CLINICAL PAIN

Not all of our pain experiences receive professional treatment, and not all of them require it. The term clinical pain refers to any pain that receives or requires professional treatment. The pain may be either acute or chronic and may result from known or unknown causes (Sanders, 1985). Clinical pain calls for treatment in and of itself, and not only because it may be a symptom of a progressive disease, such as arthritis or cancer. Relieving pain is important for humanitarian reasons, of course—and doing so also produces medical and psychosocial beneﬁts for the patient.

Let’s look at medical and psychosocial issues that are associated with controlling clinical pain, beginning with acute pain.

ACUTE CLINICAL PAIN

By preventing or relieving acute pain, practitioners make medical procedures go more smoothly, reduce patients’ stress and anxiety, and help them recover more quickly. Much of the acute pain people experience in today’s world has little survival value (Chapman, 1984). What survival value would there be in feeling the pain as a dentist drills a tooth or a surgeon removes an appendix? How would people’s survival be enhanced by feeling the intense pain that accompanies normal healing while resting in a hospital during the days after surgery?

When competent medical care is available, these pains are not useful. Yet during recovery after surgery in the United States, many patients experience higher-than-necessary pain (Chapman, 1984; Williams, 1996). As a result, the American Pain Society recommends that practitioners assess patients’ pain intensity and satisfaction with pain relief after surgery (Haythornthwaite & Fauerbach, 2001). On a visual analog scale (see Figure 11–4) with a 100 mm long line, ratings of 45 to 74 reﬂect moderate pain and 75 to 100 reﬂect severe pain; reducing pain ratings by one-third suggests a change that is meaningful for the patient (Jensen, Chen, & Brugger, 2003). Inadequately reduced pain after surgery can cause physiological reactions that can lead to medical complications and even death. For instance, high pain and muscle spasms that may arise from abdominal and chest surgery can prevent patients from breathing deeply and coughing, allowing bacterial infections to take hold in the lungs and cause pneumonia (Chapman, 1984).

CHRONIC CLINICAL PAIN

When pain persists and becomes chronic, patients begin to perceive its nature differently. Although in the acute phase the pain was very aversive, they expected it to end and did not see it as a permanent part of their lives. As the pain persists, they tend to become discouraged and angry and are likely to seek the opinions of other physicians. This can be constructive. However, when this is not successful, and as patients come to see less and less connection between their discomfort and any known or treatable disorder, increasing hopelessness and despair may lead them to resort to consulting quacks (Chapman, 1984).

The transition from acute to chronic pain is a critical time when many of these patients develop feelings of helplessness and psychological disorders, such as depression, especially if the pain is disabling (Epping-Jordan et al., 1998; Gatchel, 1996). The neurotic triad—hypochondriasis, depression, and hysteria— often becomes a dominant aspect of their personalities (Gatchel, 1996; Rosen et al., 1987). These changes typically parallel alterations in the patients’ lifestyles, employment status, and family lives—as the following letter from a wife to her husband’s therapist reﬂects:

perhaps if I could explain my husband’s attitudes it might help you understand his problems. . . . The questionnaire you gave him to complete and send back became a tremendous ordeal for him. Why, I’ll never know, because the questions were simple, but in the state of mind he is in, everything gets to be a chore. . . . Since his back operation ﬁve years ago he has become increasingly impatient and progressively slower with no ambition at all to even try to help himself. He had made himself an invalid and it has become very difﬁcult for me or my family to tolerate his constant complaining. He blames me, blames our two sons, who he says don’t help him around the house when in fact he does little or nothing to help himself. He does exactly the same things day after day with projects he starts and never completes and always because of his health. . . . To dwell on his illness is what he wants and only that he will do, believe me. He needs psychiatry of some kind. (Flor & Turk, 1985,

p. 268)

A study of people who had suffered for years with severe chronic-recurrent and chronic-intractablebenign pain found that about half had considered suicide because of their conditions (Hitchcock, Ferrell, & McCaffery, 1994). Chronic pain often creates a broad array of long-term psychosocial problems and impaired interrelationships, which distinguish its victims from those of acute pain (Weir et al. 1994).

Individuals who receive treatment for their pain after it has progressed and become chronic tend to exhibit certain physical and psychosocial symptoms that characterize a “chronic pain syndrome.” According to psychologist Steven Sanders (1985), these symptoms include:

Associated tissue damage or irritation, which may be minor or major.
Persistent pain complaints and other pain behaviors, such as grimacing or guarded movement, when in discomfort.
Disrupted daily activity patterns, characterized either by a general reduction or by recurrent large ﬂuctuations.
Disrupted social, marital, employment, and recreational activities.
Excessive use of drugs or repeated use of surgical procedures to relieve pain.
Disturbed sleep patterns.
Increased anxiety and depression.

Chronic pain patients usually exhibit the ﬁrst two symptoms and at least one of the remaining ones. Generally speaking, the more symptoms the patient presents, the greater the impact the pain has had and the greater the maladjustment it has produced.

