Date Published: 15 November 2011

Cognitive Behavioural Therapy (CBT) good for chronic widespread pain

A short course of cognitive behavioural therapy (CBT) over the telephone from trained therapists - sometimes referred to as simply "talking therapy" can help people suffering from chronic widespread pain according to recent research carried out at Manchester University, England. Cognitive behavioural therapy is a psychological method of helping people manage their pain by identifying and evaluating thoughts and behaviour.

Patients who received a short course of cognitive behavioural therapy (CBT) over the telephone from trained therapists reported that they felt "better" or "very much better" at the end of a six-month treatment period, and also three months after it ended.

The recent trial was funded by Arthritis Research UK and led by Aberdeen University working with Manchester Universityr. It was the first-ever trial of telephone-delivered CBT for people with chronic widespread pain. Physical exercise was also shown to help ease pain and disability and helped people to manage their symptoms. However, the study indicated there was no additional advantage of receiving both types of treatment (CBT and exercise) over receiving just one.

Chronic widespread pain is the main feature of fibromyalgia, is thought to affect approximately 10% of the population and is extremely difficult to treat. The main symptoms of fibromyalgia include tenderness around the body, fatigue, and sleep disturbance. Fibromyalgia is one of the main reasons for referral to a rheumatologist. Many people affected by fibromyalgia are feel the need to give up work as a result of constant pain and become increasingly isolated and frustrated. Although cognitive behavioural therapy (CBT) can be very effective it is expensive to deliver and generally requires many patient/therapist contact hours.

The trial, involving 442 people with chronic widespread pain aged between 25 and 60 from GP surgeries in Cheshire and Aberdeen, aimed to develop more effective ways of reducing and/or coping with painful symptoms of chronic widespread pain. The study was led by Professor Gary Macfarlane, professor of epidemiology at the Aberdeen University and Dr John McBeth, reader in rheumatic disease epidemiology at the Arthritis Research UK Epidemiology Unit at Manchester University.

Professor Macfarlane said:

" The management of chronic widespread pain and fibromyalgia has been difficult. There are no medicines specifically licensed for their management and GPs have felt that they have had few effective options available to them. We have examined two options – a graded exercise programme and CBT and found both to be effective. We specifically looked to deliver CBT by telephone to increase the flexibility of delivery both from a patient and service viewpoint. These results demonstrate that we can improve symptoms for many people."

Dr McBeth said:

" There's a real need to develop clinically effective and acceptable interventions at primary care level that could potentially be available to a large number of patients.

Treatment of chronic widespread pain in the UK is problematic and ad hoc. No drugs are approved for use in fibromyalgia, and access to CBT or exercise programmes is limited, if available at all. While the demand for CBT exceeds supply, our trial provides evidence that telephone-delivered CBT is effective, acceptable and accessible."

Professor Alan Silman, medical director of Arthritis Research UK, which funded the study, said:

" Persistent severe aching felt all over the body is an all too common disorder which frustrates patients and health care professionals alike and is not easily controlled by pain killers. This trial has shown how a behavioural approach can help people cope with the pain in a feasible and affordable manner. The National Institute for Health and Clinical Excellence (NICE) and health care providers will be most interested to build on the success of this trial."

Patients participating in the trial patients were split into four groups, receiving one of four possible treatment regimes:

• doing exercise - members of this group were offered six fitness instructor-led monthly appointments and were recommended to exercise between 20 and 60 minutes a day with increasing intensity over the six-month period
• receiving cognitive behavioural therapy (CBT)
• receiving a combination of exercise and cognitive behavioural therapy (CBT)
• the "usual care" by their GP.

The outcomes of the treatment regimes were measured by self-completing postal questionnaires using a seven-point patient global assessment scale on patients' health from the time of enrolling on the trial, ranging from "very much worse" to "very much better." Assessments were made at six months, when treatment ended, and three months later. A positive outcome was defined as "much better" or "very much better."

Telephone CBT and exercise were both associated with substantial, statistically significant, clinically meaningful improvements in self-rated global health.

The researchers also found that participants who expressed a preference for one or the other of the treatments did better if they got their preferred treatment.

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