07 May Not All In Your Head: Psychological Therapies Not a Panacea for Pain
MedicalResearch.com Interview with:
Dr. M. Carrington Reid, MD PhD
Associate Professor of Medicine
Irving Sherwood Wright Associate Professor in Geriatrics
Joachim Silbermann Family Clinical Scholar
Geriatric Palliative Care
Joan and Sanford I. Weill Department of Medicine
Weill Cornell Medical College
MedicalResearch.com: What is the background for this study?
Response: Major guidelines (American College of Physicians, Centers for Disease Control, Veterans Administration) on the management of chronic pain strongly encourage clinicians to use nonpharmacologic approaches to include psychological therapies when managing pain.
While many studies have evaluated psychological therapies such as cognitive behavioral theraphy (CBT) in nonelderly populations with chronic pain, far fewer have evaluated these treatments in studies of older adults. We identified 22 randomized controlled trials that evaluated a psychological therapy for chronic pain in older adults and examined the impact of these treatments on salient outcomes to include ability to reduce pain and pain-related disability, improve patients’ self efficacy to manage pain, and improve their physical health and function and their psychological health (by reducing rates of anxiety and depression).
MedicalResearch.com: What are the main findings?
Response: We found small benefits associated with these therapies. Specifically in the areas of pain reduction, reducing castrophizing beliefs and improving self-efficacy for managing pain. The treatment effects translate to about a 5% reduction in pain, reduction in castrophizing, and in improving self-efficacy. The improvements while statistically significant are not clinically significant. It is important to note that average effect sizes cannot (should not) be applied to an individual patient because some patients will experience substantial benefit using these approaches while others will not benefit at all.
Other key findings: Group-based psychologically therapies were more effective when delivered using a group based (versus individually based) delivery approach. Peer support is the most likely mechanism explaining why treatment effects would be stronger when the therapy is delivered in the group based setting.
We looked for other factors (moderators) that might impact treatment outcomes such as age and sex of the patient, intensity of the therapy (how many treatment sessions), and skill set of the therapist and did not find these factors were important in influencing treatment outcomes.
MedicalResearch.com: What should readers take away from your report?
Response: Psychological therapies for pain are not a panacea, i.e., don’t expect effective pain management when these approaches are used as mono-therapy. Our results support efforts to have patients receive these therapies but our results also clearly demonstrate that when used alone these approaches would be considered insufficient to completely address pain in older adults.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Up to 50% of older adults experience chronic pain, which can lead to frailty, disability and increased healthcare costs. We need research focused on developing more effective psychological approaches to the management of pain in older adults. We also need more research to help understand whether certain subgroups of older adults are MORE or LESS likely to benefit from these types of treatments. Finally, we need research that helps us understand what specific components that are part of psychological therapies are responsible for the beneficial effects. Psychological therapies typically involve the use of multiple modalities, it will be important to understand which modalities are responsible for the positive effects.
I have no financial disclosures to declare.
Niknejad B, Bolier R, Henderson CR, et al. Association Between Psychological Interventions and Chronic Pain Outcomes in Older AdultsA Systematic Review and Meta-analysis. JAMA Intern Med. Published online May 07, 2018. doi:10.1001/jamainternmed.2018.0756
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