Trying to follow the evidence to determine the best intervention for your patients can be a challenge, especially when it comes to persistent pain. It can be a challenge when you read well-done reviews that seem to have slightly opposite conclusions.
In one breath you can look at a study like the one by Hall, et al. and think maybe physical therapy led cognitive-behavioral (CB) interventions have some promise. This systematic review looked at 5 RCT’s including close to 1,400 subjects between the articles. It showed that CB interventions had a small to medium effect on reducing pain and disability, but limited effect on quality of life when comparing to education and/or exercise interventions. The evidence showed that when therapist received additional training in CB interventions that target both physical and psychosocial that patients were more likely to gain long lasting skills to help manage their symptoms on their own. This was compared to more traditional biomedical-based treatments that focus only on physical symptoms that provide short-term benefits but with questionable sustained effects over time.
As soon as you take that breath in and think you might be on to something to help your patients with persistent pain, you get it taken out of you by reading the next study. Markozannes, et al. did an umbrella review (a review of review studies) looking into how helpful psychological interventions are for pain reduction. They concluded that after looking at 38 papers and performing a meta-analysis that there is a lack of strong evidence supporting the effectiveness of psychological treatments for pain relief.
So what do we do now? First understand and except persistent pain is complex and it is very unlikely that one magic bullet treatment is going to produce significant effects and be the sole key to successful outcomes with this patient population. Then take the information from the studies and apply to your practice with some sound clinical reasoning. Cognitive-behavioral interventions seem to offer some small to medium effect. Not great, but some effect. So do not get too excited but also do not throw it out. Considering there is no intervention showing a large effect with this patient population you realize small to medium effect is all we have for now. Knowing that CB interventions are not the end-all-be-all, apply other treatment interventions that have shown to have some evidence behind them as well – aerobic exercise, strength training, sleep hygiene, stress reduction, meditation/relaxation, diet changes, goal setting, graded exposure, to list a few. This is what we often refer to is the PNE+ (pain neuroscience education plus other therapies). Our systematic review revealed to us that PNE (a CB type of intervention) alone did not change pain. It is unlikely that you will ever explain someone’s pain away. However, add it with other interventions (PNE+) and then we start getting some positive changes.
We need to change our focus from this intervention OR that intervention for the person with persistent pain. It most likely will be this intervention AND that intervention. This combination of interventions should be found through a shared-decision making model with a patient-centered approach to care that would most likely help a patient with persistent pain have some positive effect on their condition.