The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described in terms of such damage” (IASP, 1994). Pain is a subjective
experience dependent on the self-report of the individual. For this reason, another popular definition of pain is that it is “whatever
the experiencing person says it is, existing whenever he (or she) says it does” (McCaffrey& Pasero, 1999).
One of the most important distinctions in understanding and treating pain is between acute and chronic pain. Some of the
most important differences are highlighted below:
Less than 3 months More than 3 months
Is a symptom Is a condition
Identified cause; body’s response to injury
May develop after incident;
may have known or unknown cause
Diminishes with healing and responds
Persists beyond expected healing time
to treatment and/or despite treatment
Acute pain typically occurs following an identifiable incident where an injury is sustained, such as a broken arm or sprained
ankle. It is adaptive because it results in focused attention on a situation that is threatening. Acute pain is time-limited, diminishes
with healing, and the cause usually is known. Chronic pain, on the other hand, persists beyond the expected time and indicated
point of healing, and is typically defined as longer than 3 months duration. It may be present in multiple contexts and have an
unknown or known cause (e.g., identified injury, osteoarthritis). While pain is present and may feel identical to acute pain, the
experience does not have the same meaning. More recent understandings of chronic pain suggest that when pain continues in the
absence of ongoing tissue damage, the nervous system itself is misfiring pain signals. Chronic pain, therefore, is best understo
12 Cognitive Behavioral Therapy for Chronic Pain Among Veterans
Types and Locations of Pain
Chronic pain can affect any part of the body. Because of the complexity of chronic pain, it is often difficult to categorize
conditions into clear and simplistic categories. It is useful, however, to be familiar with the most commonly used classifications,
nociceptive and neuropathic pain:
• Pain that is caused by damage to body tissue and is based on input by specialized nerves called nociceptors
• Nociceptors sense danger to soft tissues such as muscles, bones, ligaments, and tendons
• Most nociceptive pain is musculoskeletal, and is often described as aching or deep
• Pain that occurs when there is nerve damage that typically involves either the peripheral or central nerves
• It is often described as burning, shooting, tingling, or electric
Headache pain does not fall into either of the above classes but is another large category of painful conditions:
• Pain that involves disturbance of sensitive structures around the brain
• Sensation is usually in the forehead, eyes, or upper back/neck areas
• Pain is often described as a tight band, pounding, throbbing, or dull
The evaluation of a patient who has chronic pain can be a complex process and various factors must be considered. First,
many Veterans have more than one type and location of pain. It is not uncommon for someone to have low back pain related to
degenerative disc disease (nociceptive) as well as diabetic neuropathy creating foot pain and numbness (neuropathic). This same
person may also have tension-type headaches several times per week. In addition, many individuals treated in the VA system have
numerous medical and psychiatric comorbidities that can create a multifaceted pain presentation. Furthermore, the etiology of a
specific pain complaint may be unknown; while some Veterans have an identified precipitating event or trauma demarcating the
onset of their pain issues, others do not. There may also be a lack of clarity regarding a specific diagnosis, something that can be
frustrating for the Veteran. While cases may be challenging for these reasons, many chronic pain patients are appropriate for
CBT-CP and can benefit from the intervention.
Therapist Manual 13
A comprehensive review of all pain locations and diagnoses is beyond the scope of this manual. Because of the previously
mentioned difficulties encountered in straightforward classification, the list below provides basic information on many conditions
encountered in VHA.
Low Back Pain. Low back pain (LBP or lumbago) is the most common form of pain and the most fiscally costly worldwide
in terms of medical visits and loss of work productivity (Deyo & Weinstein, 2001). Most people with acute LBP recover in a
matter of weeks but for about 10% the pain will become chronic (Costa et al., 2012). Many individuals who experience chronic
LBP report high levels of fear of movement and consequently are prone to deconditioning of the muscles leading to greater
disability. LBP may be due to factors such as herniated discs, degenerative disc disease, spinal stenosis, or arthritis, but the vast
majority of back pain is due to muscle strain (Deyo & Weinstein, 2001).
