny et al.22


147 with mixed headaches


RCT


Anger awareness and expression training (AAET; n = 50) vs. relaxation (n = 48) vs. WL (n = 49)


AAET: psychoeducation on stress-headache connection, experiential exercises for emotional awareness, assertive communication


Relaxation: psychoeducation on stress-headache connection, progressive muscle relaxation, deep breathing, brief relaxation


Three 1-h weekly sessions


Self-Assessment Manikin, Headache Management Self-Efficacy Scale, Toronto Alexithymia Scale, Rathus Assertiveness Schedule, Emotional Approach Coping Scales, Migraine Disability Assessment Scale, headache frequency, severity and duration, Brief Symptom Inventory


AAET = relaxation on self-efficacy and headache outcomes, both > control. AAET significantly improved alexithymia, emotional processing, and assertiveness, compared to the other two conditions.


Lack of f/u; lack of fidelity monitoring; use of a college sample limits generalizability; no headache diagnostic information obtained; no daily diaries of headache outcomes



Heutink et al.23


61 with neuropathic pain after SCI


RCT


CBT (n = 31) vs. WL (n = 30)


CBT: psychoeducation, ABC model, stress, movement and pain, assertiveness, relaxation, goals, social aspects; significant other attended first 2 sessions


Ten 3-h sessions over 10 wk and booster session 3 wk posttreatment


Chronic Pain Grade Questionnaire, Hospital Anxiety and Depression Scale, Utrecht Activities List, Life Satisfaction Questionnaire


CBT = WL on intensity and disability; CBT > WL on anxiety and participation in activities


Small sample size


3 and 6 mo


Thorn et al.24


83 with mixed chronic pain


RCT


Literacy-adapted CBT (n = 49) vs. EDU (n = 34)


CBT: stress-pain connection, automatic thoughts, challenging automatic thoughts and beliefs, relaxation, coping statements, expressive writing, assertive communication


EDU: psychoeducation on chronic pain treatment, gate control theory, costs of pain, acute vs. chronic pain, sleep, mood changes, pain behaviors, communication, working with health providers


Ten 1.5-h sessions over 10 wk


Brief Pain Inventory, Roland-Morris Disability Questionnaire (RMDQ), Pain Catastrophizing Scale, Center for Epidemiologic Studies Depression Scale, Quality of Life Scale


CBT = EDU; completer analysis showed CBT > EDU on catastrophizing and depression. Gains maintained at 6-mo f/u


Higher dropout rate in CBT; underpowered to detect effects of CBT compared to active treatment


6 mo


Lamb et al.25


701 with subacute or chronic low back pain


RCT + costeffectiveness


Active management consultation + CBT (n = 468) vs. active management consultation only


Active management: active advice on remaining active, avoiding bed rest, medication/symptom management, also provided with The Back Book


CBT: challenging negative thoughts and beliefs, pacing, graded activity, relaxation, activity, and avoidance


Active management: 15 min


CBT: an individual 1.5-h assessment, six 1.5-h CBT sessions


Change in RMDQ and modified Von Korff scores at 12 mo


Consultation + CBT > consultation only on both primary outcomes; inclusion of CBT > cost-effectiveness


CBT delivered by a range of professionals with a 2-d training (physiotherapists, nurses, occupational therapists, psychologists)


12 mo


Van Koulil et al.26


158 with fibromyalgia (FM)


RCT


Tailored CBT + exercise training vs. wait-list control


Pain avoidance or pain persistence treatment based on baseline cognitivebehavioral pattern


Patient’s significant other attended 3rd, 9th, and 15th sessions


16 sessions of CBT (2 h) + exercise training (2 h) over 10 wk and 1 booster session at 3 mo


Pain, fatigue, functional disability, negative mood, and anxiety scales of the Impact of Rheumatic Diseases on General Health and Lifestyle (IRGL), Pain Coping Inventory


CBT + exercise > WL on all primary outcomes, with large effect sizes


Did not compare “tailored” to nontailored treatment; inert comparison


6 mo


Falcão et al.27


60 females aged 18-65 y with FM


RCT


CBT (n = 30) vs. TAU (n = 30)


CBT: relaxation training, cognitive restructuring, stress management


CBT: 10 weekly 3-h sessions


VAS for pain, SF-36, State-Trait Anxiety Inventory, BDI, Fibromyalgia Impact Questionnaire, paracetamol


CBT > TAU on improved depression, mental health, and paracetamol. Both groups showed significant improvements on all indicators over time.


