"The Process of Change in Pain During Cognitive Behavior Therapy for Chronic Fatigue Syndrome"-Bloot

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Abstract: http://journals.lww.com/clinicalpai...of_Change_in_Pain_During_Cognitive.99354.aspx

The Process of Change in Pain During Cognitive Behavior Therapy for Chronic Fatigue Syndrome

Clinical Journal of Pain:
Post Acceptance: December 11, 2014

Bloot, Lotte Msc; Heins, Marianne J. Msc, PhD; Donders, Rogier PhD; Bleijenberg, Gijs PhD; Knoop, Hans PhD

Abstract

Background:

Cognitive behavior therapy (CBT) leads to a reduction of fatigue and pain in chronic fatigue syndrome (CFS).

The processes underlying the reduction in pain have not been investigated.

Recently, it was shown that increased self-efficacy, decreased focusing on symptoms, increased physical functioning and a change in beliefs about activity contribute to the decrease in fatigue.

Objectives:

The present study has two objectives:
(1) to determine the relationship between the reduction of fatigue and pain during CBT;
(2) test to what extent the model for change in fatigue is applicable to the reduction in pain.

Methods:

142 patients meeting US center for disease criteria for CFS, currently reporting pain, and starting CBT were included.

A cross-lagged analysis was performed to study the causal direction of change between pain and fatigue.

Pain and process variables were assessed before therapy, three times during CBT and after therapy.

Actual physical activity was also assessed. The model was tested with multiple regression analyses.

Results:

The direction of change between pain and fatigue could not be determined.

An increase in physical functioning and decrease in focusing on symptoms explained 4 to 14% of the change in pain.

Conclusions:

Pain and fatigue most probably decrease simultaneously during CBT. Pain reduction can partly be explained by a reduction of symptom focusing and increased physical functioning.

Additional, yet unknown cognitive-behavioral factors also play a role in the reduction of pain.

(note that physical functioning is measured by a questionnaire, the SF-36 physical functioning subscale)

 

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Higher levels of actual physical activity were not related to lower levels of pain, but improvement in the level of physical functioning was.

Note that physical functioning is a questionnaire asking about limitations, not an objective measure. Physical activity was measured by an actometer.

Also:

Actual changes in physical activity, self-efficacy and perceived activity did not contribute significantly to lower levels of pain.

Also

As with fatigue, actual physical activity does not lead to a reduction in pain, suggesting that in CBT physical activity is not directly related to a reduction in symptoms.

It is not clear whether there was an increase in physical activity or not in the cohort as a whole (as opposed to whether changes in physical activity were related to changes in pain reported). The study involves 78% (those with pain) from Heins et al. (2013) (free at: http://www.jpsychores.com/article/S0022-3999(13)00266-3/pdf). There was little change in physical activity in that (see Figure 3).

 

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Discussion of earlier results:

Heins et al. studied the process of change during CBT for CFS, by measuring both fatigue and the change in cognitions and behavior several times during therapy [16]. They partly replicated the findings of Wiborg et al. [15]. An increase in self-efficacy, self reported physical activity, and physical functioning was related to the reduction of fatigue. Furthermore, it was found that a decrease in focusing on symptoms is related to a decrease in fatigue. In both studies an increase in actual physical activity was not related to a decrease in fatigue.

15. Wiborg JF, Knoop H, Frank LE and Bleijenberg G. Towards an evidence-based treatment model for cognitive behavioral interventions focusing on chronic fatigue syndrome. Journal of psychosomatic research 2012;72:399-404.

16. Heins M, Knoop H, Burke W and Bleijenberg G. The process of cognitive behaviour therapy for chronic fatigue syndrome: Which changes in perpetuating cognitions and behaviour are related to a reduction in fatigue? . Journal of psychosomatic research 2013, in press.

 

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Patients:
The original sample was comprised of patients with CFS. As not all CFS patients have pain and those we have no pain cannot show a decrease in pain following CBT, the criterion for inclusion into the present data analysis was that a patient had pain at the start of therapy. Patients were only included in the current study when they answered “yes” to the question “Do you have pain complaints?”. The other inclusion criteria were the same as Heins et al. [16], namelymeeting CDC-criteria for CFS [2, 3] -being severely fatigued operationalised as scoring ≥ 35 on the subscale fatigue severity of the Checklist Individual Strength (CIS) [13, 23]. This is two standard deviations above the mean of a healthy reference group [13] - being severely disabled operationalised as scoring ≥ 700 on the Sickness Impact Profile 8 (SIP8) [24-26] -being aged between 18 and 65 years old - being able to read and write Dutch - patients were excluded if they were currently applying for a disability claim, therapy was postponed until their application was completed. Of the 183 patients Heins et al. [16] included, 142 (78%) patients reported to have pain at the start of therapy.

 

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Extract from a description of the intervention:

This activity program consists of gradually increased daily walking or cycling. The increase in activity is time contingent, which means the increase in activity is not determined by the level of symptoms. When patients succeed in increasing their physical activity, they also begin to increase their social and mental activities. In the last phase of therapy, patients work systematically towards achieving their goals. When these goals are reached, patients are encouraged to perceive feelings of fatigue as a normal part of an active and healthy life and stop labelling themselves as a CFS patient [11, 12].

 

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Here are the main results:

Table 1: Mean scores and standard deviations pre- and post therapy on the questionnaires of the
included patients
Pre Post
M (SD) M (SD)
SF-36 Pain 50.7 (21.3) 68.0 (22.6)
Daily observed pain severity (DOP) 6.1 (3.0) 4.0 (3.0)

 

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From the discussion:

During CBT patients are encouraged to increase their physical activity temporarily

This is spin in my mind. There is no suggestion that I have seen that patients should only temporarily increase their physical activity levels.

 

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However, the finding that a decreased focusing on symptom leads to a decrease in both pain and fatigue is in our view in accordance with idea that the mechanism of central sensitisation is underlying the increased perception of both pain and fatigue in CFS.

An alternative hypothesis is that decreased focusing on symptoms is leading to a biased response.

 

[Esther12]

From the discussion:
This is spin in my mind. There is no suggestion that I have seen that patients should only temporarily increase their physical activity levels.

This 2012 cancer-fatigue CBT study from the same group used actometers and had them trying out different implausible excuses. Looks like they've settled on one.

http://forums.phoenixrising.me/inde...fatigue-cbt-actometers-bleijenberg-etc.24838/