Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain - Michael K. Nicholas, Allan Molloy, Lee Beeston, Lois Tonkin (2012)

Appendix 1

Evidence of Effectiveness of ADAPT-type treatments

It is now accepted practice in health care that all treatments being offered to patients should have a reasonable amount of evidence to support their effectiveness. No treatment works for everyone, but it is reasonable that anyone considering a new treatment should know that the treatment works better than chance, or better than no treatment, for their sort of problem. In the field of chronic pain there are currently no curative treatments. Some treatments have been shown to relieve pain, but to date these have been only temporary effects. The most treatments can offer is some improvement in symptoms (such as pain severity) or reduced impact of the pain on the person and their lifestyle.

The ADAPT program is known as a cognitive behavioural treatment. As mentioned in Chapter 6 ‘Treatments for Chronic Pain’, cognitive behavioural treatments for chronic pain are not aimed at the underlying cause of pain, but rather at reducing the impact of pain on the person and their daily activities. In particular, they address the person’s emotional state, their range of daily activities, their sleep, and often their use of unhelpful medication or other passive treatments that can limit a person’s ability to rehabilitate themselves. To some extent these treatments also address pain. If a person in persisting pain can find ways to limit the impact of pain on how they feel and their daily activities they will often say that while their pain is still present it doesn’t bother them as much as it did when it was disrupting most areas of their life.

There are now more than 30 studies of cognitive behavioural treatments for chronic pain. Most of these studies have compared the treatment against either a group receiving no treatment or some standard treatment. However, it should be realised that when someone in chronic pain participates in a study of this sort of treatment they have already undergone many other treatments to no avail. In general, studies of cognitive behavioural treatments with chronic pain problems only use people in whom standard medical (mainly drug) treatments or surgery have been tried and failed or ruled out as inappropriate. So the question arises for all those who suffer from chronic pain and their doctors plus other therapists, what can a person do when they reach that point? A choice has to be made between going on as before or seeking another way. The approach outlined in this book represents an alternative to ongoing trials of passive treatments in people for whom they have not worked.

If passive treatments, whether it is analgesic drugs, surgery, chiropractic or faith healing, have helped and the person in pain is quite happy with the results then that is wonderful. They may not need to explore the approach described in this book. On the other hand, if that is not the case, this book describes an approach which has been demonstrated to be effective in achieving targeted outcomes in a number of countries. By ‘targeted outcomes’ we mean outcomes which the treatments were aiming for, rather than ones which they weren’t. That is, cognitive behavioural pain management can achieve improved mood, increased activity levels, reduced use of unhelpful medication and reduced pain levels. But this treatment does not cure the underlying cause of chronic pain.

Review studies

Three major reviews of outcome studies published during 1990s reported solid support for the effectiveness of these treatments as a group with a range of chronic pain conditions. The actual components of each cognitivebehavioural treatment do vary from study to study, as do the types of patients and their problems. Thus there is often variation in degree of outcomes achieved. In some ways this is a bit like different doses of the same drug having different degrees of effect. If you take too small a dose, the effect may be minimal. Best results may only be achieved with a large dose of the drug. Nevertheless, when the better studies of cognitive behavioural treatments for chronic pain are lumped together and their effects are compared with common alternatives, the overall trend is clear. These treatments are effective. See:

Flor, H., Fydrich, T. and Turk, D.C. (1992) Efficacy of multidisciplinary pain treatment centres: a meta-analytic review Pain 49, 221–230.

McQuay, H., Moore, Eccleston, C., Morley, S. and Williams, A.C.deC. (1997) Health Technology Assessment, 1997: Systematic Review of Outpatient Services for Chronic Pain Control

Morley, S., Eccleston, C. and Williams, A. C. deC. (1999) Systematic review and meta-analysis of randomised controlled trials of cognitive behaviour therapy for chronic pain in adults, excluding headache Pain 80, 1–13. 

Actual studies and supporting papers

In the present context, a full list of all available studies would be excessive, but the interested reader can contact the authors if they would like further information. The selection presented here includes some of the studies published by the first author as they represent the most direct evidence to support the use of the methods described in this book.

Andrews G. (1996) Talk that works: The rise of cognitive behaviour therapy British Medical Journal 313, 1501–1502.