Middle and Upper Back Pain. Middle and upper back pain is less common than LBP because the bones in these areas do
not move as often. As in the lower area of the back, pain is most often related to muscle sprain or overuse, herniated discs, or
Neck Pain. Neck pain (i.e., cervicalgia) is a common issue with about 65% of the population experiencing it at some point in
their lives. It is generally caused by activities that strain the neck such as poor posture or sleeping, muscle tightness, or whiplash
from a motor vehicle accident. Neck pain may also be associated with headache pain.
Osteoarthritis. Osteoarthritis (OA) is the most common form of arthritis (Prieto-Alhambra & Judge, 2013) and occurs when
cartilage that cushions the ends of bones and joints deteriorates. Because of this, OA is often referred to as the “wear and tear”
disease and is common among Veterans given engagement in military and non-military occupations that often involve physical
labor (Morgenroth, Gellhorn, & Suri, 2012). The most common areas of the body affected include hands, feet, neck, low back,
knees, and hips.
Rheumatoid Arthritis. Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that primarily affects the
joints. White blood cells accumulate in the joints causing swelling and pain. Progression of the disease can lead to destruction of
cartilage, ligaments, and tendons. RA typically impacts functional status to a greater degree than OA and is twice as prevalent in
women than men.
Tendonitis/Bursitis. Tendonitis and bursitis involve inflammation of one of the tendons and bursae, respectively. Tendons
are thick cords that join muscles to bones and inflammation causes pain and tenderness in the joints. Tendonitis is commonly
associated with sports involving repetitive motion such as swimming or throwing a ball but can result from any repetitive
movement involving the joints. Bursae are fluid-filled sacs found in joints that surround areas where tendons, skin, and muscle
tissues meet. Bursae provide essential lubrication to the hips, knees, elbows, and heels. Damage can cause pain, swelling,
Pelvic Floor Disorders. Pelvic floor disorders occur when the area that supports the pelvic organs becomes weak or
damaged. These may result in urinary or fecal incontinence, as well as persistent pain in the pelvic walls. Some of the
common causes are endometriosis, pelvic floor tension myalgia, pelvic inflammatory disease, fibroids, surgeries, and irritab
14 Cognitive Behavioral Therapy for Chronic Pain Among Veterans
Peripheral Neuropathic Pain. Peripheral neuropathy typically affects the hands and feet. It involves microvascular lesions
in small blood vessels and its development is often associated with high blood sugar secondary to diabetes. Pain is commonly,
but not universally, associated with peripheral neuropathy. Pain quality is often described as numb and tingling, pins and needles,
electric, or burning, as opposed to being characterized as “pain.”
Radicular Pain. Radicular pain is most commonly associated with LBP or neck pain, referred to as lumbar radiculopathy
and cervical radiculopathy, respectively. It radiates along a nerve due to inflammation or irritation of the nerve root and extends
from the spinal cord to areas such as the buttocks and down the legs in the case of back pain, or down the arms in the case of neck
pain. The sudden appearance of radicular pain, new muscular weakness, or the identification of radicular pain that is not noted by
medical providers is cause for immediate medical evaluation (Gilron, Watson, Cahill, & Moulin, 2006). Radicular pain is typically
described as burning, shooting, or shock-like (Atlas et al., 1996).
Phantom Limb Pain. A phantom limb is the sensation that an amputated or missing limb is still attached to the body.
Between 60 and 80% of individuals with an amputation experience phantom limb sensations and the majority of these sensations
are painful (Sherman, Sherman, & Parker, 1984). In addition, pain at the site of the amputation, or stump, caused by nerve damage
in the stump region is also common. Pain is variable from a dull ache to shooting and severe.
Fibromyalgia. Fibromyalgia (FM) is a disorder of unknown etiology associated with widespread pain, sleep disturbance,
fatigue, and psychological distress among other symptoms. FM pain typically includes tender “trigger” points found in soft tissue
of the back of the neck, shoulders, low back, hips, shins, and knees, and the pain is often described as a deep aching or burning.
FM is about 7 times more common in women than men (Haviland, Banta, & Prezekop, 2011) and individuals with FM are 3 times
more likely to have a comorbid diagnosis of major depression than individuals without FM.
