Pain transcends the sensory perception and is shaped by emotional, cognitive, and behavioral elements. This means that the way we react to pain, and the meaning we ascribe to the pain experience, strongly influences how we cope with pain and our ability to move beyond it.
The fear-avoidance model of pain defines two main attitudes toward pain that a person may have during its onset or as pain persists (1):
- Absence of fear, which is conducive to confrontation and recovery.
- Pain catastrophizing (PC), which is essentially the belief that pain can’t be overcome, which leads to fear of re-injury, maladaptive behaviors, and persistent (chronic) pain.
What is Pain Catastrophizing?
The term ‘catastrophizing’ was coined in 1962 by Albert Ellis, a psychologist, and refined later by Aaron Beck, a psychiatrist. PC is a relatively common ‘cognitive distortion’ associated with anxiety and depression. It impairs self-efficacy, social functioning, and is linked to physical disability in both acute injury and chronic pain (2).
Interestingly, the effects of PC may extend beyond the psychological configuration of pain. Evidence suggests that dysregulation of the hypothalamic-pituitary axis and reduced descending pain inhibitory endogenous opioid pathways are two physiological changes associated with PC that increase central sensitization to pain (a phenomenon termed ‘cognitive-emotional sensitization’) (3, 4, 5).
How is Pain Catastrophizing Assessed?
As one of the strongest psychological predictors of pain outcomes, PC needs to be assessed and addressed every time a person presents with pain as a main or relevant concern to a Physical Therapy session (6, 7).
The Pain Catastrophizing Scale (PCS), is the most widely method used to measure PC (8). The scale is based on 3 domains which include:
- Rumination: e.g. “I can’t stop thinking about how much it hurts.”
- Magnification: e.g. “This pain is everything in my life.”
- Helplessness: e.g. “There is nothing I can do to help my pain.”
The PCS in turn is based on a previous, also widely used tool, the Coping Strategies Questionnaire-Catastrophizing subscale (CSQ-CAT) (9).
What is the Most Effective Way to Reduce Pain Catastrophizing?
Physical therapists deal with pain conditions on a daily basis, and are likely to encounter patients with PC. Which begs the question: what is the most effective way to treat them?
A recent meta-analysis in the Journal of Pain critically evaluated the results of randomized controlled trials (RCTs) to find out which interventions are most effective in reducing PC in adults with chronic (non-cancer) pain (10).
These are the study’s main characteristics:
- It included a total of 79 RCTs published between 1988 and 2016, involving 9,914 participants (74% females).
- Only 8 studies specifically targeted PC and also included cohorts with high PC
- The most common measures of PC were the PCS (44 studies) and the CSQ (28 studies)
- The most common pain conditions were spinal pain (most often CLBP or neck pain; 24 studies), mixed pain cohorts (19 studies), and fibromyalgia (17 studies)
- 17 types of intervention were identified, that contained:
- mostly psychological content (48 studies)
- mostly physical treatments, such as exercise, acupuncture, or manual therapy (7 studies)
- multimodal interventions (a combination of physical and psychological content; 22 studies)
- purely pharmacological treatments (2 studies)
- Most interventions were delivered face-to-face, with 34 using a group format and 24 delivered individually. 21 studies were predominantly self-administered using some form of media (internet, telephone, etc.)
- The duration of interventions varied considerably, ranging from 1 day to 28 weeks (median = 8 hrs)
- The most common interventions were CBT (28 studies) and multimodal interventions (20 studies), all of which contained a CBT component.
The meta-analysis revealed that several interventions work modestly well in reducing PC, but Cognitive Behavior Therapy (CBT), Acceptance and Commitment Therapy (ACT), and multimodal treatment (CBT plus Physical Therapy), had the best supporting evidence. The best results were obtained with multimodal treatments combining CBT and exercise.
“When studies targeting people with high PC were assessed, Multimodal Treatment (CBT+PT) showed the strongest effects.”
3 Ways to Target Pain Catastrophizing
#1 Cognitive Behavior Therapy
In 1955 Ellis had introduced Rational Emotive Behavior Therapy (REBT). Years later, A. Beck defined the general framework for CBT. At the root of these therapies is the notion that human emotions and behavior are mainly determined by ideas, thoughts, beliefs, and attitudes, not by events. Therefore, identifying and changing maladaptive cognitions, emotions, and behaviors is a critical step to better manage and eventually overcome pain. CBT is widely used to treat functional disabilities related to pain, and most current evidence indicates that CBT is one of the most effective ways to treat PC in chronic pain patients (11),
Want to know more about CBT? Check out my blog: COGNITIVE-BEHAVIORAL THERAPY SKILLS FOR MODERN PAIN PRACTITIONERSWhen studies targeting people with high PC were assessed, Multimodal Treatment (CBT+PT) showed the strongest effects. Click To Tweet
#2 Acceptance and Commitment Therapy
While CBT focuses on recognizing, evaluating, and modifying unhelpful pain-related thoughts, emotions, and behaviors, Acceptance and Commitment Therapy promotes awareness and nonjudgmental acceptance of chronic pain while identifying and committing to pursue goals supporting highly regarded life values (12). In the context of pain, Acceptance and Commitment Therapy is based on the premise that while pain hurts, it is the struggle with pain that causes suffering (13).