Bendix, A.F., Bendix, T., Ostenfeld, S., Bush, E., and Anderson, A. (1995) Active treatment programs for patients with chronic low back pain: a prospective, randomized, observer-blinded study European Spine Journal 4, 148–152.

Fishman, B. and Loscalzo, M. (1987) Cognitive-behavioral interventions in management of cancer pain: principles and applications Medical Clinics of North America 74, 271–287.

Frost, H., Klaber Moffett, J.A., Moser, J.S. and Fairbank, J.C.T. (1995) Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain British Medical Journal, 310, 151–154.

Johansson, C., Dahl, J., Jannert, M., Melin, L. and Andersson, G. (1998) Effects of a cognitive-behavioral pain-management program Behaviour Research and Therapy 36, 915–930.

Keefe, F.J., Caldwell, D.S., Baucom, D., Salley, A., Robinson, E., Timmons, K., Beaupre, P., Weisberg, J., and Helms, M. (1996). Spouse-assisted coping skills training in the management of osteoarthritic knee pain Arthritis Care and Research 9, 279–291.

Keefe, F.J., Caldwell, D.S., Williams, D.A., Gil, K.M., Mitchell, D., Robertson, C., Martinez, S., Nunley, J., Beckham, J.C., Crisson, J.E. and Helms, M. (1990) Pain coping skills training in the management of osteoarthric knee pain: a comparative study Behavior Therapy 21, 49–63. (1990) Pain coping skills training in the management of osteoarthritic knee pain II: follow-up results Behavior Therapy 21, 453–457.

Kraaimaat, F.W., Brons, M.R., Greenen, R. and Bijlsma, J.W.J. (1995) The effect of cognitive behavior therapy in patients with rheumatoid arthritis Behaviour Research and Therapy 33, 487–495.

Loscalo, M. and Jacobsen, P.B. (1990) Practical behavioral approaches to the effective management of pain and distress Journal of Psychosocial Oncology 8, 139–169.

Lindstrom, I., Ohlund, C., Eek, C., Wallin, L., Peterson, L. And Nachemson, A. (1992) Mobility, strength and fitness after a graded activity programme for patients with subacute low back pain: A randomized prospective clinical study with a behavioural therapy approach Spine 17, 641–652.

Mayou, R.A., Bryant, B.M, Sanders, D., Bass, C., Klimes, I. and Forfar, C. (1997) A controlled trial of cognitive behavioural therapy for non-cardiac chest pain Psychological Medicine 27, 1021–1031.

Molloy, A.R., Blyth, F.M. and Nicholas, M.K. (1999) Disability and work-related injury: time for a change? Medical Journal of Australia 170, 150–151.

Nicholas, M.K., Wilson, P.H. and Goyen, J. (1991) Operant-behavioural and cognitive behavioural treatment for chronic low back pain Behaviour Research and Therapy 29, 238–255. (1992) Comparison of cognitive-behaviouralgroup treatment and an alternative non-psychological treatment for chronic low back pain Pain 48, 339–347.

Vlaayen, J.W.S., Haazen, I.W.C.J., Schuerman, J.A., Kole-Snijders, A.M.J. and van Eek, H. (1995) Behavioural rehabilitation of chronic low back pain: comparison of an operant treatment, an operant cognitive treatment and an operant-respondent treatment British Journal of Clinical Psychology 43, 95–118.

Williams, A.C.deC., Nicholas, M.K., Richardson, P.H., Pither, C.E., Justins, D.M., Chamberlain, J.H., Harding, V.R., Ralphs, J.A., Jones, S.C., Dieudonne, I., Featherstone, J.D., Hodgson, D.R., Ridout, K.L and Shannon, E.M. (1993) Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain British Journal of General Practice 43, 513–518.

Williams, A.C.deC., Richardson, P.H., Nicholas, M.K., Pither, C.E., Harding, V.R., Ridout, K.L., Ralphs, J.A., Richardson, I.H., Justins, D.M. and Chamberlain, J.H. (1997) Inpatient vs outpatient pain management: results of a randomised controlled trial Pain 66, 13–22.

Williams, A.C.deC., Nicholas, M.K., Richardson, P.H., Pither, C.E., Fernandes, J. (1999) Generalizing from a controlled trial: the effects of patient preference versus randomization on the outcome of inpatient versus outpatient chronic pain management Pain 83, 57–65.