Dropouts were excluded from the analyses; limited f/u; participants had not received any prior treatment.


3 mo


Ersek et al.28


256 with noncancer pain, ≥65 y


RCT


Pain selfmanagement (n = 133) vs. EDU (n = 123)


Self-management: education about persistent pain, problem solving, exercise for pain, relaxation training, pacing and activity scheduling, challenging negative thoughts, medication management, hot/cold packs


EDU: read an assigned book, The Chronic Pain Workbook or Managing Your Pain Before It Manages You


Self-management, 7 weekly 90-min group sessions


Primary: RMDQ. Secondary: Geriatric Depression Scale, Brief Pain Inventory (intensity and interference)


Pain self-management = EDU at posttreatment and 6- and 12-mo f/u. Use of relaxation and exercise/stretching significantly increased in self-management


The number of strategies covered in selfmanagement may have limited effectiveness.


6, 12 mo


Thorn et al.29


34 with headache


RCT compared order of treatment modules


CBT (N = 22) vs. WLC (N = 11)


Cognitive restructuring, cognitive coping, relaxation, assertiveness, behavioral pacing, homework


Ten 90-min group sessions


Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale (PASS), Beck Depression Inventory-II (BDI-II), Headache Management Self-Efficacy Scale (HMSE), pain and medication via pain diaries; no difference in outcome based on order of treatment


CBT > WLC for improvements in catastrophizing, anxiety, headache management self-efficacy. 50% treated patients showed clinically significant reductions in headache frequency, medication use.


Small sample size rendered limited power to detect potential differences in order of treatment modules.


6, 12 mo


Li et al.30


64 with work-related injuries


RCT


Training on work readiness (T) (N = 34) vs. control (C) (N = 30)


T: individual vocational counseling (3 sessions), CBT, pain and stress management, relaxation, stages of change assessment, job acquisition, preemployment training


T: 3 weekly group sessions at 2-3 h, three 1-h individual sessions


Spinal Function Sort (SFS), Loma Linda University Medical Centre Activity Sort (LLUMC), Chinese Lam Assessment of Stages of Employment Readiness (C-LASER), Chinese State Trait and Anxiety Inventory (C-STAI), SF-36


T > C for improvements in anxiety, work readiness, readiness to change, and perceived health status


T: within-group improvements from baseline for most SF-36 subscales and physical capacity


Lack of f/u, stages of change may require longer time period for assessment


None specified


Linton et al.31


185 workers with back/neck pain


RCT


CBT (N = 69) vs. CBT and physical therapy (CBT 1 PT) (N = 69) vs. minimal treatment (N = 47)


CBT: problem solving, homework, skills training, stress management, relaxation


CBT + PT: CBT plus personalized exercise program


Minimal: medical visit and advice, educational booklet


6 weekly 2-h sessions


Sick absenteeism, health care visits, Outcome Evaluation Questionnaire, VAS pain ratings, HAD, PCS, TSK, activities of daily living (ADLs), RMDQ


CBT + PT = CBT for most measures. CBT + PT > Minimal for reductions in health care visits. At f/u: CBT + PT fewest sick days, followed by CBT and Minimal. Both treatment groups 5 times less likely to be on long-term sick leave than Minimal.


Different intervention lengths


1 y


Gold et al.32


185 with vertebral fracture


RCT


Part 1: Intervention (I) (N = 94) vs. education control (EC) (N = 91)


Part 2: Crossover: EC becomes I group after 6 mo. Initial I group selfmaintenance


I: exercise, coping skills (relaxation, stress reduction)


EC: education of health issues for women


Part 1:


I: 5 weekly exercise and coping sessions (225 min)


EC: 1 weekly session at 45 min


Part 2: I: self-maintain EC = I group


Trunk extension strength, Functional Status Index (FSI), Global Severity Index of Hopkins Symptom Checklist-Revised


Part 1: I > EC for improvement in trunk extension and psychological symptoms


EC: worse for all three outcomes


Part 2: EC showed withingroup improvements in trunk extension and psychological symptoms after intervention


I: decrease in back strength from posttreatment, improvement in psychological state maintained


Different session lengths for I and EC, no control group at f/u. I group did not receive education in cross-over design.


