Cognitive Behavioural Therapy

Cognitive behavioural therapy (CBT) is a commonly used psychological intervention for chronic pain. Often used as a part of a more comprehensive pain management program, it attempts to modify beliefs and coping skills, particularly when these beliefs and coping skills are dysfunctional.

Author Year
PEDro Score
Research Design
Total Sample Size
Methods Outcome
Burke et al. 2019





Population: Mean age=51.0±13.0 yr; Gender: males= 52, females=17; Time since injury=16.0±21,1 yr; Level of injury: C=17, T=30, L=14; Severity of injury: AIS A=4, B=2, C=3, D=5, Not reported=55; Type of pain=neuropathic and nociceptive.

Intervention: Participants were randomized to a control group or a spinal cord injury (SCI) cognitive behavioural therapy pain management program (CBT-PMP) delivered once a wk for 3 mo.

Outcome Measures: Quality of life (world health organization quality of life bref (WHOQOL-BREF)), QOL (international spinal cord injury quality of life basic data set (ISCI-QOLBDS)), pain profile (international spinal cord injury pain basic data set with numeric rating scale (NRS) (ISCIPBDS)), pain presentation (douleur neuropathique en 4 questions (DN4)), pain acceptance (the chronic pain acceptance questionnaire-8 (CPAQ-8)), pain interference (brief pain inventory (BPI), mood (hospital anxiety and depression scale (HADS)), sleep (sleep quality index (PSQI)), global impression of change PGIC), adverse events.

1.     No significant difference between intervention and control groups for WHOQOL-BREF and ISCI-QOLBDS (p>0.05).

2.     Significant group X time interaction showing that pain levels differed over time between groups by NRS (p=0.016).

3.     Worst pain scores showed similar group X time interaction with differed pain levels over time between groups (p=0.0004).

4.     BPI showed a significant group X time effect (p=0.031) but not interaction.

5.     No significant group X time interaction for the HADS questionnaire, PSQI for sleep or CPAQ for pain acceptance (p>0.05 for all).

6.     Post-intervention there was a moderate linear relationship observed between number of module where users engaged with 80% or more of the content and reductions in measures of NRS (p=0.05), ISCIPBDS (p=0.08), LSF domain (p=0.04), BPI (p=0.10) and HADS depression subscale (p=0.10).

7.     3 mo follow-up revealed a moderate linear relationship between module engagement and improvements in sleep quality (p=0.06), AMS subcategory of ISCIPBDS (p=0.0), and the depression (p=0.03) and anxiety (p=0.05) subscales of HADS.

8.     Immediately post-intervention 2 participants reported being very much improved, 8 reported being much improved, 9 reported minimal improved, and 10 reported no change.

9.     At the 3 mo follow-upm 27 of the participants answered and 3 reported very much improved, 10 said much improved, 7 reported minimal improvement and 7 reported no change.

10.   Two minor adverse events, one shoulder problem and one reported an increase in leg spasms following stretches.

Heutink et al. 2012





Population: Mean age=58.8 yr; Gender: males=39, females=22; Duration of pain=5.4 yrs; Type of pain=neuropathic.

Treatment: SCI Individuals with chronic neuropathic pain were randomly assigned to receive interdisciplinary pain management which included Cognitive behavioural therapy (CBT) and education or wait list control group. The intervention consisted of 10 sessions over 10 week period with a comeback session 3 weeks after the 10th session.

Outcome Measures: Chronic Pain Grade Questionnaire; Hospital Anxiety and Depression Scale (HADS).

1.     Pain intensity decreased over time among the two group, p<0.01.

2.     Significant difference in pain intensity was seen between the two groups post intervention. However, no group difference between the two group were seen in pain intensity at 3 month follow-up.

3.     No significant difference in HADS depression was seen between the two groups or over time.

4.     Individuals in the CBT group found significant improvement in anxiety (p<0.027)and participation in activities (p<0.008) compared to the control group.

Perry et al. 2010




Population: Mean age=43.8 yr; Gender: males=28, females=8; Level of injury: tetraplegia=13, paraplegia=20, Severity of injury: complete=13, incomplete=23; Duration of pain=60.5 mo; Type of pain=neuropathic and musculoskeletal.

Treatment: SCI patients with chronic pain were placed in either the multidisciplinary cognitive behavioural pain management program (PMPs) group (N=19) which involved a pharmacological treatment plan and individual and group based cognitive behavioural therapy for pain; or the usual care group (N=17).

Outcome Measures: Pain response self-statement scale; Pain self-efficacy questionnaire; Multidimensional Pain Inventory (MPI); Hospital Anxiety and Depression Scale (HADS); SF-12 Mental Component Scale

1.     At baseline, the PMP group had significantly worse usual pain intensity scores than the usual care group.

2.     A significant improvement was seen in MPI and SF-12 MCS scores in the PMP group compared to the control group post treatment (p=0.026, p=0.015).

3.     Mean scores of participants in the PMP group moved from moderate to mild disability.

4.     A trend towards improvement on the usual pain intensity and HADS depression score was seen in the PMP group at 1 mo post treatment; however, the HADS depression scores returned to pre-treatment levels at 9 mo follow-up.

Norrbrink et al. 2006




Population: SCI: Treatment: Mean age=53.2 yr; Gender: males=9, females=18; Control: Mean age=49.9 yr; Gender: males=5, females=6; Severity of injury: AIS A-E. Type of pain=neuropathic.