Complex Regional Pain Syndrome. Complex regional pain syndrome (CRPS), previously known as reflex sympathetic
dystrophy syndrome or RSD, is a poorly understood pain condition that often starts after a minor injury or complication, usually
to a hand, arm, foot, or leg, and often spreads. Type 1, the form most commonly seen, has no demonstrable nerve lesions
while there is nerve damage in Type 2. Pain is described as severe and changes in the appearance and texture of the skin are
Types of Headaches
The most common types of headaches are listed below. It is important to remember, however, that patients may have more
than one kind of headache (e.g., tension-type headaches a few times per week and migraines a few times per month). In addition,
in the same way that other pain locations may be difficult to classify, Veterans may present with mixed symptoms that do not fall
neatly into one category.
Tension-type. Tension-type headaches (TTH) are by far the most common type, accounting for over half of all headaches
(ICHD, 2nd edition, 2004). The primary sensation associated with TTH is the feeling of a tight-band wrapped around one’s head.
These range in intensity from mild to moderate and also range in frequency from episodic to chronic. Criterion for chronic TTH is
met when an individual experiences headaches for 15 days a month for at least 6 months (ICHD, 2nd edition, 2004).
Migraine. Migraine headaches occur in about 10% of the population at some point in their lifetime (Rasmussen, Jensen,
Schroll, & Olesen, 1991). They are classified as either with or without aura, defined by symptoms such as sensory or motor
disturbance that precede or accompany the headache. Migraine headaches tend to be recurrent and are associated with a number
of autonomic nervous system symptoms. The typical migraine headache is unilateral and pulsing in nature, lasts from 2 to 72
hours and may be associated with nausea, vomiting, sensitivity to light and sound, and aggravated by physical activity. Migraines
are 2 to 3 times more common in women than men (ICHD, 2nd edition, 2004).
Cluster. Cluster headaches involve severe unilateral pain that is orbital, supraorbital, or temporal, lasting 15 to 180 minutes,
and occurring in frequency from every other day to up to 8 times per day (ICHD, 2nd edition, 2004). Painful episodes may be
accompanied by tearing, nasal congestion, sweating, a drooping eyelid, or a contracted pupil. These all occur on the affected side
of the face. The intense pain of cluster headaches is due to dilation of blood vessels creating pressure on the trigeminal nerve.
However, the underlying cause of the dilation is not understood. This type of headache is much less common, affecting .1% of the
population, and is 3 to 4 times more common in men than women (ICHD, 2nd edition, 2004).
Therapist Manual 15
Post-traumatic. Headaches associated with head trauma (e.g. mild to severe traumatic brain injury) is common immediately
following an injury, with a prevalence up to 90%. Up to 44% of patients report continued headaches 6 months following an injury
(Nicholson & Martelli, 2004). The three most common presentation patterns are tension-type, migraine type, or cervicogenic
(Gironda et al., 2009). Exposure to blasts and concussions while deployed make this type of headache more common among
Veterans and military Servicemembers.
Medication Overuse. Medication overuse headaches, previously known as rebound headaches, are a secondary cause of
chronic daily headaches due to the overuse of acute headache analgesics. Overuse is defined by treatment days per month and
depends on the drug. Overuse is often motivated by the desire to treat headaches or a fear of future headaches, but regardless can
make headaches refractory to preventative medications (Silberstein, Lipton, & Saper, 2007).
Treatment Options for Chronic Pain
The following section provides an introduction to interventions for pain management that Veterans may receive. The intent of
this section is to familiarize non-medical providers with common treatment modalities by providing basic information that does
not include data on efficacy.
The following section is an introduction to analgesic, or pain relieving, medications. It is not meant to guide prescription of
medications but instead to help providers understand the likely uses of medications taken by Veterans with chronic pain. A table
of medications including both generic and brand names is also included (Figure 1).
Non-Opioid Analgesics. Aspirin and other related compounds constitute a class of drugs known as nonsteroidal antiinflammatory
drugs (NSAIDS). This class of medication produces three desirable effects including anti-inflammatory, analgesic,
and antipyretic (fever reducing). Commonly used medications in this category include aspirin, ibuprofren, naproxen, etolodac,
meloxicam, and piroxicam. The most common adverse effects of NSAIDs are gastrointestinal and renal (kidney). Acetaminophen
is also a non-opioid analgesic but is not an NSAID because, though possessing pain relieving and antipyretic properties, it lacks
an anti-inflammatory effect.