Because of the differences between acute pain and chronic pain in their duration and the effects they have on their victims, these conditions usually require different treatment methods. Health care professionals need to distinguish between acute and chronic pain conditions and provide the most appropriate pain relief techniques for the patient’s needs (Gatchel, 1996). Failing to do so can make the condition worse. Keeping this caution in mind, we’ll turn our attention for the remainder of this chapter to the many medical, psychological, and physical techniques available to help control patients’ pain.

MEDICAL TREATMENTS FOR PAIN

A few centuries ago, peasants in Western cultures commonly treated pain by piercing the affected area of the body with a “vigorous” twig of a tree, believing that the twig would absorb the pain from the body (Turk, Meichenbaum, & Genest, 1983). Then, to prevent anyone from getting the pain from that twig, they buried it deep in the ground. Other early practices for controlling pain were not so farfetched, but they were crudely applied, even by physicians. In 19th-century America, alcoholic beverages and “medicines” laced with opium were readily available (Critchlow, 1986; Kett, 1977). Many people used these substances to alleviate pain, and physicians commonly employed them as anesthetics for surgery before ether was introduced. Today when patients suffer from pain, physicians try to reduce the discomfort in two ways— chemically and surgically.

SURGICAL METHODS FOR TREATING PAIN

Treating chronic pain with surgical methods is a relatively radical approach, and some surgical procedures are more useful than others. In some procedures, the surgery removes or disconnects portions of the peripheral nervous system or the spinal cord, thereby preventing pain signals from reaching the brain. These are extreme procedures—and if they are successful, they produce numbness and, sometimes, paralysis in the region of the body served by the affected nerves. But these procedures seldom provide long-term relief from the pain, which is often replaced after some days or months by pain and other sensations that are worse than the original condition (Hare & Milano, 1985; Melzack & Wall, 1982). Because of the poor prospects of permanent relief and the risks involved in these surgical procedures, they are rarely used today.

Other surgical procedures for relieving pain do not remove or disconnect nerve ﬁbers and are much more successful. One example is the synovectomy, a technique whereby a surgeon removes membranes that become inﬂamed in arthritic joints (AMA, 2003; Anderson et al., 1985). Another example is spinal fusion, a procedure that joins two or more adjacent vertebrae to treat severe back pain (AMA, 2003). Surgery is often used in the United States to treat back pain, but there is little evidence that it produces better long-term pain reduction than nonsurgical methods. They are used at a far lower rate in other developed countries, such as Denmark and England (Cherkin et al., 1994; Turk, 2002). Surgery for chronic skeletal pain conditions is most appropriate when the person is severely disabled and nonsurgical treatment methods have failed. Physicians and patients usually prefer other medical approaches, such as chemical methods.

CHEMICAL METHODS FOR TREATING PAIN

Although medical research has led to many advances in treating pain since the 1800s, this progress has been slow. The ﬁeld of medicine has focused much more on developing methods for curing disease than on reducing pain (Melzack & Wall, 1982). Let’s look at the use of chemical methods for treating acute and chronic pain. (Go to

Using Chemicals for Acute Pain

Many pharmaceuticals are very effective for relieving acute pain, such as occurs after surgery. Physicians choose the speciﬁc drug and dosage by considering many factors, such as how intense the pain is and its location and cause. Their effective use of these chemicals, giving as much pain relief as they safely can, depends on characteristics of the drug, the patients, and sociocultural factors. In some countries, such as in Latin America, using narcotics for pain relief is extremely rare (DePalma, 1996). Other cultures have become much more accepting of narcotic pain control.

Many hospital patients in pain are undermedicated, and those who receive too little pain relief tend to be children and minority group members, even when compared against other patients with the same medical condition (Bush & DeLuca, 2001; Cleeland et al., 1994; Ng et al., 1996). For instance, when the patient is a child, practitioners tend to administer painkillers less frequently, give doses below the recommended level, and discontinue it earlier, especially if the drug is a narcotic. The reasons for these age and sociocultural differences are unclear. In the case of children, it may be that practitioners believe children feel less pain than adults or are more likely to become addicted to a drug (Bush, Holmbeck, & Cockrell, 1989). Or children may simply request less medication, perhaps because they dislike injections or taking pills more than adults do. Similar reasons may explain the ethnic differences.

The conventional ways for administering painkilling chemicals involve giving injections or pills, and these are given under one of two arrangements: a prescribed schedule or “as needed” (called PRN for the Latin pro re nata) by the patient. But two other methods are available today (AMA, 2003; Zeltzer et al., 1997). In one of these methods—called an epidural block—practitioners inject narcotics or local anesthetics epidurally, that is, near the membrane that surrounds the spinal cord. These chemicals then prevent pain signals from being transmitted to the brain. The second technique is called patient-controlled analgesia. This procedure allows the patient to determine how much painkiller, such as morphine, he or she needs, and get it without delay. The patient simply pushes a button to activate a computerized pump that dispenses a preset dose of the chemical through a needle that remains inserted continuously. Practitioners monitor the patient’s use of the drug and set limits on the rate and amount of its use.

