A recent review in the Journal of Pain Research concluded that the psychosocial approach with the strongest evidence base for rheumatoid arthritis (RA) pain is cognitive behavioral therapy (CBT).1 For the review, author Louise Sharpe, PhD, professor of clinical psychology at the University of Sydney, Australia, examined published reviews, meta-analyses, and individual randomized clinical trials (RCTs) of the psychosocial interventions that researchers have investigated for RA pain.
Her review was intended to build on what scientists already know about the efficaciousness of psychological therapy in patients with RA for managing pain. CBT, expressive writing, mindfulness, problem-solving, internal family systems (IFS) psychotherapy, and acceptance-and-commitment therapy (ACT) were the psychosocial interventions analyzed.
Dr Sharpe wrote, “the fact that cognitive behavioral therapy (CBT) is efficacious for chronic pain is not a controversial claim.” CBT is a multimodal approach that encompasses a number of behavioral and cognitive strategies intended to help patients identify and change unhelpful patterns of behavior and attitudes toward RA.
While there is no standardized CBT protocol, frequently employed techniques include relaxation training, goal-setting (often aimed at increasing physical activity), advice on activity pacing, problem-solving, assertiveness-training, managing high-risk time and relapse, and the restructuring of deleterious cognitive beliefs.2
“In the case of RA, behavior change is usually helping patients to achieve a balance between rest and exercise, through strategies such as pacing, goal-setting, problem-solving, and relaxation strategies. Cognitive change helps patients to develop a more optimistic but realistic attitude toward the illness and to manage other stresses in their lives,” wrote Dr Sharpe.
Sharpe deemed CBT to be of Level 1 evidence for RA, as defined by the availability of systematic review or meta-analysis of RCTs on the topic, and to be “definitely efficacious,” based on evidence from two or more RCTs from different researchers. Expressive writing, a behavioral intervention in which participants write about stressful experiences in their lives as a form of emotional expression, was likewise identified as being of Level 1 evidence and as “definitely efficacious.”
However, expressive writing was found to be less efficacious than CBT in a randomized trial; moreover, that trial found that pain levels increased in patients in the expressive writing arm, and that positive effects on disease activity and disability were not maintained at follow-up.
Mindfulness, a meditative approach that teaches patients how to be present with their experience from a non-judgmental and accepting vantage point, was found to be “definitely efficacious;” however, as no systematic reviews describing its use in RA were available, mindfulness was deemed to be of Level 2 evidence, a designation signifying the availability of one or more RCTs.
Problem-solving, an approach that frequently is employed as a component of CBT, internal family systems (IFS)-based psychotherapy, and acceptance-and-commitment (ACT) therapy were designated as “possibly efficacious” in RA based on evidence from a single RCT or multiple RCTs from a single group of researchers.
Sharpe noted in the review that introducing psychosocial interventions early in the course of RA is superior to late intervention. She wrote, “In RA, the first 2 years of illness are seen as particularly important for intervention, considering that RA is typically most active in terms of inflammation during this early period and therefore early intervention can prevent long-term damage.”
She describes a study involving 53 consecutive patients with less than a 2-yr history of classic or definite RA. All participants received routine medical management during the study, with half randomized to an 8-week adjunctive behavioral intervention with CBT.3 Upon a 5 year follow-up, patients who underwent CBT had significantly lower total health care expenditures in the 5 years subsequent to treatment.4
Sharpe warned that the effects of CBT and other modalities discussed in her review may not be generalizable to patients who have comorbid psychological conditions. Some evidence suggests that mindfulness-based interventions may be superior to CBT in patients with a history of depression.1
Summary and Clinical Applicability
In an email interview, Rheumatology Advisor asked Dr Sharpe about the practical ramifications of her research for clinicians who treat RA.
“For the rheumatologist, they should be aware that patients with RA, especially early in the course of their illness once the disease is stable on medication, can benefit from a brief CBT approach to pain management.” Dr Sharp noted that there was no evidence to guide the choice of individual vs. group therapy. “There is no evidence that one modality is better than any other,” she stated.
“Early on, I suspect — this is an opinion rather than evidence-based — that individual may be better because the issues and prognosis differ markedly between patients, but for chronic RA, I suspect that groups are equally efficacious and there is no evidence that individual is better than group. There is currently limited evidence for internet-based approaches specifically for RA, but we have recently published some very encouraging data in chronic pain patients generally, and RA patients were included in this study.”
She added, “I would say that internet-delivered options, once shown to be effective, are likely to be the best option for patients to access these approaches.”
Limitations and Disclosures
Professor Sharpe stated that she is paid on a casual basis to deliver workshops for local and international conferences concerning the role of cognitive behavioral therapy in facilitating adjustment to illness or in the treatment of chronic pain. She reports no other conflicts of interest in this work.
1.Sharpe L. Psychosocial management of chronic pain in patients with rheumatoid arthritis: challenges and solutions. J Pain Res. 2016;9:137-146.
2.Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69:153-166.
3.Sharpe L, Sensky T, Timberlake N, Ryan B, Brewin CR, Allard S. A blind, randomized, controlled trial of cognitive-behavioural intervention for patients with recent onset rheumatoid arthritis: preventing psychological and physical morbidity. Pain. 2001;89:275-283.
4.Sharpe L, Allard S, Sensky T. Five-year followup of a cognitive-behavioral intervention for patients with recently-diagnosed rheumatoid arthritis: effects on health care utilization. Arthritis Rheum. 2008;59:311-316.
This article originally appeared on Rheumatology Advisor