Pain Management

Conventional Approaches

Psychological/Mind-Body Therapies

Psychological factors are important contributors to the intensity of pain and to the disability associated with chronic pain. Pain and stress are intimately related. There may be a vicious cycle in which pain causes stress, and stress, in turn, causes more pain. Mind/body approaches address these issues and provide a variety of benefits, including a greater sense of control, improved coping skills, decreased pain intensity and distress, changes in the way pain is perceived and understood, and increased sense of well being and relaxation. These approaches may be very valuable for adults and children with pain (Rusy, 2000).

For pain specialists, the therapies that are psychological, or focused on the relationship between mind and body, are considered mainstream; for many others in the health professions, and for the public at large, the same therapies might be considered complementary/alternative. The evidence in support of these approaches is very strong and how they are labeled is less important than their acceptance as necessary treatments.

Cognitive-Behavioral Therapy (CBT)

CBT has proven to be effective in reducing pain and disability when it is used as part of a therapeutic strategy for chronic pain. CBT addresses the psychological component of pain, including attitudes and feelings, coping skills, and a sense of control over one's condition. It can provide educational information and diffuse feelings of fear and helplessness. It can help a patient look at ways in which their attitudes contribute to inaccurate and unrealistic expectations, and can help them find a more realistic and balanced view of the problem. CBT may include training in various types of relaxation approaches, which can help people in chronic pain lower their overall level of arousal, decrease muscle tension, control distress, and decrease pain, depression and disability (Barkin, 1996). Relaxation imagery or pain-management imagery may also be taught to promote relaxation and changes in pain intensity or quality (Fernandez, 1989). Finally, CBT may include the teaching of life skills and coping skills that can assist the patient in productive problem solving and the prevention or minimization of future pain episodes.

CBT has been found to be effective as part of a treatment regimen for a variety of pain conditions including episodic migraine and chronic daily headache (Lake, 2001), chronic musculoskeletal pain (Haigh, 1999), pain in the well elderly (Manetto, 1996), chronic cancer pain (Thomas, 2000), rheumatoid arthritis and osteoarthritis (Bradley, 2002), fibromyalgia (Berman, 1999), myofascial temporomandibular disorders (Sherman, 2001), chronic low back pain (van Tulder, 2001), carpal tunnel syndrome pain (Feuerstein, 1999), and chronic pelvic pain (Reiter, 1998). It has been suggested to benefit patients with chronic fatigue syndrome, irritable bowel syndrome (Kroenke, 2000), and anxiety (Ketterer, 1999). Although research into the use of CBT in children is in the early stages, it holds promise for reducing pain-related distress in children (Chen, 2000).

Biofeedback

Biofeedback is the use of electronic monitoring instruments to provide patients with immediate feedback on heart rate, blood pressure, muscle tension, or brain wave activity. This allows the patient to learn how to influence these bodily responses through conscious control and regulation. Electromyographic (EMG) biofeedback, for example, can teach patients how to relax a particular muscle or how to achieve more generalized relaxation for stress reduction. Biofeedback has been shown to be effective in the management of migraine headaches, fibromyalgia, temporomandibular disorders, and rheumatoid arthritis (Barkin, 1996), Raynaud's disease, tension headaches (DePalma, 1997), headaches in children (Serration, 2000) and the pain associated with irritable bowel syndrome (Leafy, 1998). Many other applications of biofeedback continue to be studied.

Hypnosis

Hypnosis is a highly relaxed, trance-like state in which the conscious or rational part of the brain is temporarily tuned out through a focus on relaxation and non-attention to distracting thoughts. During hypnosis, changes like those found in meditation can occur, such as a slowing of the pulse and respiration, and an increase in alpha brain waves. The person may become more open to specific suggestions and therapeutic goals such as pain reduction. In the post-suggestion phase, the continued use of the new behavior after the hypnosis session is reinforced.