Do patients abuse the opportunity to control their use of narcotics for pain control? Current evidence suggests that the risk of abuse is low for most patients, at least under certain circumstances. A study by Marc Citron and his colleagues (1986) examined this issue in hospitalized men with severe cancer pain who were placed on a patient-controlled analgesia procedure for about 2 days. A physician preset for each patient the dosage of morphine the pump would deliver and a lockout time, that is, the interval after a dose when no more morphine would be available (about 30 minutes). The patients’ rate of morphine use actually declined over time rather than increased, being used far more heavily in the ﬁrst few hours than it was later: after the ﬁrst 4 hours, the rate dropped sharply to less than 40% of the earlier rate. These patients were free to take much more medication, but they did not. Similar results have been found with male and female adolescent patients following surgery (Tyler, 1990). But there is a caution in using patient-controlled analgesia with patients who are relatively young, have high levels of anxiety, or have low levels of social support. They tend to use more of the drug than other acute pain patients do (Gil et al., 1990).

Using Chemicals for Chronic Pain

Chronic pain occurs most commonly with disorders that are not life threatening, such as arthritis, but it can also occur with cancer, which practitioners generally view differently for pain relief. Using opioids for managing moderate to severe cancer pain is widely accepted today (DEA, 2004). But despite guidelines to treat pain more aggressively, many cancer patients receive inadequate analgesic drugs (Cleeland et al., 1994). Why? Part of the reason is that cancer patients—especially older, less educated ones—often fear they will become addicted if the drug is a narcotic and believe that “good” patients don’t complain (Ward et al., 1993). Practitioners need to discuss these issues with their patients and correct misconceptions.

Should narcotics be used in treating chronic non-cancer pain? Practitioners ﬁrst consider other treatment methods—other chemicals or methods discussed later in this chapter—but if those don’t provide enough relief, they can consider long-term opioid treatment with careful monitoring (DEA, 2004). Narcotics provide effective pain relief for many patients with a variety of chronic pain conditions (Jadad et al., 1992; Turk, 2002). For example, researchers tested drug therapy, combining methadone and an antidepressant, over a 2-year period for men and women patients with long-term, severe phantom limb pain (Urban et al., 1986). These people were in pain almost constantly and had tried a variety of treatments for pain relief in the past. They began the drug therapy as hospital inpatients, reported at discharge that their pain had been reduced by about two thirds, and maintained this level of pain reduction throughout the next 2 years with very low daily doses of each drug.

These ﬁndings are very important and indicate that narcotics in low doses can provide effective pain relief without requiring progressively larger doses or leading to addiction. Because of a growing body of similar ﬁndings, American practitioners are using narcotics more than in the past for patients who are severely disabled by their chronic pain conditions, such as rheumatoid arthritis and severe back injury (Turk, Brody, & Okifuji, 1994). But increases in using narcotics for chronic pain are occurring cautiously for at least three reasons. First, the ﬁndings we have described need to be conﬁrmed with a greater variety of subjects and types of pain conditions. Despite the low risk that drug abuse appears to have for most pain patients, it probably poses a high risk for some patients. Second, studies need to determine speciﬁcally how taking daily doses of narcotics alters patients’ lives and functioning. Third, researchers need to ﬁnd out why tolerance and addiction to narcotics are less likely when they are taken for pain relief. Is it because the doses are so small, for instance, or that the practitioners monitor and set limits on the drug use? Or is it that the patients believe they may lose their painkillers if they use them too much?

Chemical methods alone are usually not sufﬁcient for controlling pain. The need for other approaches in helping pain patients is suggested in the research ﬁndings on three psychosocial factors. First, chronic headache patients tend to use maladaptive ways of coping with everyday stressors more than people without chronic headaches (Mosley et al., 1990). Second, arthritis patients with high feelings of helplessness before drug treatment begins report poorer treatment success in reducing pain and disability than do comparable low-helplessness patients (Nicassio et al., 1993). Third, many patients in research who receive placebo drugs with double-blind procedures report substantial pain relief (Andrasik, Blake, & McCarran, 1986; Feuerstein & Gainer, 1982). Because placebo effects result from psychological processes, we might expect that psychological methods might also relieve pain. As we saw in the gate-control theory in Chapter 11, separating physiological and psychosocial aspects of a person’s pain experience is artiﬁcial.

To summarize, medical treatments of pain focus mainly on using chemical approaches to reduce discomfort. For chronic pain patients, these approaches can be enhanced when combined with pain control methods that other health care professions provide.

Collaborating with Other Professionals

Because psychosocial factors are so important in people’s experience of chronic pain, many medical practitioners treat pain patients by joining forces with psychologists and other health care professionals, such as social workers and physical and occupational therapists. When introducing a team approach to chronic pain patients, physicians need to describe the rationale for it and the functions each professional can provide. For instance,

pain patients might balk at the suggestion that they see a psychologist. They typically believe, generally quite correctly, that their problems have a physical basis. Hence, the relevance of a psychological consultation may not be evident to the patient. The meaning of the referral also may be unclear. The patient may infer that the physician making the referral believes the problem to be somehow less than real, or believes the patient to be seriously maladjusted psychologically. Patients who interpret the referral this way are likely to be guarded with the psychologist. (Cameron & Shepel, 1986, p. 242)

The physician should state clearly that (1) he or she realizes the patient is “obviously living in a great deal of pain,” (2) patients can help themselves control their pain by working with these other professionals, and (3) the physician will be an active part of the team.