Opioid Analgesics. Opioid analgesics (or narcotics) refer to compounds that act by binding to opioid receptors in the
brain. Though often used interchangeably, the term opiate refers only to the naturally occurring resin found in opium poppy
while opioids also include synthetically produced substances and thus is the preferred general term. This class of medications
can either be short- or long-acting. Commonly used opioids include morphine, hydrocodone, oxycodone, codeine, methadone,
and hydromorphone. The analgesic effects of opioids are due to decreased perception of pain, decreased reaction to pain, and
increased pain tolerance. The most commonly cited side effects of opioids (in order of frequency reported) include nausea,
constipation, drowsiness, dizziness, and vomiting (Eisenberg, McNicol, & Carr 2006). Opioids may be associated with risk of
misuse (Comptom & Volkow, 2006) and physiological dependence. Measuring the risk to benefit ratio of opioid therapy for
patients with chronic pain is complicated and prescribing providers are encouraged to follow the 2010 VA/Department of Defense
(DoD) Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. (see http://www.healthquality.va.gov/
16 Cognitive Behavioral Therapy for Chronic Pain Among Veterans
Muscle Relaxants. Muscle relaxants (or spasmolytics, antispasmodic) are most commonly prescribed for LBP, neck pain,
fibromyalgia, and tension headaches in situations where muscular contractions appear to be a prominent component of pain.
Muscle relaxants used most commonly in VA include cyclobenzaprine, tizanidine, baclofen, and methocarbamol. Muscle relaxants
work by inhibiting the central nervous system, which contributes to the commonly reported side effect of sedation and the
recommendation against driving or operating heavy machinery. Other common side effects include dizziness, headache, nausea,
irritability, and nervousness. Muscle relaxants also pose a risk of physiological dependence.
Adjuvant Analgesics. Adjuvant analgesics, or co-analgesics, are medications that were originally developed and marketed
for uses other than analgesia and are also used in pain management. The two most common classes of medications that fall
into this category are certain types of antidepressants and anticonvulsants. Antidepressants commonly used for analgesic
purposes include duloxetine, venlafaxine, and nortriptyline. Anticonvulsants, primarily used to relieve neuropathic pain, include
gabapentin, pregablin, topiramate, and lamotrigine. Common side effects of antidepressants include nausea, vomiting, insomnia,
decreased sex drive, and constipation. Common side effects of anticonvulsant medications include dizziness, fatigue, weight gain,
Headache Analgesics. Analgesics used to treat headaches vary widely and do not fall into a neat class. Migraine medications
are generally categorized by nature of their action into those that are preventative (e.g., propranolol, topiramate or Topamax),
abortive (e.g., sumatriptan or Maxalt), and rescue (butalbital/acetaminophen/caffeine or Fioricet). Of note, medication overuse
headaches, or rebound headaches, may occur when excessive analgesics are taken for headache relief, leading to chronic daily
headaches of a different type.
Figure 1. Medications for Pain
Category Generic Name(s)
aspirin, acetylsalicylic acid (i.e., ASA) Bayer Aspirin
ibuprofen Advil Motrin
naproxen Aleve Naprosyn
Analgesic and Antipyretic acetaminophen (i.e., APAP) Tylenol
Opioid Analgesics codeine
codeine + acetaminophen Tylenol #3
duragesic Fentanyl patch
hydrocodone + acetaminophen Vicodin
morphine MS Contin
Therapist Manual 17
Figure 1. Medications for Pain (continued)
Opioid Analgesics (continued) oxycodone Oxycontin
oxycodone + acetaminophen Percocet
Opioid and Antidepressant tramadol Ultram
Muscle Relaxants baclofen
Topical Analgesics capsaicin cream/patch
diclofenac gel Voltaren
gel/cream/ointment/ patch Lidoderm
Adjuvant Analgesics: Anticonvulsants carbamazepine Tegretol
Adjuvant Analgesics: Antidepressants amitriptyline Elavil
Headache Analgesics butalbital + acetaminophen + caffeine Fioricet
Invasive Medical Treatment Options for Chronic Pain
Epidural Steroid Injections. Epidural Steroid Injections (ESIs) are used for back pain complaints associated with conditions
such as spinal stenosis or spinal disc herniation. ESIs include a combination of corticosteroids and local anesthesia that is injected
into the epidural space around the spinal cord and nerves. The injection may be guided by fluoroscopy or x-ray. The effects of the
injection last from one week to six months.