6 mo


van Lankveld et al.33


59 with rheumatoid arthritis (RA)


RCT compared couples to patient-only group


Couples (C) (N = 31) vs. patient-only (P) (N = 28)


Education, cognitive restructuring, encouragement to use active coping skills


C: 2 weekly 1.5-h sessions for 4 wk


Disease Activity Score (DAS): swollen joint count


IRGL, Coping with Rheumatoid Stressors Questionnaire (CORS), Maudsley Marital Questionnaire (MMQ)


Sample improvements in disease activity, cognitions, coping, physical and psychological function (C = P). At f/u: C > P for improvements in diseaserelated communication with spouse.


Possible selection bias of highly invested couples because of study design


6 mo


Ersek et al.34


45 elderly with chronic pain


RCT


Self-management (SM) (N = 17) vs. educational booklet (control) (EB) (N = 23)


SM: education, self-monitoring, communication, relaxation, individualized goals, homework


EB: booklet with information about pain, medications, instructions for self-management, and pain resources


SM: 7 group sessions at 90 min


SF-36, Graded Chronic Pain Scale, Geriatric Depression Scale, Survey of Pain Attitudes (SOPA), survey assessing use of pain management strategies, treatment usefulness scales


SM > EB for improvements in pain intensity and physical role function (pre- to postchange); clinically significant improvement in 43% SM and 13% EB; SM = EB at f/u.


Brief f/u


3 mo


Tkachuk et al.35


28 with irritable bowel syndrome (IBS)


RCT


CBT (n = 14) vs. home-based symptom monitoring with weekly telephone contact (SMTC) (n = 14)


CBT: education, relaxation, cognitive restructuring, assertiveness training


SMTC: daily symptom monitoring, discussion of symptom patterns


Ten 90-min sessions for 9 wk


Daily monitoring IBS scores, BDI-II, cognitive emotional distress (CSFBD), trait anxiety (STAI-T), discomfort with assertion (AQ), quality of life (SF-36)


CBT > SMTC for pain relief ratings, improvement in GI symptoms, quality of life. Maintained at f/u.


One-third treated patients experienced clinically significant improvement.


Brief f/u


3 mo


Mishra et al.36


94 with chronic TMD


Urn method of assignment


CBT (n = 22), biofeedback (n = 23), CBT + biofeedback (n = 24), no treatment (n = 25)


CBT: self-change plain; relaxation training; distraction; pleasant activity scheduling; cognitive restructuring; social skills and assertive communication.


Biofeedback: 15 min of temperature feedback and 15 min of electromyography (EMG) biofeedback


Combined: include components of both of the above


12 sessions of 1.5 h, except for combined treatment which was 2 h; 2/wk for first 4 wk, 1/wk for other 4-wk


Characteristic Pain Intensity (CPI), Graded Chronic Pain Score (GCPS), Profile of Mood States (POMS)


CBT = biofeedback = combined and all 3 greater than no treatment on CPI and POMS. No significant pre- to posttreatment change was observed for GCPS across any group. Biofeedback improved the most compared to the no treatment control on CPI.


Combined treatment was a higher dose.


Lack of f/u



Leibing et al.37


55 with RA


RCT


CBT (N = 19) vs. TAU (N = 36), change in medication-matched control group (CN) (N = 20)


CBT: education, relaxation, cognitive restructuring, pain management, pleasant activity scheduling


CBT: 12 weekly sessions at 90 min


C-reactive protein (CRP), blood sedimentation rate (Westergren), swollen joint count, Hannover Functional Ability Questionnaire (HFAQ), medication types, VAS pain intensity, affective pain score, pain diary, STAI, Depression Scale (DS), Arthritis Helplessness Scale (AHI), Bernese Coping Modes


Overall increase in disease activity across sample


CBT less progressive inflammation than TAU. CBT > CN for pain reduction, improvements in depression, anxiety, helplessness; CBT: improved depression, helplessness, positive coping from baseline


Potential type I error from multiple significance tests; lack of f/u


None specified


Potts et al.38


60 with noncardiac chest pain


RCT


CBT (N = 34) vs. WLC (N = 26)


CBT: education, relaxation, biofeedback, graded exercise, challenging automatic thoughts, homework


WLC: delayed treatment


6 sessions at 2 h


HADS, Nijmegen hyperventilation scale, Sickness Impact Profile (SIP), Nottingham Health Profile (NHP), chest pain diaries, hyperventilation: portable carbon dioxide monitor, exercise electrocardiography (ECG)


CBT > C for improvements in chest pain frequency, pain-free days, anxiety, and depression, disability, and exercise tolerance. Similar results for delayed treatment group once treated. Overall, 76% had improvements in chest pain. Maintained at f/u.