Psychologists conduct therapy with patients individually and in groups. Table 12.1 describes some advantages of a group format in helping patients cope with their pain and disability. The pain group provides a forum for talking about their worst fears and conﬂicts to people who share these concerns and understand. Patients often say, “I’m afraid the pain will get worse,” “I was beginning to believe I was imagining the pain,” and “I can’t do things because of the pain,

Table 12.1 Advantages of Group Psychotherapy Over Individual Therapy in Treating Pain

Efﬁciency. Although each patient has unique problems, chronic pain sufferers also face common difﬁculties, such as depression and addiction to medication. As a result, they often need similar types of advice and information. Group meetings use the therapist’s time more efﬁciently.
Reduced isolation. Chronic pain sufferers are typically isolated from extended social contact. This situation can lead to a sense of alienation, which involves feelings of being different from others and of anger and suspicion toward them. Group meetings can help to overcome these feelings.
Credible feedback for patients. Pain patients often resist feedback or advice from therapists, saying such things as, “You don’t know what it’s like to live with pain 24 hours a day!” In their eyes, the type of feedback other patients can give may be more believable.
A new reference group for patients. Patients in a pain group develop new social networks of individuals who are comparable to themselves and who can provide social pressure to conform to the realities and constructive “rules” of living with pain and physical limitations.
A different perspective for the therapist. Watching the patient relate to other individuals in a group provides the therapist with certain kinds of information that may aid in identifying speciﬁc problems therapy should address, such as maladaptive coping styles.

Source: Based on Gentry & Owens (1986).

and I feel guilty, helpless, frustrated, and angry” (Hendler, 1984). Patients in the group may answer, for instance, “You hurt whether you go shopping or not; so the choice isn’t between having pain or not, it’s between whether you go shopping or stay home!” (Gentry & Owens, 1986). These people can say things to each other that others could not, without seeming cruel. Group members can also disconﬁrm each other’s misconceptions, share their own ways for managing pain on a day-to-day basis, give each other hope and social support, and detect and confront each others’ pain games, such as when patients engage in pain behaviors that bring them attention and sympathy.

The goals of psychological treatments for pain include helping clients’ reduce their frequency and intensity of pain, improve their emotional adjustment to the pain they have, increase their social and physical activity, and reduce their use of analgesic drugs. Physicians usually want to minimize their patients’ use of medication, especially when drugs are to be taken on a long-term basis.

BEHAVIORAL AND COGNITIVE METHODS FOR TREATING PAIN

Gate-control theory changed the way many health care workers conceptualize pain by proposing that pain can be controlled not only by biochemical methods that alter sensory input directly, but by modifying motivational and cognitive processes, too. This more complex view of pain provided the rationale for psychologists to develop techniques to help patients cope more effectively with the pain and other stressors they experience and reduce their reliance on drugs for pain control. Some of these techniques use behavioral and cognitive methods, such as by changing patients’ pain behaviors through techniques of operant conditioning.

THE OPERANT APPROACH

At the start of this chapter, we considered the case of a 3-year-old girl whose pain behaviors hampered her rehabilitation after she suffered severe burns months earlier. The help therapists provided was successful. It used an operant approach, in which therapists apply operant conditioning techniques to modify patients’ behaviors.

The approach the therapists used with this girl involved extinction procedures for her pain behavior and reinforcement for appropriate, or “well,” behavior (Varni et al., 1986; Varni & Thompson, 1986). Observations of the child’s social environment revealed that the hospital staff reinforced her pain behaviors— crying, complaining of pain, resisting the nurse’s efforts to put her splints on, and so forth—by giving attention to those behaviors and allowing her to avoid uncomfortable or disliked activities, such as physical therapy. To change this situation, the therapists instructed the hospital staff to:

Ignore the pain behaviors they paid attention to in the past; this method is extinction.
Provide rewards for compliant behavior—telling her, for instance, “If you don’t cry while I put your splints on, you can have some cookies when I’m ﬁnished,” or, “If you do this exercise, we can play a game.”
Praise her if she helps in putting on the splints, sleeps through naptime, goes for a period of time without complaining, or does an exercise.

Changing the consequences of her behavior in these ways had a dramatic effect: her pain behaviors decreased sharply, and she began to comply with requests to do exercises, make positive comments about her accomplishments, and assist in putting on her splints.

The operant approach to treating pain can be adapted for use with individuals of all ages, in hospitals and at home—and elements of the operant approach can be introduced before pain behavior becomes chronic. But treatment programs using this approach are usually applied with patients whose chronic pain has already produced serious difﬁculties in their lives. These programs typically have two main goals: the ﬁrst is to reduce the patient’s reliance on medication. This can be achieved, with the patient’s approval, by mixing the painkiller with a ﬂavored syrup, called a “pain cocktail,” and giving it on a ﬁxed schedule, such as every 4 hours, rather than whenever the patient requests it (Fordyce, 1976). Because receiving the painkiller is not tied to requesting it, any reinforcing effect the drug may have on that pain behavior is eliminated. Then, over a period of several weeks, the dosage of medication in the cocktail is gradually reduced until the syrup contains little or no drugs.