Nerve Blocks. Nerve blocks (aka, regional nerve blockade) are used for pain in the neck, back, feet or even the head. Nerve
blocks may include local anesthetic and epinephrine, with corticosteroids, and/or opioids that are injected directly into the nerve
group associated with reported pain. Nerve blocks can be used to treat painful conditions, to determine sources of pain, or to judge
the benefits of more permanent treatments such as surgery.
18 Cognitive Behavioral Therapy for Chronic Pain Among Veterans
Trigger Point Injections. Trigger point injections (TPI) are used to relieve muscles where knots form when muscles do not
relax. TPI is used in many muscle groups ranging from arms, legs, low back, and neck and is most associated with treatment of
fibromyalgia and tension headache. The injection contains a local anesthetic that may include a corticosteroid.
Facet Injections. Facet injections are used for those with chronic neck or back pain caused by inflamed facet joints,
which are located between each set of vertebrae in the spine from the neck to the tailbone. A mixture of local anesthetic and
corticosteroid medication is injected into the facet joint to reduce swelling and inflammation around the facet joint space.
Radiofrequency Ablation. Radiofrequency ablation (RFA) is used to treat severe chronic low back pain. Radiofrequency
waves produce high heat on specifically identified nerves surrounding the facet joints in the lumbar spine, ablating the nerves and
destroying their ability to transmit pain signals. RFA is an outpatient procedure using local anesthesia. While the procedure may
provide pain relief, in most patients the nerves regenerate.
OnabotulinnumtoxinA (Brand name: Botox). Botox injections are typically used for relief of frequent migraine headaches.
Botox received approval from the FDA as a treatment for chronic migraines in 2010.
Spinal Cord Stimulator. The most common use of spinal cord stimulators (SCS) is with patients diagnosed with failed back
syndrome (see definition under Surgery below). A SCS includes electrodes implanted in the epidural space, an electrical
pulse generator implanted in the lower abdominal area of gluteal region, connecting wires to the generator, and a generator
Intrathecal Pump. An intrathecal pump is an implantable device that delivers pain medication directly to the spinal fluid.
Common medications used in pumps include baclofen or morphine. The pumps deliver medications at higher dosages than
possible with oral medications.
Surgery. Surgery may be offered for various pain locations such as back, neck, knee, shoulder, or ankle. Surgery for chronic
pain is usually considered only after conservative treatments have failed or if seen as medically necessary.
Individuals who have undergone one or more unsuccessful back surgeries may receive the diagnosis or label of “failed back
syndrome” or “failed back surgery syndrome.” Causes for failure of surgery vary but the results can lead to frustration and distrust
of medical providers, increased depression, and increased perceptions of disability (Onesti, 2004).
Non-Invasive Treatment Options for Chronic Pain
Physical Therapy. Reduction in bodily movement that can be related to fear of pain or re-injury is common in chronic pain
and often leads to physical deconditioning and, subsequently, increased pain. Physical therapy is an integral part of chronic pain
interventions as it helps restore physical functioning and reengagement in rewarding life activities. Physical therapy involves
a range of activities including stretching exercises, strengthening exercises, and use of graded exercise techniques such as
therapeutic pools or stationary bikes, in addition to a range of palliative therapies such as spinal manipulation and ultrasound,
Cold/Heat. Application of cold and heat are often used for the management of chronic pain. Cold and heat may decrease
sensitivity to pain and provide competing sensory central nervous system input that can reduce pain sensations.
