Is cognitive behaviour therapy for chronic fatigue syndrome also effective for pain symptoms?
Introduction
Chronic fatigue syndrome (CFS) is characterised by severe fatigue lasting longer than 6 months and leading to functional impairment. CFS is neither the result of an organic disease or ongoing exertion nor alleviated by rest. According to the Centre for Disease Control (CDC) definition of CFS, the patient should have four out of eight additional symptom criteria (Fukuda et al., 1994). Four of these are pain symptoms, i.e. muscle pain, multi-joint pain, headaches and a sore throat. The other four are post-exertional malaise, unrefreshing sleep, concentration and/or memory impairments and sensitive lymph nodes. The frequency of pain symptoms in CFS differs between studies (King & Jason, 2005; Meeus, Nijs, & De Meirleir, 2007; Vercoulen et al., 1994) but is usually high. In the study of Vercoulen et al. (1994), the frequency of spontaneously reported pain symptoms ranged from 13% (sore throat) to 71% (muscle pain). King and Jason (2005) systematically assessed complaints and found much higher frequencies ranging from 60% for a sore throat to 93% for headaches and muscle pain. The chronic pain symptoms in CFS are disabling and compromise physical and social functioning (Meeus et al., 2007).
The aetiology of CFS is unknown, but cognitions and behaviour can perpetuate CFS (Prins, van der Meer, & Bleijenberg, 2006; Suraway, Hackmann, Hawton, & Sharpe, 1995). A statistically tested model of perpetuating factors in CFS showed that a low sense of control of symptoms and a focus on bodily symptoms had a direct causal effect on fatigue (Vercoulen et al., 1998). Furthermore, attributing the symptoms of CFS to a somatic cause produced low levels of physical activity which in turn had a negative causal effect on fatigue. More recently, it was found that a perceived lack of social support can also perpetuate the fatigue (Prins et al., 2004).
Several controlled trials have found that cognitive behaviour therapy (CBT) aimed at the perpetuating factors of CFS leads to a reduction of fatigue and disabilities (Whiting et al., 2001). A recent systematic review showed that of the eight CBT trials for CFS that have been performed, six reported a positive outcome (Chambers, Bagnall, Hempel, & Forbes, 2006). Most studies used fatigue as an outcome measure.
There are no interventions in the different treatment protocols for CFS that focus on pain symptoms, but it is implicitly assumed that an effective treatment of fatigue will also lead to a reduction of pain. Recently, it was shown that adolescents indeed report a decrease of muscle pain and headache following CBT for CFS (Stulemeijer, de Jong, Fiselier, Hoogveld, & Bleijenberg, 2005). However, the measure used was a four-point Likert scale in which the prevalence of pain had to be evaluated retrospectively over a period of 6 months. This type of pain assessment is easily influenced by situational circumstances and memory biases which can be prevented with the use of a pain diary (Smith & Safer, 1993). To our knowledge, there are no published data pertaining to the effect of CBT for CFS on pain in adult patients.
The first objective of this study was to determine whether an effective treatment of CFS with CBT also leads to a significant reduction of pain symptoms when these symptoms are evaluated with an appropriate assessment method. CBT is considered effective if a patient is recovered, that is reporting a level of fatigue within the range of healthy individuals (Prins, Bleijenberg, & van der Meer, 2002). In assessing pain symptoms we looked at pain severity and the location of the pain symptoms.
The second objective was to investigate the mechanisms of possible changes in pain severity following CBT. A central feature of CBT for CFS is the gradual increase of physical activity. It is possible that the increased activity levels also lead to a decrease of pain. CBT for CFS also aims to modify those cognitions and cognitive processes that perpetuate fatigue. The persistent focus on bodily symptoms or body consciousness is one of these cognitive processes (Vercoulen et al., 1998). If this focus is lessened as a consequence of therapy, it is likely that this generalises to other symptoms than fatigue, e.g. pain. Finally, CBT for CFS leads to a reduced negative affectivity, which could lead to a diminished report of physical symptoms (i.e. pain).
The third objective was to assess the predictive value of pain severity at baseline on the outcome of the treatment. Although physical activity has a positive effect on chronic pain in the long term (Busch, Schachter, Peloso, & Bombardier, 2002), increase in activity can have a negative influence on pain symptoms in the short term. Whiteside, Hansen, and Chauduri (2005) found that CFS patients reported a lower pain threshold following physical activity. In their study, the pain threshold of patients was repeatedly determined after graded exercise. Since graded activity is an important feature of CBT, this could mean that CBT leads to a lower pain threshold. This lower pain threshold might hamper the increase in activity level during therapy and could lead to a less favourable outcome of CBT. We suspected that this was especially true for those patients who already had a high pain severity at the start of the therapy. In determining the predictive value of pain for treatment outcome, we controlled for the relationship between pain and physical activity.
Section snippets
Subjects
To answer our research questions, data from two previous CBT studies with patients with CFS were used. In the first study, the outcome of CBT for CFS in adults was evaluated (Knoop, Bleijenberg, Gielissen, van der Meer, & White, 2007). The effect of CBT on pain symptoms was not determined in this study. Ninety-six adult patients who met the CDC criteria for CFS participated in the study. They were severely fatigued and functionally impaired. Severe fatigue was defined by a cut-off score of 35
Pain symptoms at baseline
All but one of the adult patients had one or more of the four CDC pain symptoms. All adolescent patients had one or more CDC pain symptoms. Table 1 shows the percentage of patients who reported at baseline that daily or several times a week they experienced muscle pain, headache, multi-joint pain or a sore throat.
The percentage of adult patients with pain at a location identified with the bodily outline of the MPQ is shown in Table 2. Seventy-three patients (78%) reported pain in two or more
Discussion
The first objective of this study was to determine if an effective treatment of CFS with CBT leads to a reduction of pain symptoms. It was remarkable to find that a treatment aimed at reducing fatigue also had an effect on pain. Patients who recovered following CBT for CFS reported a reduction of pain severity. Furthermore, more recovered than non-recovered adults had a level of pain following treatment that is comparable to healthy controls. The results also showed that most adults report
Acknowledgements
The authors thank Theo Fiselier for his contribution in the selection of adolescent CFS patients, Lammy Elving for her contribution in the selection of adult patients, and Ria te Winkel for assisting in data collection. Funding for the study of adolescent CFS patients was provided by the Children's Welfare Stamps Netherlands (Stichting Kinderpostzegels Nederland) and the ME Foundation (ME Stichting).
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