Medical hypnosis has been shown to be helpful in reducing both acute and chronic pain (Holyroid, 1996). A National Institutes of Health panel found hypnosis to be effective in alleviating the pain associated with cancer (NIH, 1996). A 1997 review of the literature on hypnosis in pain control, which evaluated all controlled scientific studies comparing hypnosis to other psychological interventions for pain, showed hypnosis to be equally or more effective in reducing suffering and possibly even reducing pain sensation (Holyroid, 1996). Other studies have shown effectiveness of hypnosis for pain associated with burns, cancer, and rheumatoid arthritis (DePalma, 1997) (Sellick, 1998) and pain and anxiety reduction related to surgery (Lang, 2000). Clinical evidence supports the use of hypnosis in reducing pain in a wide variety of acute and chronic pain conditions for a substantial number of patients.

Imagery

Imagery is the use of imagined pictures, sounds, or sensations for generalized relaxation or for specific therapeutic goals, such as the reduction of pain. These images can be initiated by the patient or guided by a practitioner. The sessions in which imagery is used can be individual or group.

More than half the studies of imagery for pain--postoperative pain, cancer pain, chronic low back pain, burns, and migraine headache--report significant relief from the procedure (Eller, 1999). In a review of laboratory research on coping strategies for pain control, imagery was the most effective in relieving pain (Eller, 1999). Many of these studies, however, evaluate imagery together with other interventions such as hypnosis, cognitive-behavioral therapy and relaxation techniques. Nonetheless, the limited evidence suggests the usefulness of guided imagery in reducing the sensory and emotional components of pain. The Agency for Health Care Policy and Research recommends the use of imagery for reduction of pain intensity and distress for cancer pain and for the management of mild to severe acute pain (AHCPR, 1992).

Relaxation Therapies

Relaxation therapies include a range of techniques such as autogenic training, various forms of meditation, progressive muscle relaxation, deep breathing, and paced respiration. The goal of these therapeutic approaches is overall relaxation and stress reduction. Practice can produce a set of physiologic changes that result in slowed respiration, lowered pulse and blood pressure, an increase in alpha wave brain activity, and possibly even reduction in the body's inflammatory response mechanism (Lutgendorf, 2000). This can have a positive impact on health and improve symptoms in many acute and chronic illnesses and conditions, including pain.

Relaxation training may decrease pain, depression and disability (Barkin, 1996). According to the 1996 National Institutes of Health report on the treatment of chronic pain and insomnia, there is strong evidence for the effectiveness of relaxation techniques in reducing chronic pain in a variety of medical conditions. Effects may include reduced pain and muscle tension, reduced anxiety and insomnia, and increased activity level (Good 1996, Carroll, 1998; Mandle, 1996).

Meditation is a specific type of relaxation intervention that also can have an effect on pain. Results suggest that meditation can result in a higher tolerance to pain; decreased anxiety, stress and depression; increased activity levels; decreased use of pain-related medications; and increased levels of self-esteem (Mills, 1981; Kabat-Zinn, 1985; Harmon, 1999). The meditative technique based on increased awareness and staying in the moment, called mindfulness meditation, has been successfully used in treatment programs to reduce pain and improve mood in patients with chronic pain from a variety of conditions, including facial pain, coronary and noncoronary chest pain, gastrointestinal pain, low back, neck and shoulder pain and headache (Kabat-Zinn, 1982).

Prayer

Prayer is not usually considered a mind-body or a psychological approach, but it is worthwhile considering it in this context of mind/body treatments. Changes in the concept of health and illness, a broadening view of healing and curing, and interest in other cultural systems of medicine have created a growing openness to the spiritual dimensions of health. There are many anecdotal reports of the power of prayer and its effects on health. This has led to a substantial number of scientific research studies. As of 1992, there were at least 131 controlled trials that evaluated the effect of prayer on humans, microorganisms, plants, cancer cells and animals; 56 of these studies found significant effects (Targ, 1997). In human trials, prayer had a positive effect on levels of stress, depression, hypertension and substance abuse, illness-related complications, and life satisfaction (Targ, 1997). In a systematic review of randomized trials of distant healing, 57% of 23 trials showed a positive treatment effect (Astin, 2000). A recent study of the effects of direct and distant healing on chronic pain, however, showed no specific effect after eight weekly 30 minute treatments (Abbot 2001). This is an area that clearly warrants further study.