How much do mental interventions help pain?

Posted on August 6, 2018

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(Last Updated On: August 6, 2018)

The study,

Association Between Psychological Interventions and Chronic Pain Outcomes in Older Adults A Systematic Review and Meta-analysis

Scattered points:

 

“The study was only done on older people!”

Good. Older people are those with the most bias and preconceived notions. If anybody is going to have misbeliefs about what causes pain, it will be them. Thus, if anybody is going to be prone to getting a benefit from having their beliefs corrected, it would be them.

Said another way- you can’t approach a five year old and try to change their concept of why they have pain from “You have a bad MRI” to “You are excessively catastrophizing the cause of your pain is tissue damage.” They aren’t mentally mature enough to even have that kind of reasoning in the first place.

(Which is why you won’t be seeing pain science education done on dogs or rats any time soon. Despite dogs suffering an amazingly similar array of chronic pain issues as humans…)

-> Plus, how many people are in chronic pain AFTER knowing their X-ray or MRI? We don’t go around X-raying people, telling them they’re bone on bone, then finding out that causes pain.

 

The gist,

“This review, which included 12 clinical trials and 5 uncontrolled pilot studies, found that psychological approaches were moderately effective in reducing pain but did not have [statistically] significant effect on depressive symptoms, physical functioning, or pain medication use.”

Clinically, or from the patient’s perspective, I’d argue if you get treatment for musculoskeletal pain, and after treatment you’ve had no improvement in your physical function or pain medication use, you basically had no benefit from the treatment.

I mean, if someone came to me for a knee problem, and after a month or two they told me, “Well, I don’t feel as much pain, but I can’t squat or walk any better, and I’m still taking my opiates” I’m not exactly enthralled with the results! (Not one single study examining pain medication use found a reduction in use!)

And as we’ll see, the term “moderately effective” is an ENORMOUS leap in this study.

 

Many in the pain science community have harped on the connection between depression and pain. Well, in this systematic review, of 2608 participants, pain was found to improve, but depression was not…


-> Note, if you come across a study which does find an improvement in pain and depression simultaneously, be sure to examine how long the study was carried out. This current study explicitly states after six months a lot of benefits of psychological intervention, in this context, dissipate.

-> We have not made ANY dent in treating depression. The amount of time you’re disabled with depression has not budged for at least two decades. Here, pain science researchers will tell you this. Cognitive Behavioral Therapy has not made a dent in depression, yet it’s a revolution for treating your shoulder pain?!

-> Please don’t assume I’m saying nobody should get therapy for depression. I’m not at all saying that. See my comments on averages at the end.

Annnnnnd in the last two decades we *have* made a dent in treating lower back disability. Making the connection between lower back pain and depression, i.e. that you need to treat depression in order to treat lower back pain, even more tenuous:

Lower back pain is 12.4% less while depression is 0.1% more.


 

As far as the improvement that was found, our psychological intervention study examined a host of studies regarding cognitive behavioral therapy (CBT) alone OR in conjunction with other therapies. This is a recurring issue for the pain science world. We are still not examining treating the mind in isolation.

For instance, never mind other modalities such as using behavioral therapy with say, exercise. This study also examined using the therapy in group OR individual settings. Is it the therapy that’s helpful, or is it simply being in a group? Group therapy is when the benefits were strongest. Is it the treating the mind aspect? Or is it being given awareness others have the same problem as you?

 

How much improvement in pain was there? After discussing it in more statistical terms, the authors note,

“The…terms reported above (for pain, catastrophizing, and self-efficacy) correspond to a baseline to posttreatment reduction in pain intensity on a 0 to 10 scale of 0.49, in catastrophizing on a 0 to 6 scale of 0.32, and an improvement in self-efficacy on a 0 to 60 scale of 4.11 points.”

Is anybody yearning to take their lower back pain, which is at an, for example, 8 out of 10, down to 7.5? Calling that “moderately effective” is deceiving.