Lack of control group at f/u


6 mo


Cole39


113 with mixed chronic pain


Non-RCT


CBT (N = 88) vs. TAU (N = 25)


Coping skills, pain self-management, adjustment, stress management, relaxation, self-esteem, positive thinking


75 min, 1 per week for 16 wk


Multidimensional Pain Inventory (MPI), Minnesota Multiphasic Personality Inventory-2 (MMPI-2), BDI


Reported narcotic medication usage, health care visits, work status


CBT: decreases in BDI and MPI scores, and health care visits from baseline, increase in return to work


f/u: medication decreased from 75% at baseline to 44%, health care visits decreased from 5/mo to 1/mo. Work status increased from 10% to 31%.


Patients not randomly assigned. No direct comparison between CBT and control groups.


1 y


Keel et al.40


27 with FM


RCT


CBT (N = 14) vs. autogenic (N = 13)


CBT: stress inoculation, cognitive restructuring, activities for pain diversion, information, relaxation, group discussion, stretching, aerobic exercise


Autogenic: practice relaxation


15 weekly sessions lasting 1-2 h


Freiburg Personality Inventory, Locus of Control Scale, Rosenzweig Picture-Frustration Diary (of active hours, resting hours, sleep index, pain intensity, and medication consumption), General Symptom Checklist


2 CBT clients vs. 1 autogenic had clinically significant improvement in medication consumption, physical therapies, sleep, pain scores, general symptoms


At f/u, CBT > autogenic for improvement in pain ratings. 4 CBT vs. 0 autogenic had clinically significant improvements at f/u.


Small sample size; statistical analyses not described


3 mo


Keel et al.41


411 with low back pain


Non-RCT


Experimental (E) (N = 243) vs. standard physiotherapy (S) (N = 168)


E: coping strategies, stress management, relaxation, simulated work situations fitness training, education and group activity, individual physiotherapy or psychotherapy for acute pain


S: mostly individual physiotherapy


E: 4-wk (27 d) inpatient program


S: 3-wk (20 d) inpatient program


Work situation, physical activities, pain history, VAS pain rating, pain drawing, RMDQ, Psychological General Well-Being Index (PGWB), health costs, quality of life, impairment


E = S for improvements in functional ability, limitations in daily life, health care visits


E: higher proportion of individuals in work rehabilitation (23% work incapacity decrease), E > S daily hours worked, decrease in professional handicaps; at f/u, larger proportion of S worsened


Preexisting differences between groups on demographic variables; different predominant treatment modalities in each condition (E = group, S = individual)


3 mo, 1 y


Basler et al.42


94 with low back pain


RCT


CBT (N = 36) vs. TAU (N = 40)


Education, relaxation, modifying thoughts and feelings, pleasant activity scheduling, postural training


12 weekly sessions at 150 min


Pain diary (pain intensity, control over pain, medication consumption), Heidelberg Coping Scale (HCS), Dusseldorf Disability Scale (DDS)


CBT: decreases in pain intensity, improvements in coping with pain, mental performance, and disability


Gains maintained at 6-mo f/u


TAU: little or no change


High attrition rate at f/u


6 mo


van Dulmen et al.43


45 with IBS


Non-RCT


CBT (N = 25) vs. WLC (N = 20)


Patient education (e.g., roles of cognitions, behaviors, in IBS), homework, discussion, progressive muscle relaxation


8 weekly sessions lasting for 2 h


Diary (duration of pain, daily avoidance behavior, GI complaints), Abdominal Complaint Inventory, Symptom Checklist 90


(SCL-90)