The second goal of the operant approach is to reduce the disability that generally accompanies chronic pain conditions. This is accomplished by altering the consequences for behavior so that they promote “well” behavior and discourage pain behavior, as we just saw in the program with the young burn patient. The chief feature of this approach is that the therapist trains people in the patient’s social environment to monitor and keep a record of pain behaviors, try not to reinforce them, and systematically reward physical activity. The reinforcers may be of any kind— attention, praise and smiles, candy, money, or the opportunity to watch TV, for example—and may be formalized within a behavioral contract (Fordyce, 1976). The therapist periodically reviews the record of pain behavior to determine whether changes in the program are needed.

Is the operant approach effective? Studies have shown that operant techniques can successfully decrease patients’ pain reports and medication use and increase their activity levels (Morley, Eccleston, & Williams, 1999; Roelofs et al., 2002). Although these ﬁndings are promising, some limitations should be mentioned. First, after the operant intervention ends and rewards are discontinued, some patients revert to their old pattern of inactivity and pain behavior. Second, not all chronic pain patients are likely to beneﬁt from operant methods. For one thing, the goals of this approach seem more appropriate for patients with chronic-recurrent or chronic-intractable-benign pain than for those with chronic-progressive pain, such as in cancer patients. Also, patients are less likely to show behavioral improvements if they or people in their social environment are unwilling to participate and if they receive disability compensation (Fordyce, 1976). Despite these limitations, it seems clear that the operant approach can be a very useful component in treatment programs for many acute and chronic pain patients.

RELAXATION AND BIOFEEDBACK

Many people experience chronic episodes of pain resulting from underlying physiological processes that can be triggered by stress. If these patients could control their stress or the physiological processes that cause pain, they should be able to decrease the frequency or intensity of discomfort they experience. We saw in Chapter 4 that stress is one of many factors that can produce episodes of migraine and tension-type headache. Until recently, researchers thought that stress triggers migraine headache by dilating arteries surrounding the brain and triggers tension-type headache by persistently contracting muscles of the scalp, neck, and shoulders (Andrasik, 1986). However, it is now clear that nervous system dysfunction is involved, such as sensitization or inﬂammation of nerves in the face and arteries around the brain (AMA, 2003; Holroyd, 2002).

Although the exact role of stress in these processes is not yet known, researchers have applied progressive muscle relaxation and biofeedback to reduce stress and related physiological processes in an effort to decrease headaches. These treatments are usually conducted in weekly sessions that span about 2 or 3 months (see, for example, Blanchard et al., 1986). We saw in Chapter 5 that individuals using the technique of progressive muscle relaxation focus their attention on speciﬁc muscle groups while alternately tightening and relaxing these muscles. In biofeedback procedures, people learn to exert voluntary control over a bodily function, such as heart rate, by monitoring its status with information from electronic devices (Saraﬁno, 2001). Of the many physiological processes people can learn to control through biofeedback, we’ll consider one: to treat tension-type headaches, patients learn to control the tension of speciﬁc muscle groups, such as those in the forehead or neck. They learn by receiving biofeedback from an electromyograph (EMG) device, which measures electrical activity in those muscles. Therapists urge patients to practice these skills at home and use them when they feel pain episodes beginning—doing so improves treatment success (Gauthier, Côté, & French, 1994).

Do Relaxation and Biofeedback Help Relieve Pain?

Relaxation and biofeedback methods relieve pain. This broad conclusion comes from reviews and metaanalyses of studies that examined the effectiveness of these procedures (Bogaards & ter Kuile, 1994; Holroyd & Penzien, 1986; Morley, Eccleston, & Williams, 1999; Penzien, Rains, & Andrasik, 2002; Roelofs et al., 2002). But several points need to be made about this conclusion. First, although studies have demonstrated that relaxation and biofeedback treatments can help alleviate many types of pain, such as arthritic, phantom limb, and low back pain, the large majority of studies testing these treatments have focused on headache pain. Treatment with relaxation or biofeedback reduces the frequency of migraine and tension-type headaches by about 40 to 50% (Holroyd, 2002).

Second, progressive muscle relaxation and biofeedback treatments are about equally effective in relieving headache pain, but EMG biofeedback is somewhat more effective than relaxation (Holroyd, 2002). Studies have examined the success of these procedures by assessing whether the patients’ daily records at the end of treatment showed decreases in the headache pain (its frequency, intensity, and duration) and by comparing the headache pain of patients who received these treatments with those who were in control groups. In one type of control group, the subjects receive no training but monitor their headache pain with daily records. In another type of control condition, subjects keep records and receive a placebo treatment, such as by taking sham medication or by receiving biofeedback sessions that give false feedback about changes in their bodily functions. Generally speaking, treatment with relaxation or biofeedback is about twice as effective in relieving pain as placebo conditions, which are more effective than just monitoring headache pain (Holroyd & Penzien, 1986). Figure 12–1 depicts these effects for tension-type (muscle-contraction) headache sufferers, averaged across subjects in many studies.

