Clinical Psychology Studies

Clinical Psychology Studies

Comparison of the Effectiveness of Cognitive Behavioral Therapy with and without Transcranial Direct Current Stimulation on Pain-Related Disability in Patients with Musculoskeletal Pain

Document Type : Research Paper

Authors
Zohreh Mahmoudabadi 1
Sara Saedi 2
Azita Amirfakhraei 1
1 Department of Psychology, Bandar Abbas Branch, Islamic Azad University, Bandar Abbas, Iran.
2 Department of Psychology, Bo.C., Islamic Azad University, Borujerd, Iran.
10.22054/jcps.2026.89805.3307
Abstract
Background and Aim: Musculoskeletal pain is one of the major causes of disability, and comparing the effectiveness of cognitive-behavioral therapy (CBT) with and without Transcranial direct current stimulation may play a crucial role in improving pain-related dysfunction. The present study aimed to compare the effectiveness of CBT, with and without transcranial direct current stimulation, on pain-related disability in patients with musculoskeletal pain.
Research Methodology: This applied quasi-experimental study employed a pretest–posttest design with a follow-up phase and a non-equivalent control group. A total of 45 patients with chronic musculoskeletal pain and a minimum pain duration of three months in the lower back, neck, and shoulder regions, who had referred to specialized orthopedic clinics in Sirjan, were selected by convenience sampling and allocated into three groups of 15 participants each: CBT with tDCS, CBT without tDCS, and control. The experimental groups received 12 sessions of group-based CBT according to McFarlane’s protocol, and the combined group additionally underwent 20 sessions of transcranial direct current stimulation at 2 mA targeting the dorsolateral prefrontal cortex. Pain-related disability was assessed using the Roland–Morris Disability Questionnaire (Roland & Morris, 1981). Data were analyzed using repeated-measures ANCOVA and Bonferroni post-hoc tests in SPSS version 26.
Findings: ANCOVA results indicated a significant effect of group on pain-related disability. Both CBT groups—with and without tDCS—showed significantly greater reductions in disability compared to the control group (F = 66/586). Although the difference between the two experimental groups was not statistically significant (p>0.05), the combined group demonstrated slightly greater improvement..
Conclusion: The findings indicate that CBT is an effective intervention for reducing pain-related disability, and although tDCS appears to enhance these effects, its statistical advantage was not confirmed. Therefore, while CBT remains a robust therapeutic approach, further research is needed to determine the definitive added value of combining it with tDCS.
Keywords
Cognitive-behavioral therapy
Transcranial direct current stimulation
pain-related disability
musculoskeletal pain
Alonzo, A., Brassil, J., Taylor, J. L., Martin, D., & Loo, C. K. (2012). Daily transcranial direct current stimulation (tDCS) leads to greater increases in cortical excitability than second daily transcranial direct current stimulation. Brain Stimulation, 5(3), 208–213. https://doi.org/10.1016/j.brs.2011.04.006
Aust, S., Brakemeier, E. L., Spies, J., Herrera-Melendez, A. L., Kaiser, T., Fallgatter, A., ... & Bajbouj, M. (2022). Efficacy of augmentation of cognitive  behavioral therapy with transcranial direct current stimulation for depression: a randomized clinical trial. JAMA psychiatry, 79(6), 528-537. https://doi.org/10.1001/jamapsychiatry.2022.0696
Bishop, J. H., Shpaner, M., Kubicki, A., Clements, S., Watts, R., & Naylor, M. R. (2018). Structural network differences in chronic musculoskeletal pain: beyond fractional anisotropy. NeuroImage, 182, 441-455. https://doi.org/10.1016/j.neuroimage.2017.12.021
Breggin, P. R., & Stolzer, J. (2020). Psychological helplessness and feeling undeserving of love: Windows into suffering and healing. The Humanistic Psychologist, 48(2), 113–132. https://doi.org/10.1037/hum0000175
Brown, V. M., Zhu, L., Solway, A., Wang, J. M., McCurry, K. L., King-Casas, B., & Chiu, P. H. (2021). Reinforcement Learning Disruptions in Individuals With Depression and Sensitivity to Symptom Change Following Cognitive Behavioral Therapy. JAMA Psychiatry, 78(10), 1113-1122. https://doi.org/10.1001/jamapsychiatry.2021.1844
Chen, S., Cheng, Y., Zhao, W., & Zhang, Y. (2023). Psychological pain in depressive disorder: A concept analysis. Journal of clinical nursing, 32(13-14), 4128-4143. https://doi.org/10.1111/jocn.16543.