CBT > WLC for improvement in Daily Abdominal Complaint Score (DAC), duration, avoidance, and number of successful coping strategies delayed treatment group: decreases in DAC; improvements maintained at f/u


No WLC at f/u, wide range of f/u assessment times (6 mo-4 y)


Mean = 2.25 y


Vlaeyen et al.44


131 with FM


RCT


Cognitive educational intervention (ECO; N = 47) vs. attention control condition of education and discussion (EDI; N = 39) vs. WLC (N = 40)


ECO: imaginative transformation of pain, relaxation and biofeedback, homework


EDI: education, sharing thoughts with group members, listening to music, homework


ECO and EDI = 12 90-min sessions conducted in 6 wk


Pain cognition list, Coping Strategies Questionnaire (CSQ), Behavioral Approach Test, Pain Behavior Scale, McGill Pain Questionnaire (MPQ), Multidimensional Pain Locus of Control Scale, Checklist for Interpersonal Pain Behavior, Fear Survey Schedule, BDI


ECO = EDI for improvements in pain coping and knowledge


EDI > WLC on knowledge and pain control. At 12-mo f/u, ECO = EDI, although ECO had an increase in pain intensity.


Potential confounding of treatment (EDI group shared thoughts, completed homework). Low education level of participants may have made ECO difficult.


12 mo


Newton-John et al.45


44 with chronic back pain


RCT


CBT (N = 16) vs. electromyographic biofeedback (EMGBF; N = 16) vs. WLC (N = 12)


CBT: education, goal setting, relaxation, cognitive restructuring, homework


EMGBF: education, diaphragmatic breathing, adaptation, homework


8 sessions at 1 h (2 sessions per week)


BDI, STAI, CSQ, Pain Disability Index, Pain Beliefs Questionnaire (PBQ)


CBT and EMGBF > WLC for improvements in intensity, disability, adaptive beliefs, and depression. Improvements maintained at f/u, along with improvements in anxiety and active coping


Small sample size per group


6 mo


James et al.46


33 with headache


RCT


CBT with goals (goal group) (N = 13) vs. CBT with no goals (open group) (N = 13) vs. WLC (N = 7)


Both CBT groups: education, coping, developing appropriate self-talk, generalization of skills, relaxation


Goal: specific time goals for coping with pain/stress


Open: instructions to cope as long as possible


6 weekly sessions at 90 min


Goal specificity: coping with daily stressors and pain, daily self-monitoring, pain index, medication intake, downtime, Pain Behavior Questionnaire, SCL-90, SIP, BDI, STAI, Cognitive Coping Index


Goal and open groups > WLC for improvements in pain coping skills, goal group > open and WLC group for reduction of headache and nonnarcotic medication use


Lack of f/u period


None specified


Turner and Jensen47


102 with low back pain


RCT


Relaxation (R) (N = 17) vs. cognitive therapy (C) (N = 21) vs. cognitive therapy and relaxation (CR) (N = 16) vs. WLC (N = 18)


R: imagery, progressive muscle relaxation (PMR)


C: identify negative thoughts, counter negative automatic thoughts


CR: combined treatment


6 weekly sessions at 2 h


VAS pain ratings, SIP, BDI, Observed Pain Behaviors, Cognitive Errors Questionnaire, BDI


R, C, and CR > WLC for improvements in pain ratings and disability.


At f/u: all three patient groups improved. At both f/u, patients in all groups improved R = C = CR.


No comparison to control group at f/u, attrition rates for control condition


6, 12 mo


Kneebone and Martin48


35 with headache


Non-RCT


Compared couples to standard noncouple and control groups


Partners involved (PI) (N = 12) vs. no partners (NPI) (N = 10) vs. no treatment control (NTC) (N = 13)


PI and NPI: selfmonitoring, relaxation, cognitive restructuring, assertiveness, group process (e.g., support), homework


PI: partners educated in reinforcement principles


10 weekly sessions at 1.5-2 h


Headache activity, intensity, medication usage, relaxation practice, Partner Involvement Questionnaire, Dyadic Adjustment Scale (DAS), self-monitoring forms


PI = NPI for relaxation time, PI > NPI for partner involvement: spouse assisted with relaxation


PI: decrease headache activity from baseline


NPI: decreased medication usage from baseline. NTC increased medication usage. At f/u: NPI > NTC for reductions in medication. Other measures: PI = NPI at f/u.