Third, the graph in Figure 12–1 suggests that headache sufferers get more pain relief when biofeedback and progressive muscle relaxation are combined, but these differences are not reliable because patients vary greatly in the amount of beneﬁt they get from

Percent Change in Headache Pain

+50 −5 −10 −20 −30 −40

Relaxation and Biofeedback

Biofeedback only

Relaxation only

Placebo Biofeedback

Monitor Headache

these treatments. For instance, among individuals who received relaxation treatment only, the percentage by which their pain improved ranged from 17 to 94%; among those who had the combined treatment, improvements ranged from 29 to 88% (Holroyd & Penzien, 1986). This variability is important: it reﬂects that many patients—especially middle-aged and elderly ones—seem to gain relatively little relief with these treatments (Blanchard & Andrasik, 1985; Holroyd & Penzien, 1986). Since biofeedback treatment is relatively expensive to conduct, being able to predict who will beneﬁt from it most would be useful. Some evidence suggests, for example, that most children and those individuals of all ages who show certain psychophysiological patterns, such as a high correlation between their pain and EMG levels, may be better candidates for biofeedback treatment than other people (Keefe & Gil, 1985; Saraﬁno & Goehring, 2000).

Fourth, although the pain relief patients experience with progressive muscle relaxation or biofeedback treatment may result from the speciﬁc skills they have learned for controlling physiological processes, other psychological factors also seem to play a role. Consider, for instance, two ﬁndings. One is that placebo conditions often produce more relief than simply monitoring headache pain (Andrasik, 1986). The other is that massage therapy over a period of time can reduce chronic pain (Moyer, Rounds, & Hannum, 2004). Why? Patients’ thoughts, beliefs, and spontaneous cognitive strategies probably account for these ﬁndings and contribute to part of the success of relaxation and biofeedback treatments in controlling pain (Turk, Meichenbaum, & Genest, 1983).

−50 −60

Figure 12–1 Percentage of change in headache pain, pretreatment to posttreatment, across many studies with patients suffering from chronic muscle-contraction (tension-type) headaches. Treatments consisted of EMG biofeedback, or relaxation, or EMG biofeedback and relaxation combined. Control conditions consisted of placebo biofeedback or simply monitoring headache pain. (Data from Holroyd & Penzien, 1985, Table IV.)

Are the Improvements from Relaxation 3 and Biofeedback Durable?

After a patient completes the treatment for chronic pain, how long do the effects of the treatment last? ₂

Do the effects wear off in a few weeks or months? This is an issue of great importance in health psychology. As we saw in earlier chapters, interventions do not always last, such as in cases of alcohol abuse, and relapse often occurs. Pain researchers have addressed this issue by conducting a 5-year followup investigation on chronic headache patients who completed training for either progressive muscle relaxation or for

Headache pain

both relaxation and biofeedback (Blanchard et al., 1986; Blanchard, Andrasik, et al., 1987; Blanchard, Appelbaum, et al., 1987).

The subjects in this research were adult patients who had suffered many years either from muscle-contraction (tension-type) headache or from “vascular” headache, which includes both migraine and combined (migraine plus tension-type) headache. All patients received relaxation training in ten sessions, spanning 8 weeks. Those people whose headache pain had not improved by at least 60% were offered additional treatment with biofeedback. All subjects had an audiotape to guide their practice of relaxation, and the vascular patients who received training in temperature biofeedback were given a temperature-monitoring device to use at home. The patients kept daily “headache diaries” with four ratings each day of their headache pain. Psychological assessment before and after the treatment revealed that their feelings of depression and anxiety decreased substantially (Blanchard et al., 1986). For 6 months after completing the treatment, the patients received treatment booster sessions if they desired them.

A difﬁculty in doing longitudinal research is that the number of original subjects who are available and willing to participate declines over time. At the time of the last annual followup, a little more than half of the patients could be located and agreed to participate. Figure 12–2 presents the people’s ratings of headache pain during each of seven 4-week periods: pretreatment, post-treatment, and years 1 through 5 in the followup. As you can see, the treatment effects were quite durable for these patients. What about the patients who did not continue through the 5-year followup? Although there is no way of knowing for sure, the researchers presented evidence to suggest that the treatments were durable for them, too (Blanchard, Andrasik, et al., 1987; Blanchard, Appelbaum, et al.,

PrePost1 2 3 4

Figure 12–2 Averaged ratings of headache pain for muscle-contraction (tension-type) and vascular (migraine and combined) headache patients who successfully completed treatment and continued to participate in the followup. The graphs depict these ratings at pretreatment, post-treatment, and followup years 1 through 5. (Data from Blanchard, Appelbaum, et al., 1987, Table 1.)

1987). And ﬁndings of other followup studies conﬁrm that completing relaxation training or both relaxation and biofeedback training provides durable headache relief for at least 2 years (Blanchard, 1987).

