Excerpt from: Kelly, J.F. (1994). Psychological approaches to management of chronic pain. In P. Raj (Ed.), Current Review of Pain. Philadelphia: Current Science.
Effective use of psychological techniques has been associated with improved functioning in patients with chronic pain. The improvements observed include decreased pain perception, decreased psychological distress, and the use of more appropriate coping strategies. Additionally, decreased clinic visits have been observed in patients receiving psychological intervention. This translates to decreased health care costs. One of the main goals of the psychological approach is to help patients learn techniques to effectively manage the condition themselves.
The psychological interventions can be categorized in terms of the component of the pain experience that it is to target, physiologic, subjective, or behavioral. Biofeedback and relaxation training are used to treat the physiologic component of the pain. For example, a patient would use electromyographic (EMG) biofeedback to treat muscle contraction headache. Hypnosis and “pain-directed” cognitive methods focus on sensations and feelings of distress and discomfort, whereas contingency management, or operant approaches, target the behavioral component of the pain experience, such as wincing or taking pills. Patients should be treated with a combination of the various methods simultaneously, depending on the nature of their pain problem.
BIOFEEDBACK
Biofeedback is now a widely accepted approach in the management of chronic pain, primarily because of its noninvasive nature, as its effectiveness relies mostly on the patient’s internal resources. Biofeedback uses equipment to reveal involuntary physiologic events so that patients can learn to bring them under voluntary control. It has been successfully employed to treat a variety of pain syndromes, including muscle contraction and migraine headache, low back pain, myofascial pain syndrome, reflex sympathetic dystrophy, and arthritis.
The rationale for using biofeedback in treating chronic pain are as follows:
1. To modify the specific physiologic process that is thought to underlie the pain disorder. For example, EMG biofeedback is used to treat muscle-contraction headache. A reduction in muscle tension achieved through biofeedback training should result in a corresponding decrease in muscle contraction headache. This rationale is not supported by many researchers, mainly because there are some pain syndromes in which the etiology is not clear.
2. To facilitate the relaxation response. A reduction in autonomic arousal is expected to lead to a corresponding reduction in pain. Stress and tension are known to exacerbate pain; therefore, relaxation should be associated with its relief.
3. To help the patient develop self-regulation. In using biofeedback, patients become more aware of their own contribution to the pain experience as well as their ability to influence the pain. For biofeedback to be effective, patients must take responsibility for coping with the pain. With the technique, they also learn that their pain may be under internal, as op posed to external, control. The patient’s view of the pain should change, which can result in greater acceptance of personal responsibility for managing the pain. The internal focus can also facilitate patients in developing a more optimistic outlook for the future. The patient’s affective state may improve and participation in the treatment process can increase.
The most common forms of biofeedback used with the chronic pain population continue to remain EMG biofeedback and skin temperature or thermal biofeedback.
Electromyographic (EMG) biofeedback provides a measure of the electrical discharge in the muscle fibers, which indicates relaxation or contraction of the muscles. The effective use of EMG biofeedback should result in reduction in muscle tension, which in turn produces a decrease in pain experienced. The pain syndromes that EMG biofeedback has been successfully used to treat include muscle contraction headache, temporomandibular joint pain, myofascial pain syndrome, and fibromyalgia.
A potential problem with EMG feedback is that the EMG readout may not provide an accurate measure of the muscle tension and pain that the patient is actually experiencing. In these cases, the pain could be the result of deep muscle tension that is not easily measured by EMG surface electrodes or the pain may originate at a site different from where it is experienced. Also, studies have not consistently shown a positive correlation between reported pain relief and reduction in EMG. It is, therefore, possible for a patient to be successfully trained in EMG biofeedback, yet not have a reduction in pain. In some cases, there may be a delay between reduction of EMG and the corresponding reduction of pain.
The basis for the use of skin temperature, or thermal biofeedback in treating chronic pain is that activity in the sympathetic nervous system may result in vasoconstriction of peripheral arterioles and that reduced sympathetic nervous system activity is associated with vasodilation. The goal of skin temperature biofeedback is to teach patients to increase the skin temperature in their extremity, usually their finger, thereby increasing vasodilation and reducing sympathetic nervous system activity. Additionally, an increase in skin temperature is associated with a full relaxation response. Pain syndromes that skin temperature biofeedback has been used to treat include reflex sympathetic dystrophy and migraine headaches; however, the exact physiologic mechanism by which it works with the syndromes remains unclear.
RELAXATION TRAINING
The main purpose of the various relaxation techniques in pain management is to elicit the relaxation response. Relaxation is thought to reduce pain by reducing arousal. Studies have shown that physiologic changes consistent with decreased sympathetic nervous system activity often accompany the relaxation response. The changes observed include decreases in oxygen consumption, reduction in heart rate, and a marked decrease in arterial blood lactate concentration. Relaxation facilitates one’s ability to use suggestion and imagination to provide relief of pain. Focused concentration helps the patients learn ways of disrupting preoccupying thoughts, especially those related to pain [23].
Relaxation has also been used to teach patients body awareness. Patients experiencing pain, especially myofascial pain, frequently tense their muscles in response to pain or in anticipation of pain, thereby exacerbating the pain. By becoming more aware of the physical sensations in their bodies, patients can learn to reliably decrease the muscle tension and thereby cope with the pain more effectively.
There are various forms of relaxation approaches available to use with patients with chronic pain. Progressive muscle relaxation is the most common approach used. This technique involves tensing and relaxing the major muscle groups so that patients can learn to relax the tense muscles that contribute to pain.
When the patients have consistently achieved success with progressive muscle relaxation, a shorter version of the technique can be substituted. The eventual goal is reduction of tension by recall, thus eliminating the need to actively tense muscle groups. As patients become more advanced with using the technique, they can incorporate visual imagery and autogenic phrases to elicit relaxation.