Potential for type 1 inflation; low motivation across treatment groups to practice relaxation


2, 12 mo


Nicholas et al.49


58 with low back pain


RCT


Cognitive therapy (CT) + relaxation (N = 8) or CT (N = 10) vs. behavior therapy + relaxation (N = 9) or BT (N = 10) vs. attention (ATC; N = 10) and no attention control (N = 11)


All groups: physiotherapy, education, exercise


CT: cognitive restructuring, distraction, imagery, self-monitoring


BT: activity pacing, medication reduction, reinforcement


Relaxation: PMR


ATC: group discussion about back pain


Five 1.5- to 2-h sessions twice per week


Pain Rating Chart


STAI, PBQ, CSQ, SIP, SIP-Others (SIP-O), medication intake, report of alternative treatments, visits to health care facilities


Sample improved on affective distress, functional impairment, medication use, and active coping. Both CBT groups and both BT groups > ATC and control for improvements in pain intensity, self-reported disability, pain beliefs, and active coping. BT > CBT for improvements in impairment. Improvements somewhat maintained at f/u.


Physiotherapy included as part of all treatments


Small sample size


6, 12 mo


Subramanian50,51


39 with mixed chronic pain


Long-term f/u = 22


RCT


Structured group therapy (N = 19) vs. WLC (N = 20)


Therapy: stress management, relaxation cognitive restructuring (coping thoughts, self-defeating, selfenhancing thoughts), assertiveness training


8 weekly 2-h sessions


SIP, Pain level (0-10 scale) used a control variable


Profile of Mood States (POMS), Social Support Questionnaire


Therapy > WLC for improvements in physical and psychosocial dysfunction, negative mood states. Within-group improvements also apparent.


Long-term f/u: improvements maintained, improvement in pain severity observed, 77% improved from posttreatment to f/u, 36% reduction in prescription medication usage


No comparison group at longterm f/u


6 mo


Long-term: 18-22 mo


Peters and Large52


68 with chronic pain


RCT


Group inpatient program (IPMP) (N = 29) vs. Group outpatient program (OPMP) (N = 23) vs. control (C) (N = 16)


IPMP: education, pain management, relaxation, cognitive restructuring, exercise, vocational counseling, reinforcement


OPMP: education, activity goal setting, exercise, medication and stress management, relaxation


Inpatient: 4 wk


Outpatient: 9 weekly sessions at 2 h


BDI, MPQ, General Health Questionnaire (GHQ), SIP, Pain Behaviour Checklist, pain drawings, VAS ratings, VAS stair climbing test, physiologic measures, physical endurance


Sample improvements in disability, GHQ scores, BDI, and MPQ scores


IPMP and OPMP > control for improvements in disability, VAS pain ratings, and pain behavior


Results may have been influenced by timing of the assessments; lack of f/u


None specified


Turner et al.53


96 chronic low back pain patients


RCT


Group behavioral and aerobic exercise (BE) (N = 18) vs. behavioral therapy only (B) (N = 18)


Aerobic exercise only (E) (N = 21) vs. WLC (N = 23)


BE: behavioral intervention followed by exercise in each session


B: reinforcement role-playing, discussion, homework, communication


E: Exercises 5 times per week


BE and B: 8 weekly 2-h sessions


E: 5 weekly sessions


MPQ, SIP, Pain Behavior Checklist (PBC), PBCspouse ratings, Physical Work Capacity (PWC), Center for Epidemiologic Studies—Depression Scale (CES-D), recorded pain behaviors


All three groups improved more than the WLC from pre- to posttreatment,


BE > WLC from preto posttreatment on self-report and observer rated pain behavior measures, BE > E on PBC Spouse ratings


F/u: all treatment groups improved over time


Interaction with therapists varied by condition


6, 12 mo


Linton et al.54


66 nurses with back pain


RCT


Physical and behavioral preventive intervention (PBI) (N = 36) vs. WLC (N = 30)


PBI: physical therapy, “low back school,” relaxation, pain control instruction, goal setting, problem solving, coping, identifying high-risk situations


PBI: 8 h/d for 5 wk


Daily pain diaries, VAS intensity, fatigue, anxiety, sleep, pain behavior, ADLs, BDI, AHI, marital satisfaction, absenteeism, medication intake