Progressive muscle relaxation and biofeedback techniques are very helpful in controlling the discomfort many chronic pain patients experience, but these treatments do not provide all the pain relief most patients need. Because chronic pain involves a complex interplay of sensory and psychosocial factors, therapists generally use these techniques along with several other approaches, especially cognitive therapies that address the thought patterns that occur when people experience pain.

COGNITIVE METHODS

What do people think about when they experience pain? In an acute pain situation, some people focus on the ordeal and how uncomfortable and miserable they are, but others do not (Turk & Rudy, 1986). For example, researchers asked children and adolescents what they think about when getting an injection at their dentist’s ofﬁce (Brown et al., 1986). Over 80% of the subjects reported thoughts that focused on negative emotions and pain, such as, “This hurts, I hate shots,” “I’m scared,” and “My heart is pounding and I feel shaky.” One-fourth of the subjects had thoughts of escaping or avoiding the situation, as in, “I want to run away.” Thoughts like these focus the person’s attention on unpleasant aspects of the experience and make the pain worse (Keefe et al., 1994; Turk & Rudy, 1986).

Not all people who experience acute pain focus on the ordeal and discomfort; many use cognitive strategies to modify their experience. For instance, by 10 years of age, many children report that they try to cope with pain in a dental situation by thinking about something else or by saying to themselves such things as, “It’s not so bad” or “Be brave” (Brown et al., 1986). But even when children know ways to cope with pain and recommend them for others to use, they don’t necessarily use those skills themselves (Peterson et al., 1999). Although coping skills tend to improve as children get older, many patients in adulthood still exaggerate the fearful aspects of the painful medical procedures they experience (Chaves & Brown, 1987).

How do people cope with chronic pain? Some approaches they use involve active coping, in which they try to keep functioning by ignoring their pain or keeping busy with an interesting activity. Other approaches involve passive coping, such as taking to one’s bed or curtailing social activities. For many chronic pain patients, a vicious circle develops in which passive coping leads to feelings of helplessness and depression, which leads to more passive coping, and so on (Smith & Wallston, 1992). Family and friends inﬂuence people’s coping patterns by reinforcing some behaviors but not others (Menefee et al., 1996). The impact of chronic pain also depends on they way patients view their conditions (Jensen et al., 1999; Williams & Keefe, 1991). Those who believe their pain will last a very long time, is a sign of a disabling injury, and has unknown causes tend to show more pain behaviors and cope poorly, thinking the worst about their conditions and feeling that active coping strategies will not work. On the other hand, patients who believe that they understand the nature of their pain and that their conditions will improve tend to use active coping strategies. Those who cope well are more likely to return to work despite their pain (Linton & Buer, 1995).

To help people cope effectively with pain, medical and psychological practitioners need to assess and address their patients’ beliefs. Cognitive techniques for treating pain involve active coping strategies, and many of these methods are, in fact, quite effective in helping people cope with pain. These techniques can be classiﬁed into three basic types: distraction, imagery, and redeﬁnition (Fernandez, 1986; McCaul & Malott, 1984). We will examine these methods and consider their usefulness for people with acute and chronic pain.

Distraction

At your dentist’s ofﬁce, do the examination rooms have colorful pictures or large windows with nice views on all the walls that a patient can see while in the dental chair? My dentist’s rooms do, and I use the pictures and windows to distract my attention when I feel the need. Distraction is the technique of focusing on a nonpainful stimulus in the immediate environment to divert one’s attention from discomfort (Fernandez, 1986). We can be distracted from pain in many ways, such as by looking at a picture, listening to someone’s voice, singing a song, counting ceiling tiles, playing a video game, or doing mathematics problems.

Not all distraction attempts are likely to work in relieving pain. Research on acute pain has shown that these strategies are more effective if the pain is mild or moderate than if it is strong (McCaul & Malott, 1984). Three aspects of the distraction task seem to affect how well it works. One aspect is the amount of attention the task receives; the greater the attention the task requires, the lower the pain ratings. Experiments with college students with the cold-pressor procedure found this effect, particularly when the ratings of pain were taken several minutes after the arm was removed from the cold water rather than while it was in the water (Christenfeld, 1997; McCaul, Monson, & Maki, 1992). The distraction tasks involved watching and reacting to numbers or colored lights on a panel or screen. High-distraction tasks required frequent or complex reactions to the stimuli.

The second factor that seems to affect whether distraction relieves pain is the extent to which the task is interesting or engrossing. Researchers compared the pain and coping behavior of 10-year-old children when receiving immunization injections under three conditions: standard care, application of a local anesthetic, or distraction (Cohen, Blount et al., 1999). The distraction task was engrossing: it involved watching a movie of the child’s choice and answering a nurse’s questions, such as “Which one is the good guy?” The children showed less distress and better coping under the distraction condition than under the standard care or anesthetic conditions. Similar distracting tasks have been applied successfully with infants and with preschoolers undergoing repeated injections (Cohen, 2002; Dahlquist et al., 2002).

