Mediators, moderators, and predictors of therapeutic change in cognitive–behavioral therapy for chronic pain

Abstract

Although cognitive-behavioral therapies (CBT) have been demonstrated to be effective for a variety of chronic pain problems, patients vary in their response and little is known about patient characteristics that predict or moderate treatment effects. Furthermore, although cognitive-behavioral theory posits that changes in patient beliefs and coping mediate the effects of CBT on patient outcomes, little research has systematically tested this. Therefore, we examined mediators, moderators, and predictors of treatment effects in a randomized controlled trial of CBT for chronic temporomandibular disorder (TMD) pain. Pre- to post-treatment changes in pain beliefs (control over pain, disability, and pain signals harm), catastrophizing, and self-efficacy for managing pain mediated the effects of CBT on pain, activity interference, and jaw use limitations at one year. In individual mediator analyses, change in perceived pain control was the mediator that explained the greatest proportion of the total treatment effect on each outcome. Analyzing the mediators as a group, self-efficacy had unique mediating effects beyond those of control and the other mediators. Patients who reported more pain sites, depressive symptoms, non-specific physical problems, rumination, catastrophizing, and stress before treatment had higher activity interference at one year. The effects of CBT generally did not vary according to patient baseline characteristics, suggesting that all patients potentially may be helped by this therapy. The results provide further support for cognitive-behavioral models of chronic pain and point to the potential benefits of interventions to modify specific pain-related beliefs in CBT and in other health care encounters.

Change in Psychosocial Distress Associated With Pain and Functional Status Outcomes in Patients With Lumbar Impairments Referred to Physical Therapy Services

“…29,34,56 Briefly, treatment mediators are factors that change during treatment and are associated with a defined outcome versus a prognostic factor, which estimates a patient's likely outcome irrespective of the chosen intervention. 29,34,56 It is plausible that, as suggested by our data, elevated intake PD is likely to have an important role as a treatment mediator for patients receiving physical therapy care and, therefore, positive changes in PD may be anticipated during rehabilitation. Overinterpretation of elevated intake PD scores should be avoided if PD symptoms are treatment mediators.…”

The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management

“…96 In studies of CBT for chronic pain there are data showing that change in the content of thoughts can be associated with improvements during treatment. 9,35,79 At the same time a substantial number of studies suggest that it is unnecessary to employ methods that target the content of thoughts for change in treatment for chronic pain. Thoughts may change substantially or not very much during treatment and in either case good outcomes can be achieved.…”

Patients’ perceptions of the effectiveness of guided imagery and progressive muscle relaxation interventions used for cancer pain

“…Cognitive-behavioral strategies such as guided imagery and relaxation are recommended as adjuvant interventions to enhance pain relief and to increase patients' perceptions of control over pain [1,14]. Guided imagery involves the use of one's imagination to create mental images that distract attention away from pain or that alter the pain sensation itself.…”