Treatment: SCI individuals were provided standard treatment of interdisciplinary pain management. The individuals in the interdisciplinary pain management participated in a 10 wk, 2x/wk treatment program which included four elements: 1) education (1.5 hr); 2.) behavioural therapy (1.5 hr); 3) relaxation techniques and stretching/light exercise (1 hr); and 4) body awareness training (1hr).

Outcome Measures: Pain Chart and pain rating was completed, pain intensity and unpleasantness was assessed with the Borg CR10 scale, Quality of sleep (survey), Nottingham Health Profile (Quality of life) was completed, Mood (Hospital Anxiety and Depression) was assessed, Coherence and use of the healthcare system were also assessed.

1.     From baseline to 12 mo evaluation period, the treatment group experienced decrease in:

·       Anxiety and depression.

·       Sleep.

2.     No change was seen over time in:

·       Pain intensities and unpleasantness.

·       Health-related quality of life.

·       Life satisfaction.

3.     A significant improvement was noted for the Emotional Reaction subscale only (p<0.01).

4.     The two groups showed significant differences on the depression and SOC scores.

5.     A significant decrease in the number of visits between baseline and the 12 mo assessment period was noted for the treatment group (from 15 to 5; p<0.03), along with the median number of visits to physicians (from 3 to 1; p<0.03).

Dear et al. 2018




Population: Mean age=48.0±13.0 yr; Gender: males=34, females=34; Time since injury=8.0±10.0 yr; Level of injury: paraplegia=43, tetraplegia=16, undiagnosed=9; Severity of injury: complete=15, incomplete=44, undiagnosed=9; Type of pain=neuropathic.

Intervention: Participants enrolled in a pain management program where they completed five online lessons and homework that was systematically released over an 8-wk period.

Outcome Measures: Pain disability index (PDI), patient health questionnaire 9-item (PHQ-9), Wisconsin brief pain questionnaire (WBPQ), generalized anxiety disorder scale 7-item (GAD-7), pain self-efficacy questionnaire (PSEQ), pain catastrophizing questionnaire (PCS), satisfaction with life scale (SWLS).

1.     Significant overall effect observed for pain-related disability (p<0.001), depression (p<0.001), and anxiety (p<0.001).

2.     Significant improvements in disability, depression and anxiety levels after treatment (p<0.001) and 3-mo follow-up (p<0.015).

3.     Significant improvements in average pain levels from baseline to post-treatment (p<0.001).

4.     Significant overall time effects observed for PSEQ (p=0.002), PCS (p<0.001) and SWLS (p<0.001) as well as a significant increase in PCS and SWLS (p<0.001).

5.     SWLS continued to increase from post-treatment to 3-mo follow-up (p=0.006) but PCS did not (p=0.062).

6.     No significant improvements in PSEQ from baseline to post-treatment (p=0.631) but significant improvements were observed from post-treatment to 3-mo follow-up (p=0.018).

Burns et al. 2013




Population: Mean age=48 yr; Gender: males=11, females=6; Level of injury: tetraplegia=8, paraplegia=9, Severity of injury: complete=3, incomplete=14; Duration of pain>6 mo; Type of pain=neuropathic and musculoskeletal.

Treatment: SCI Individuals with chronic pain were provided group based interdisciplinary pain management which included Cognitive behavioural therapy (CBT) self-management, and exercise biweekly for 10 weeks.

Outcome Measures: Multidimensional Pain Inventory (MPI)

1.     No significant improvement in pain severity subscale of MPI was seen post intervention or at 12 months.

2.     Significant improvement in life interference and life control subscales was seen (p<0.01) up to the 12 month follow up.


Two studies examined the effect of internet delivered CBT on pain intensity post SCI (Burke et al. 2019; Dear et al. 2018). Burke et al. (2019) found significant improvement compared to control. In a pre-post trial, Dear et al. (2018) found improvement in pain intensity post intervention. Four studies examined the effectiveness of interdisciplinary pain management on chronic pain post SCI. Perry et al. (2010) placed SCI individuals with chronic pain into a multidisciplinary cognitive behavioural pain management program, involving pharmacological and CBT treatment, or in a usual care control group. This was the only study to find significant improvement in both the MPI and SF-12 MCS scores in the treatment group compared to the control group post treatment. A trend towards improved pain intensity and HADS score was also seen in the treatment group post treatment; however, scores returned to pre-treatment scores by nine month follow-up. Norrbrink et al. (2006), Burns et al. (2013), and Heutink et al. (2012) found no improvement in pain intensity among individuals receiving treatment. However, both studies found significant improvement in related psychosocial factors post treatments. Norrbrink et al. (2006) found significant improvement in anxiety, depression and sleep interference post treatment. Burns et al. (2013) found change in life interference and locus of control. Significant improvement in anxiety and participation in activities was seen in Heutink et al. (2012) among individuals that received CBT.


There is level 1b evidence (from one randomized controlled trial: Heutink et al. 2012) that cognitive-behavioural therapy improves pain intensity post-SCI in the short-term.

There is level 1b evidence (Burke et al. 2019) that internet delivered CBT may improve pain intensity compared to control.

There is level 2 evidence (from one prospective controlled trial: Perry et al. 2010) that a cognitive behavioural pain management program with pharmacological treatment may improve secondary outcomes among SCI individuals with chronic pain post SCI.

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