Relaxation training has been used to treat a wide variety of painful disorders, with much success. The syndromes include muscle contraction headache, migraine headache, temporomandibular joint pain, chronic back pain, and myofascial pain syndrome.
COMPARISON BETWEEN BIOFEEDBACK AND RELAXATION TRAINING
Studies have compared the relative effectiveness of biofeedback and relaxation training in treating chronic pain. The majority of research indicates that relaxation and biofeedback training are equally effective in the management of pain. However, the two approaches can be useful to the patients in different ways. Biofeedback provides patients with an overt indicator of the relationship between behaviors and cognitions and changes in physiologic processes. With this feedback, the patients can develop control over the specific physiologic mechanism that contributes to pain. Biofeedback provides patients with objective data on the progress during the treatment sessions. The main advantages of using relaxation training are its practicality and cost effectiveness.
In many settings, biofeedback and relaxation arc used as conjunctive treatments. The relaxation training provides the technique to alter physiologic processes and the biofeedback is used to shape the patient’s relaxation response. The biofeedback can help pinpoint the source of training problems as well as open up new intervention tactics. By providing objective data to the patients, the instrumentation and measurement techniques can serve to place the techniques in a “scientific’. explanatory framework. In the treatment sessions, the patients should be encouraged to verbalize the control strategies, attend to sensations experienced during the training sessions, and use conditioned verbal cues to promote generalization of techniques learned to daily life. The patient should not develop excessive reliance on the machine.
HYPNOSIS
The mechanism by which patients with pain are able to achieve dramatic pain relief with hypnosis is not well understood. Studies have indicated that the hypnotic analgesia received is not mediated by the endorphin. However, there has been research support for the theory that cognitions play an important role in hypnosis and hypnotic analgesia. Hypnosis focuses on the subjective aspect of the pain experience, such as feelings of distress and discomfort.
Hypnosis can provide an analgesic experience for many patients, but the technique in and of itself is not expected to cure chronic pain. It provides a sensation of peacefulness and comfort, and short-term relief of pain can be experienced. For lasting benefit to occur, however, hypnosis should be part of a broader psychotherapeutic regimen. It is more effective in managing pain of organic etiology than in managing psychogenic, or functional, pain. This is because persistent psychogenic pain often has complicating factors that need to be addressed, such as secondary gain.
Generally, the effectiveness of hypnosis depends on two factors-the patient’s imagination and the ability of the clinician to capitalize on that imagination. Hypnotic responsiveness varies considerably among individuals, and hypnotizability can be modified by various means, such as through operant training and biofeedback. What appears to be most important is the specific technique that is used with the individual, as it has been shown that subjects with low responsiveness on susceptibility tests often respond favorably when different approaches are introduced.
COGNITIVE APPROACHES
The basic premise with the cognitive approaches is that expectations, attitudes, and beliefs affect the manner in which patients cope with pain. Changes in negative cognitions can result in better pain control. It is believed that behavior and affect result from the way in which a person construes the world. Inadequate coping mechanisms seen in patients with chronic pain are related to errors in cognition. Patients who tend to misinterpret their experience of pain arc usually more severely disabled. The goal of the intervention is to correct faulty thought processes that contribute to prolonged suffering and disability, and maladaptive beliefs are replaced with more adaptive ones [40].
Studies conducted provide support for the use of cognitive approaches in treating chronic pain. The cognitive approaches have been associated with the following benefits:
- Patients have the necessary coping skills to deal with the pain more effectively.
- Patients live more satisfying lives despite the presence of physical discomfort.
- Patients have decreased reliance on the health care system and a reduction in dependence on analgesic medications. A message emphasized to the patients is that they are not helpless in dealing with their pain and it should not control their lives.
OPERANT APPROACHES
The operant approach in the management of chronic pain is based on the assumption that the patient’s behavior is governed by its consequences in that the environmental consequences of a behavior determine whether or not it will reoccur. If the reinforcers are positive, then there is an increased likelihood that the behavior will reoccur, while negative reinforcement decreases the likelihood. The goal of the operant approach, or contingency management, is to replace learned maladaptive behaviors with behaviors that are incompatible with the sick role. Environmental contingencies are changed so that appropriate “healthy” behaviors are reinforced, and pain behaviors are not rewarded. For this to occur, the targeted behaviors and possible reinforcers need to be identified, and there should be a manipulation of the reinforcers. Family members and health care providers are instructed to encourage and reinforce appropriate behaviors, while ignoring pain behaviors, such as complaining of pain, using narcotics, and remaining inactive. Other forms of intervention, such as marital counseling, family therapy, and vocational planning, can be incorporated in the treatment.
GROUP THERAPY
An important component of a pain management program is group therapy. The two main purposes for group intervention are to provide psychological support and to disseminate information. The use of group therapy is time efficient for the psychologist, who generally has many patients to treat. Its format allows multiple ideas to be presented, shared, and discussed. The members of the group provide support, encouragement, and can serve as a reality check for other group members.
In the group setting, patients can obtain information regarding the psychosocial influences on their pain experience. Among the educational topics that I discuss in the group setting are vicious pain cycles (e.g., pain-depression cycle, pain-narcotics cycle, and pain-stress cycle), effective coping strategies, acceptance of the pain, and compliance issues.
SUMMARY
In summary, there is much support for the use of behavioral approaches in managing chronic pain. Effective use of psychological techniques has been associated with decreased pain perception, decreased psychological distress, the use of more appropriate coping strategies, decreased clinic visits, and decreased health care costs. For the approaches to be successful, patients need to fully participate in treatment. The interventions are most beneficial when they are incorporated into a comprehensive pain management program.