Transcutaneous Electrical Nerve Stimulation (TENS). TENS units stimulate nerves by introducing a mild electrical
current. The electric current is not strong enough to cause muscle contraction but, instead, is thought to interfere with the
transmission of pain signals to the brain. Electrodes are placed on the skin and a battery-powered unit is carried or worn on the
person. No surgical procedures are involved in the use of a TENS unit.
Complementary and Alternative Therapies (CAM)
Chiropractics. These interventions primarily focus on spinal adjustment or adjustment to other joint areas. Spinal or other
joint manipulations involve a dynamic thrust that causes an audible release and attempts to increase range of motion.
Therapist Manual 19
Chiropractic care may also involve soft tissue therapy, strength training, dry needling, functional electrical stimulation, traction,
or nutritional recommendations.
Acupuncture. Acupuncture involves the insertion of needles into acupuncture points in the skin in an effort to relieve pain.
Acupuncture produces physiologic effects that are relevant to analgesia; however, the mechanism for how acupuncture affects
chronic pain remains unclear (Vickers, Cronin, et al., 2012).
Yoga/Tai Chi. Yoga and Tai Chi may provide a source of graded physical exercise combined with relaxation to improve
Biofeedback. Biofeedback involves gaining greater awareness of physiological functions or processes such as muscle tone,
skin conduction, heart rate, or brainwaves. Awareness of different physiological processes is gained through use of a variety of
types of monitoring devices specific to the process being monitored, such as an electromyography (EMG) to measure muscle
activity or electrodermograph to register skin conductance or resistance. Information on a specific process is gathered, amplified,
and displayed (fed back) to the patient who then uses the visual or auditory feedback to gain control over the targeted behavior.
Biofeedback has been used to treat a variety of chronic pain disorders but is most often used in the management of headaches.
Relaxation Training. Relaxation training, which may be done in the context of biofeedback, focuses on identifying tension
within the body and applying systematic techniques for decreasing that tension. The most common techniques, which
will be described in detail later in this manual, include diaphragmatic (or deep) breathing, progressive muscle relaxation,
Selected Psychological Approaches
Operant Behavioral Therapy. The operant-behavioral formulation of chronic pain by Fordyce (1976) marked a significant
development in the understanding and treatment of chronic pain by introducing the concept of pain behaviors. These refer to
forms of communication that are observable expressions of pain and suffering such as moaning, clenching, grimacing, sighing,
or limping. The model suggests that reinforcement of such behaviors, often by those in one’s social environment, could lead to
maintenance of subjective reports of pain and increased self-perceptions of disability.
Cognitive Behavioral Therapy (CBT). CBT helps individuals resolve their problems concerning maladaptive emotions,
behaviors, and cognitions through a goal-oriented, systematic process. While it was originally used for treatment of those with
depression and anxiety disorders, it has been used with a variety of other conditions from insomnia to substance abuse. Since
this manual is focused on CBT-CP, a more in depth review of its application to chronic pain follows in the next section (History,
Components, and Support).
Acceptance and Commitment Therapy (ACT). Acceptance and Commitment Therapy, (ACT: Hayes et al., 1999) is
an acceptance- and mindfulness-based intervention that teaches patients to observe and accept thoughts and feelings without
judgment and without trying to change them. It focuses on identifying core values and behaving in accordance with those values.
As applied to chronic pain, ACT emphasizes that while the physical sensation may be painful, the patient’s struggle with pain
is what causes suffering and emotional distress (Dahl & Lundgren, 2006). The aim of therapy, therefore, is to develop greater
psychological flexibility in the presence of thoughts, feelings, and behaviors associated with pain.
Hypnotherapy. Hypnotherapy utilizes suggestive statements made by a therapist to alter the patient’s attention and focus
away from pain. Deep breathing is often used as a behavioral cue in the effort to alter the subjective experience of pain, however
there is significant variation in specific techniques.
Mindfulness. Mindfulness meditation is another approach combining elements of relaxation and hypnotherapy, which
seeks to increase focused attention and facilitate relaxation. Based in Theravada Buddhism, it seeks to increase intentional selfregulation
to what is occurring in the present without attaching negative associations. As applied to pain management, a primary
goal is to separate the pain sensation from unhelpful thoughts.