For expert discussions on CBT and ACT for chronic pain in Physical Therapy practice, check out these podcasts:
#3 Multimodal Treatment (CBT + Physical Therapy)
All the multimodal interventions included CBT, which was the most common psychological intervention across studies. When combined with exercise, PC reduction was greater than that obtained through ACT or CBT alone. Even more, CBT plus exercise had the largest effect sizes for studies that included only high baseline PC subjects and targeted catastrophizing as primary outcome, and for those that included active controls (intervention cross-comparisons) rather than waitlist/usual care. Since exercise does not directly target negative thinking associated with PC, the reason(s) behind its beneficial effects on PC are not immediately apparent; the authors propose several possible explanations about this (10):
- Exercising without catastrophic outcomes could contribute to cognitive restructuring by providing disconfirmatory evidence.
- Exercise may help to shift attention away from rumination due to its attentional demands and mood effects.
- The use of exercise as a self-management tool could increase self-efficacy and thereby reduce helplessness.
- Given the evidence of a bidirectional relationship between pain intensity and PC, the modulation of descending inhibitory control mechanisms associated with paced exercise may indirectly reduce PC via pain reduction.
As the authors point out, yet another possibility is that multimodal treatments are more likely to match at least one treatment component to a patient strength or deficit (14).
From Fear to Hope. Physical Therapists’ role.
The evidence shows that several approaches may be adequate to reduce PC in chronic pain patients, and among those CBT plus exercise may work best for most people. And this makes good sense; at a time when psychologically informed care for pain management has taken the spotlight, exercise has always and will continue to deliver a wide range of benefits on both physical and mental health. This is why the importance of exercise prescription cannot be overestimated.
Physical Therapy patients come from all walks of life and have different lifestyles. Two key aspects physical therapists should evaluate are: whether a preferred treatment, or particular components therein, will be a good match to his/her patient profile (14); and his/her own confidence and competence in delivering these therapies.
On the other hand, as awareness of the influence of psychosocial factors in pain coping and management continues to grow, the importance of empathy and compassion in physical therapist-client interactions should be appreciated. It’s not just the message, but the messenger as well. Not only what is instructed or advised, but the delivering ways; the self-confidence that can be instilled, the mutual trust that can be cultivated through genuine and open exchange.
Check out my blog Pain and the Power of Your Thoughts to learn more about PC and how CBT may help overcome it.
How do you evaluate and treat pain catastrophizing in your practice?
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1- Vlaeyen, J. W., Crombez, G., & Linton, S. J. (2016). The fear-avoidance model of pain. Pain, 157(8), 1588-1589.
2- Leung, L. (2012). Pain catastrophizing: an updated review. Indian journal of psychological medicine, 34(3), 204.
3- Edwards, R. R., Kronfli, T., Haythornthwaite, J. A., Smith, M. T., McGuire, L., & Page, G. G. (2008). Association of catastrophizing with interleukin-6 responses to acute pain. Pain, 140(1), 135-144.
4- Goodin, B. R., McGuire, L., Allshouse, M., Stapleton, L., Haythornthwaite, J. A., Burns, N., … & Edwards, R. R. (2009). Associations between catastrophizing and endogenous pain-inhibitory processes: sex differences. The Journal of Pain, 10(2), 180-190.
5- Huysmans, E., Ickmans, K., Van Dyck, D., Nijs, J., Gidron, Y., Roussel, N., … & De Kooning, M. (2018). Association between symptoms of central sensitization and cognitive behavioral factors in people with chronic nonspecific low back pain: A cross-sectional study. Journal of manipulative and physiological therapeutics, 41(2), 92-101.
6- Bergbom, S., Boersma, K., Overmeer, T., & Linton, S. J. (2011). Relationship among pain catastrophizing, depressed mood, and outcomes across physical therapy treatments. Physical therapy, 91(5), 754-764.
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10- Schütze, R., Rees, C., Smith, A., Slater, H., Campbell, J. M., & O’Sullivan, P. (2017). How can we best reduce pain catastrophizing in adults with chronic non-cancer pain? A systematic review and meta-analysis. The Journal of Pain.
11- Williams, A. C., Eccleston, C., & Morley, S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults.
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13- Dahl, J., & Lundgren, T. (2006). Acceptance and commitment therapy (ACT) in the treatment of chronic pain. Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications, 285-306.
14- Day, M. A., Ehde, D. M., & Jensen, M. P. (2015). Psychosocial pain management moderation: The limit, activate, and enhance model. The Journal of Pain, 16(10), 947-960.
Ellis A. Reason and emotion in psychotherapy. New York: L. Stuart; 1962. p. 442.
Fisher, E., Heathcote, L. C., Eccleston, C., Simons, L. E., & Palermo, T. M. (2017). Assessment of pain anxiety, pain catastrophizing, and fear of pain in children and adolescents with chronic pain: A systematic review and meta-analysis. Journal of pediatric psychology, 43(3), 314-325.