Trauma-focused psychological therapies for chronic pain in trauma-exposed adults: a systematic review and meta-analysis

Background

Chronic pain frequently co-occurs with psychological trauma and is associated with dysregulation of stress-response systems, including the hypothalamic–pituitary–adrenal axis, alterations in affect regulation and changes in central pain processing. These alterations may reflect persistent changes in neurobiological stress systems and brain networks involved in threat detection and emotional regulation. These mechanisms may contribute to central sensitisation [1] and maladaptive predictive processing, reinforcing persistent pain perception and functional impairment. Conventional treatments often show limited effectiveness in trauma-exposed individuals, suggesting shared vulnerability and mutual maintenance processes between pain and trauma-related symptoms [2]. This overlap may contribute to symptom persistence, increased disability and poorer treatment response. However, the effectiveness of trauma-focused psychological therapies for pain outcomes remains insufficiently characterised.

Aims

To evaluate the effectiveness of trauma-focused psychological therapies in reducing pain intensity in adults with chronic pain and psychological trauma, and to examine their effects on trauma-related symptoms, anxiety, depression and functional outcomes.

Methods

A systematic review and meta-analysis of randomised controlled trials was conducted. PubMed, Embase and Cochrane CENTRAL were searched from inception. Eligible studies included adults (≥18 years) with chronic pain (≥3 months) and documented psychological trauma receiving trauma-focused psychological therapies compared with control conditions. The primary outcome was pain intensity; secondary outcomes included trauma-related symptoms, anxiety, depression and functional outcomes. Random-effects meta-analyses were performed using standardised mean differences with 95% confidence intervals. Statistical heterogeneity was assessed using the I² statistic, and sensitivity and subgroup analyses were conducted where appropriate. To our knowledge, this is the first meta-analysis specifically focusing on trauma-focused psychological therapies in chronic pain populations with documented trauma exposure.

Results

Eight randomised controlled trials (N = 615) met inclusion criteria. Trauma-focused psychological therapies were associated with a statistically significant reduction in pain intensity at post-treatment (standardised mean difference = −0.71, 95% confidence interval −1.36 to −0.05), indicating a moderate effect size. A smaller but statistically significant effect was observed at six-month follow-up (standardised mean difference = −0.32, 95% confidence interval −0.55 to −0.09), although data were limited. Significant improvements were also found in trauma-related symptoms (standardised mean difference = −0.54, 95% confidence interval −0.91 to −0.17). Reductions in anxiety, depressive symptoms and functional outcomes were also reported, with variability in effect sizes. Heterogeneity ranged from low to substantial across outcomes.

Conclusions

Trauma-focused psychological therapies are associated with improvements in pain intensity and trauma-related symptoms in adults with chronic pain and psychological trauma, with additional benefits in emotional and functional domains. These findings support models in which targeting trauma-related processes may modulate stress-system dysregulation, reduce central sensitisation and update maladaptive predictive models of pain. These effects may reflect improvements in affect regulation, threat processing, cognitive-emotional integration and behavioural flexibility. However, the current evidence base is limited by heterogeneity and the small number of trials, particularly regarding long-term outcomes. Further high-quality randomised studies with extended follow-up and mechanistically informed designs are required.

References

1. Woolf, C.J., 2011. Central sensitization: Implications for the diagnosis and treatment of pain. Pain 152 (3 Suppl), S2–S15.
2. Asmundson, G.J.G., Coons, M.J., Taylor, S., Katz, J., 2002. PTSD and the experience of pain: Research and clinical implications of shared vulnerability and mutual maintenance models. Can. J. Psychiatry 47 (10), 930–937.