Ehsani, F., Hafez Yousefi, M. S., Jafarzadeh, A., Zoghi, M., & Jaberzadeh, S. (2023). Does Multisession Cathodal Transcranial Direct Current Stimulation of the Left Dorsolateral Prefrontal Cortex Prime the Effects of Cognitive Behavioral Therapy on Fear of Pain, Fear of Movement, and Disability in Patients with Nonspecific Low Back Pain? A Randomized Clinical Trial Study. Brain Sci, 13(10). https://doi.org/10.3390/brainsci13101381
Ghadiri Niari, M., & Moshkbid Haghighi, M. (2023). The Effectiveness of Life Skills Training on Psychological Helplessness and Improving the Psychological Capital of Patients with Diabetes in Gilan Province [Research]. journal of Psychology new Ideas, 15(19), 1-17. http://jnip.ir/article-1-850-en.html
Hale, L., Perry, M., Gray, A. R., Leung, W., Dean, S. G., Hempel, D., Davies, C., Dowell, A., Grainger, R., Ingham, T., Jones, B., Saipe, B., Dassanayake, S., & Devan, H. (2025). A group-based, online-delivered pain management programme (iSelf-help) is not inferior to a group-based, in-person programme in reducing pain-related disability for people with persistent pain: A non-inferiority randomised, two-arm, parallel, open-label trial. J Pain, 32, 105447. https://doi.org/10.1016/j.jpain.2025.105447
Jacobson, L., Koslowsky, M., & Lavidor, M. (2012). tDCS polarity effects in motor and cognitive domains: a meta-analytical review. Exp Brain Res, 216(1), 1-10. https://doi.org/10.1007/s00221-011-2891-9
Karyotaki, E., Efthimiou, O., Miguel, C., Bermpohl, F. M. G., Furukawa, T. A., Cuijpers, P., Riper, H., Patel, V., Mira, A., Gemmil, A. W., Yeung, A. S., Lange, A., Williams, A. D., Mackinnon, A., Geraedts, A., van Straten, A., Meyer, B., Björkelund, C., Knaevelsrud, C., . . . Forsell, Y. (2021). Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry, 78(4), 361-371. https://doi.org/10.1001/jamapsychiatry.2020.4364
Knotkova, H., Hamani, C., Sivanesan, E., Le Beuffe, M. F. E., Moon, J. Y., Cohen, S. P., & Huntoon, M. A. (2021). Neuromodulation for chronic pain. Lancet, 397(10289), 2111–2124. https://doi.org/10.1016/s0140-6736(21)00794-7
Kuo, M. F., & Nitsche, M. A. (2012). Effects of transcranial electrical stimulation on cognition. Clin EEG Neurosci, 43(3), 192–199. https://doi.org/10.1177/1550059412444975
Kuut, T. A., Müller, F., Csorba, I., Braamse, A., Aldenkamp, A., Appelman, B., Assmann-Schuilwerve, E., Geerlings, S. E., Gibney, K. B., Kanaan, R. A. A., Mooij-Kalverda, K., Olde Hartman, T. C., Pauëlsen, D., Prins, M., Slieker, K., van Vugt, M., Keijmel, S. P., Nieuwkerk, P., Rovers, C. P., & Knoop, H. (2023). Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial. Clin Infect Dis, 77(5), 687-695. https://doi.org/10.1093/cid/ciad257
Lee, G. S., Kim, H. K., & Kim, M. E. (2022). Relevance of sleep, pain cognition, and psychological distress with regard to pain in patients with burning mouth syndrome. Cranio®, 40(1), 79-87. https://doi.org/10.1080/08869634.2019.1681621
Lefaucheur, J. P., Aleman, A., Baeken, C., Benninger, D. H., Brunelin, J., Di Lazzaro, V., Filipović, S. R., Grefkes, C., Hasan, A., Hummel, F. C., Jääskeläinen, S. K., Langguth, B., Leocani, L., Londero, A., Nardone, R., Nguyen, J. P., Nyffeler, T., Oliveira-Maia, A. J., Oliviero, A.,…Ziemann, U. (2020). Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018). Clin Neurophysiol, 131(2), 474–528. https://doi.org/10.1016/j.clinph.2019.11.002
Miller, B. T., Scheman, J., Petro, C. C., Beffa, L. R. A., Prabhu, A. S., Rosen, M. J., & Krpata, D. M. (2023). Psychological disorders in patients with chronic postoperative inguinal pain. Hernia, 27(1), 35-40. https://doi.org/10.1007/s10029-022-02662-2.
Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive-behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. Biopsychosoc Med, 15(1), 16. https://doi.org/10.1186/s13030-021-00219-w
Navarro-Ledesma, S., Hamed-Hamed, D., Gonzalez-Muñoz, A., & Pruimboom, L. (2024). Impact of physical therapy techniques and common interventions on sleep quality in patients with chronic pain: A systematic review. Sleep Med Rev, 76, 101937. https://doi.org/10.1016/j.smrv.2024.101937
Nitsche, M. A., Cohen, L. G., Wassermann, E. M., Priori, A., Lang, N., Antal, A., Paulus, W., Hummel, F., Boggio, P. S., Fregni, F., & Pascual-Leone, A. (2008). Transcranial direct current stimulation: State of the art 2008. Brain Stimul, 1(3), 206–223. https://doi.org/10.1016/j.brs.2008.06.004
Puntillo, F., Giglio, M., Paladini, A., Perchiazzi, G., Viswanath, O., Urits, I., Sabbà, C., Varrassi, G., & Brienza, N. (2021). Pathophysiology of musculoskeletal pain: a narrative review. Ther Adv Musculoskelet Dis, 13, 1759720x21995067. https://doi.org/10.1177/1759720x21995067
Ren, C., Pagali, S. R., Wang, Z., Kung, S., Boyapati, R. B., Islam, K., Li, J. W., Shelton, K. M., Waniger, A., Rydberg, A. M., Hassett, L. C., Croarkin, P. E., Lundstrom, B. N., Pascual-Leone, A., & Lapid, M. I. (2025). Transcranial Electrical Stimulation in Treatment of Depression: A Systematic Review and Meta-Analysis. JAMA Netw Open, 8(6), e2516459. https://doi.org/10.1001/jamanetworkopen.2025.16459
Roland, M., & Morris, R. (1983). A study of the natural history of low-back pain. Part II: development of guidelines for trials of treatment in primary care. Spine (Phila Pa 1976), 8(2), 145-150. https://doi.org/10.1097/00007632-198303000-00005
Salazar-Méndez, J., Núñez-Cortés, R., Suso-Martí, L., Ribeiro, I. L., Garrido-Castillo, M., Gacitúa, J., Mendez-Rebolledo, G., Cruz-Montecinos, C., López-Bueno, R., & Calatayud, J. (2023). Dosage matters: Uncovering the optimal duration of pain neuroscience education to improve psychosocial variables in chronic musculoskeletal pain. A systematic review and meta-analysis with moderator analysis. Neurosci Biobehav Rev, 153, 105328. https://doi.org/10.1016/j.neubiorev.2023.105328
Siddall, B., Ram, A., Jones, M. D., Booth, J., Perriman, D., & Summers, S. J. (2022). Short-term impact of combining pain neuroscience education with exercise for chronic musculoskeletal pain: a systematic review and meta-analysis. Pain, 163(1), e20-e30. https://doi.org/10.1097/j.pain.0000000000002308
Smith, J. A., Tain, R., Chrisman, I., Sharp, K. G., Glynn, L. M., Van Dillen, L. R., Jacobs, J. V., & Cramer, S. C. (2025). Gray matter morphology and pain-related disability in young adults with low back pain. Neuroimage, 312, 121227. https://doi.org/10.1016/j.neuroimage.2025.121227
Teixeira, P. E. P., Alawdah, L., Alhassan, H. A. A., Guidetti, M., Priori, A., Papatheodorou, S., & Fregni, F. (2020). The Analgesic Effect of Transcranial Direct Current Stimulation (tDCS) combined with Physical Therapy on Common Musculoskeletal Conditions: A Systematic Review and Meta-Analysis. Princ Pract Clin Res, 6(1), 23-26. https://doi.org/10.21801/ppcrj.2020.61.5
Tork, A., & Sajjadian, I. (2020). The Effect of Acceptance and Commitment Based Therapy on Psychological Distress and Negative Automatic Thoughts in Mothers of Children with Cerebral Palsy [Research]. Quarterly Journal of Child Mental Health, 6(4), 156-167. https://doi.org/10.29252/jcmh.6.4.15
Trivedi, M., Dumkrieger, G., Chong, C. D., Leibovit-Reiben, Z., & Schwedt, T. J. (2024). A history of abuse is associated with more severe migraine- and pain-related disability: Results from the American Registry for Migraine Research. Headache, 64(9), 1109-1123. https://doi.org/10.1111/head.14787
Van der Groen, O., Rafique, S. A., Willmot, N., Murphy, M. G., Tisnovsky, E., & Brunyé, T. T. (2025). Transcutaneous and transcranial electrical stimulation for enhancing military performance: an update and systematic review. Front Hum Neurosci, 19, 1501209. https://doi.org/10.3389/fnhum.2025.1501209
Wang, J., Xu, J., Ma, Z., Jia, C., Wang, G., & Zhou, L. (2021). The mediating role of depressive symptoms, hopelessness, and perceived burden on the association between pain intensity and late-life suicide in rural China: a case–control psychological autopsy study. Frontiers in psychiatry, 12 (2), 779-787. https://doi.org/10.3389/fpsyt.2021.779178
Wansbrough, K., Tan, J., Vallence, A. M., & Fujiyama, H. (2024). Recent advancements in optimising transcranial electrical stimulation: reducing response variability through individualised stimulation. Current opinion in behavioral sciences, 56, 101360. https://doi.org/10.1016/j.cobeha.2024.101360
White, K. M., Zale, E. L., Lape, E. C., & Ditre, J. W. (2025). The association between chronic pain acceptance and pain-related disability: A meta-analysis. Journal of Clinical Psychology in Medical Settings, 32(3), 448-459. https://doi.org/10.1007/s10880-024-10061-1
WHO, C. O. (2020). World health organization. Air Quality Guidelines for Europe, (91). https://doi.org/10.1111/j.1600-0668.2005.00395.x.
Wild, M. G., Herbert, M. S., & Creech, S. (2024). Longitudinal associations of physical and emotional distress tolerance with pain intensity and pain-related disability in United States veterans. The Journal of Pain, 25(4), 60-61. https://doi.org/10.1016/j.jpain.2024.01.278  
Clinical Psychology Studies
Volume 16, Issue 61
Autumn 2025
Pages 99-116