PBI > WLC for improvements in pain intensity, fatigue, pain behavior, sleep, ADLs, helplessness


Most differences maintained at f/u


Use of nonstandardized measures of sleep quality, ADLs, marital satisfaction


6 mo


Puder55


69 with mixed chronic pain


RCT


Stress inoculation training (SIT) (N = 31) vs. WLC (N = 38)


SIT: explaining treatment, reviewing progress, problem solving


10 weekly 2-h group sessions


Daily pain diary, nontreatment technique usage: psychological support, exercise, heat/cold, massage, TENS, injections


SIT > WLC for improvements in pain interference, coping, decreased analgesic intake, discontinuation of heat/cold, and home traction technique. No difference according to age. Improvements maintained at f/u.


Use of nonstandardized measures


1, 6 mo


Bradley et al.56


53 with RA


RCT


Biofeedbackassisted CBT (N = 17) vs. structured group social support therapy (SGT) (N = 18), no adjunct treatment (NAT) (N = 18)


CBT: thermal biofeedback, education, relaxation, behavioral goal setting, self-rewards


SGT: education, discussion of coping strategies, encouragement to develop improved strategies


CBT: 5 thermal sessions, 10 family/friend meetings


SGT: 15 sessions family/friends


STAI, Depression Adjective Checklist (DACL), Health Locus of Control Scale (HLCS), AHI, pain behaviors, rheumatologist ratings of disease activity level, rheumatoid factor titers, sedimentation rate (Westergren)


CBT > SGT and NAT for decreases in pain behavior, pain ratings, rheumatoid activity (RAI), NAT: lower RAI scores than SGT


SGT and NAT increased in depression and rheumatoid factor titer across assessments


CBT and SGT > NAT for improvement in anxiety


CBT maintained improvement at f/u


Session duration not specified


6 mo


Larsson et al.57


36 high school students with tension/migraine headaches


RCT


Self Help Relaxation (SHR) (N = 12) vs. Problem Discussion Condition (PDC) (N = 10) vs. Untreated Self-Monitoring Condition (SM) (N = 12)


SHR: relaxation programs, rapid cue-controlled strategy, homework, help solving problems during relaxation


PDC: discussion of conflicts in everyday life, role-play, identifying stressors, assertiveness


5 weekly sessions


SHR = 3 h


PDC = 7 h


Headache diary: frequency, duration headache free days, peak intensity, modified Depression Scale for Female adolescents, Children’s Manifest Anxiety Scale, Social Relationship-Competence Questionnaire (SRCQ)


Headache activity:


Greatest reductions for SHR group, SHR > SM and PDC


Headache sum and peak intensity: SHR > PDC during pre-f/u interval


Headache duration and headache-free days:


SHR > SM and PDC


Small sample size, different therapist interaction for two interventions


5 mo


Bradley et al.58


33 with RA


RCT


Thermal biofeedback and group cognitive behavioral (CB = 11) vs. social support (SS = 10) vs. NAT (N = 12)


CB: thermal biofeedback, education, skills acquisition, self-instructional training, application


SS: education, support, encouragement to develop own coping strategies


NAT = control


CB: 5 individual thermal sessions, 10 family meetings


SS: 15 family meetings


STAI, DACL, VAS ratings of pain intensity, unpleasantness, severity of morning stiffness, pain behaviors, HLCS, rheumatoid factor titers, Westergren, rheumatologist ratings of disease activity


CB > NAT group for significant decreases in pain intensity, pre- to posttreatment: CB less pain behavior from preto posttreatment, less rheumatoid activity, and rheumatoid factor titer. CB and SS less anxiety and depression. SS increase in sedimentation rate NAT: significant reduction in morning stiffness.