To read anything into these improvement scores is silly. You can often find clinical significance in the absence of statistical significance. Well, in this case we have statistical significance in the absence of clinical. (Very large sample sizes are able to do that.) These improvement scores are imperceptible to a patient or client.

-> I’m reminded of a Robert Sapolsky story. He asked a Stanford class about a twin IQ study. It was extremely well done, finding a difference in IQ between twins. He asked the class to determine what the cause was. Nobody could come with anything. Finally, someone asks “What was the improvement?”

Sapolsky (paraphrasingly) “Ah, now you’re thinking! It was a couple points…who cares about that!? For goodness sake someone could have coughed next to you during the test to cause that difference!”

Does the difference matter?

 

I’ve gotten in some arguments with pain science advocates about how they act like the rest of the world is ignorant of pain science. My personal experience, and frankly, common sense, says this isn’t true. Unbeknownst to me, I learned from this study even the CDC recommends cognitive behavioral therapy for chronic pain!

Sure, some are ignorant, but the rest of the world is fairly attuned to this approach. Maybe the fact it doesn’t work very well is why it’s not as widespread as some would like? Since it doesn’t work very well yet is still recommended by the CDC means pain science advocates should be ecstatic they have as much traction as they do.

 

Despite all that, I want to end on this,

First, clearly, the balance does lean towards giving some pain science / psychological intervention versus doing nothing at all. Granted, you could also say the same about endless therapies. Placebo pills, or hell, cans of beer, included.

Second,

“Mean treatment results demonstrated in the present study obscure variations at the individual patient level. Some older patients with chronic pain may receive substantial benefit through psychological therapy, while others may not benefit.”

I write about this at length in,

Why are we so confused about how and what to eat?

That with research, you need to be careful only looking at the average. You need to consider a given modality may be very beneficial for the half the group, yet negative for the other half, causing the average benefit to be zero.

That said, pain science proponents do not, at all, speak about pain science this way. They act as if the average chronic pain person is dramatically missing out by not getting this therapy. They aren’t. Again, pain education is worth doing. I do it with every client. When used in conjunction with e.g. exercise, it can be quite beneficial.

A simple way to read research (issues with pain science)

And there are definitely some people where psychological intervention is much more important than physical. But they are not the average. They are the exceptions. The pain science world has been bitching and moaning the rest of us aren’t generalizing an approach for like 5% of people to the other 95%. Yet if it’s focus on the average or focus on the exceptions, you want the average.

-> I don’t know the exact number. Nobody does. Add that to the list of issues. Pain science has little insight as to properly categorizing their likely-to-benefit population. Here, the researchers (who are not the problem; the zealots are) freely admit this. Point being, whatever the number is, it’s very small.

That said, while I should write about this more, this is a fantastic introduction for how I personally categorize some. My experience says it is at most 5% of all chronic musculoskeletal pain, and that’s being generous.

I’ve been saying this for years and will continue to: there is no “revolution” in our treating pain by obsessing on the brain or psychology. (At least not yet.) We’re simply saying practitioners handling people in pain should give some consideration to how they talk about pain to people who are in pain. I know, right? Someone cue up the Nobel Prize.

-> The irony of this article is I’m speaking to a very small group. The majority of patients and practitioners grasp this the moment I talk to them about it. It’s not at all controversial or debated. Whenever I tell people there is a group out there who is harping on getting knee pain better by talking about it, and I try to slightly defend some of their points, my sanity is questioned.

-> When I talked to Shirley Sahrmann about this -years ago- all the above was basically her response. She even acknowledged “Hey, maybe the doctors referring me patients all these years only sent me people who they knew didn’t need pain science, or catastrophizing education…but I doubt it.” Where the point of a book, or most articles, is (or at least should be) to discuss the majority of the bell curve. Not the tails. Pain science is pure tail oriented, and thus on the edge of useless to the majority.

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Posted in: Miscellaneous, Pain