Small sample size, lack of f/u


None specified


Linton et al.59 and Melin and Linton60


28 with heterogeneous chronic pain


26 with heterogeneous chronic pain


RCT


Long-term f/u


Regular treatment (RT) vs. applied relaxation and operant activities (RT + BT) vs. WLC


RT: prescribed treatment plan


RT + BT: plan and relaxation training, operant training, reinforcement of well behaviors, decrease in medication


12 sessions


BDI, Activities of Daily Living questionnaire, self-monitoring of pain, medication consumption, sleep f/u measures also included pain, health, activity, level, sleep, occupation


RT + BT > RT and WLC for improvements in pain level and leisure activity


Improvements maintained at f/u


Small sample size


Long-term f/u: WLC group received individual treatment prior to assessment


14-16 mo


Moore and Chaney61


43 with mixed chronic pain


RCT


Couples group therapy (CBT) (N = 17) vs. patient-only group therapy (N = 14) vs. WLC (N = 12)


Couples and patient only: education, goal setting, problem solving, relaxation and controlled breathing, direct pain reduction method, coping strategies, homework


16-h program, couples: 8 biweekly 2-h sessions


VAS pain severity (patient and spouse)


MMPI Hs, D, and Hy scales only, SIP, PARS IV Community Adjustment Scale (spouses), Locke-Wallace Marital Adjustment Test (LMAT), utilization of medical resources medication usage


Couples and patient-only groups > WLC for improvements in VAS ratings, pain severity and pain behavior ratings, somatization, and PARS (spouse rating)


Patient-only groups > controls on LMAT and SIP scores


Treatment gains maintained at f/u


Couples = patient-only therapy


Small sample sizes for each condition


3, 7 mo


Cohen et al.62


25 with chronic low back pain


RCT


Behavioral intervention (BT) (N = 13) vs. physical therapy (PT) (N = 12)


PT: pain control strategies, relaxation, exercise, pool therapy, use of body mechanics


BT: goal setting, activity pacing, problem solving, assertiveness


10 weekly 2-h sessions


Physical Abilities and Walking Abilities testing, Knowledge and Functional Measure of Body Mechanics, CES-D, Psychological Adjustment to Role Scale (PARS-V)


PT: greater low back control and decreases in CES-D score. BT and PT: lower anxiety and depression per patients and significant others on PARS-V, others.


Decreases in physical and activity limitations for both groups


Small sample size, validity data for some instruments not provided


None specified


Figueroa63


15 tension headache patients


RCT


Behavior therapy (BT) (N = 5) vs. psychotherapy (P) (N = 5) vs. self-monitoring (SM; N = 5)


BT: problem solving, relaxation, anxiety management training, stress inoculation


P: discussion, conflict resolution, discussion of stressful events


BT: seven 90-min sessions


P: seven 90-min sessions (twice weekly)


Headache questionnaire, headache checklist (e.g., level of relaxation, number of headaches, duration, severity, medication usage, disability), self-monitoring forms


Pre to f/u: B > P and SM for improvements in perceived disability


BT > SM for reductions in headache frequency and duration, medication usage, level of relaxation, and pain severity


Small sample size, use of nonstandardized measures


Time not specified


Turner64


36 chronic low back pain patients


RCT


CBT (N = 13), vs. relaxation (N = 14) training, WLC/attention conditions (N = 9)


CBT: stress inoculation, behavioral goals, cognitive and affective responses to pain, coping self-statements, relaxation


Wait-list/attention: gave daily pain ratings to therapist in weekly phone calls


5 weekly 90-min sessions


SIP, SIP Significant Other (SIP-O), VAS ratings, self-ratings of improvement, BDI, work hours, health care usage


CBT and relaxation groups > WLC for improvements in pain, depression, disability, and spousal ratings of physical and psychosocial function


At f/u: CBT improved on SIP, SIP-O, pain severity, relaxation: worse pain severity


1.5- to 2-y f/u: both groups retain improvements, CBT > in hours worked per week


Small sample size


1 mo, 1.5-2 y


AQ, Assertiveness Questionnaire; CBT, cognitive-behavioral therapy; CSFBD, Cognitive Scale for Functional Bowel Disorders; GI, gastrointestinal; HADS, Hospital Anxiety and Depression Scale; IPMP, inpatient pain management program; OPMP, outpatient pain management program; RAI, Rheumatoid Activity Index; RCT, randomized controlled trial; SCI, spinal cord injury; STAI-T, State-Trait Anxiety Inventory-Trait Scale; TMD, temporomandibular disorder; VAS, Visual Analog Scale; WL, wait-list; WLC, wait-list control.

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Sep 21, 2020 | Posted by in PAIN MEDICINE | Comments Off on Group Therapy for Chronic Pain

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