The third factor in whether distraction relieves pain is its credibility to the person. A study demonstrated this by having college students undergo the cold-pressor procedure while listening to distracting stimuli through earphones (Melzack, Weisz, & Sprague, 1963). During the cold-pressor test, the students in one condition listened to a clearly noticeable sound, such as music, after having been told that they could control its volume and that dentists had found that loud sound helps reduce pain. Students in another condition got similar instructions, but they tried to listen for a low-intensity “hum” that really didn’t exist. The subjects who heard the noticeable sound kept their hands in the cold water longer than those who listened for the hum. Since there was no sound, the students probably didn’t believe the technique would work.

Because of the role of credibility in using distraction methods, therapists may need to help patients understand how these techniques can work. One therapist described the following approach for doing this:

First, I ask the patient to be aware of the sensations in his thighs as he sits in his chair. I note that those sensations are real, and they have a physical basis, but they are not normally experienced because other things occupy his attention. Then I suggest that he think of a TV set: he could block out the channel 9 signal by tuning in channel 11; the channel 9 signal is still there, but not being tuned in. I suggest that while his pain signals are real, he can learn to “tune them out.” . . . A number of pain patients have reported that they frequently think of the TV metaphor when experiencing pain and take appropriate action to “tune out.” (Cameron, quoted in Turk, Meichenbaum, & Genest, 1983, p. 284)

By providing plausible explanations for a recommended technique, therapists can increase its effectiveness and the likelihood that the patient will use it.

Distraction strategies are useful for reducing acute pain, such as that experienced in some medical or dental procedures, and they can also provide relief for chronic pain patients in some circumstances (McCaul & Malott, 1984). Singing a song or staring intently at a stimulus can divert the person’s attention for a short while—and this may be a great help, such as for an arthritis sufferer who experiences heightened pain when climbing stairs. People who want to use distraction for moderate levels of continuous pain may get longer-lasting relief by engaging in an extended engrossing activity, such as watching a movie or reading a book.

Imagery

Sometimes when children are about to receive injections, their parents will say something like, “It’ll be easier if you think about something nice, like the fun things we did at the park.” Nonpain imagery—sometimes called guided imagery—is a strategy whereby the person tries to alleviate discomfort by conjuring up a mental scene that is unrelated to or incompatible with the pain (Fernandez, 1986). The most common type of imagery people use involves scenes that are pleasant to them—they think of “something nice.” This scene might involve being at the beach or in the country, for instance. Therapists usually encourage, or “guide,” the person to include aspects of different senses: vision, hearing, taste, smell, and touch. As an example, the scene at the beach could include the sight and smell of the ocean water, the sound of the waves, and the warm, grainy feel of the sand. The person generally tries to keep the imagined event in mind as long as possible.

The imagery technique is in many ways like distraction. The main difference is that imagery is based on the person’s imagination rather than on real objects or events in the environment. As a result, individuals who use imagery do not have to depend on the environment to provide a suitably distracting stimulus. They can develop one or more scenes that work reliably, which they “carry” around in their heads. They can then call one of these scenes up for pain relief whenever they need it. Imagery seems to work best when it attracts high levels of the person’s attention or involvement, and it is likely to work better with mild or moderate pain than with strong pain (McCaul & Malott, 1984; Turk, Meichenbaum, & Genest, 1983). Although imagery clearly helps in reducing acute pain, the extent of this technique’s usefulness with longer-lasting pain episodes is unclear. One limitation with using imagery in pain control is that some individuals are less adept in imagining scenes than others (Melzack & Wall, 1982).

Redeﬁnition

The third type of cognitive strategy for reducing discomfort is pain redeﬁnition, in which the person substitutes constructive or realistic thoughts about the pain experience for thoughts that arouse feelings of threat or harm (Fernandez, 1986; McCaul & Malott, 1984). Therapists can help people redeﬁne their pain experiences in several ways. One approach involves teaching clients to engage in an internal dialogue, using positive self-statements that take basically two forms (Fernandez, 1986):

Coping statements emphasize the person’s ability to tolerate the discomfort, as when people say to themselves, “It hurts, but you’re in control,” or, “Be brave—you can take it.”
Reinterpretative statements are designed to negate the unpleasant aspects of the discomfort, as when people think, “It’s not so bad,” “It’s not the worst thing that could happen,” or, “It hurts, but think of the beneﬁts of this experience.”

This last statement can be particularly appropriate for persons undergoing painful medical procedures.

Two other methods can help people redeﬁne their pain experiences. First, therapists can provide information about the sensations to expect in medical procedures, thereby reducing the pain that patients experience when undergoing these procedures (Anderson & Masur, 1983). The information therapists provide can also help clients remember more accurately the amount of pain they experienced in these procedures in the past and how well they coped (Chen et al., 1999). Since many patients exaggerate the discomfort they will feel and misremember past pain experiences, providing realistic information helps them redeﬁne the experiences before they occur. Second, therapists can help individuals see that some of their beliefs are illogical and are making the discomfort worse. (Go to

The Value of Cognitive Strategies in Controlling Pain

Studies have found that cognitive strategies effectively reduce acute pain (Fernandez & Turk, 1989; Manne et al., 1994). Distraction and imagery seem to be particularly useful with mild or moderate pain, and redeﬁnition appears to be more effective with strong pain (McCaul & Malott, 1984). How helpful are cognitive methods for treating chronic pain? The answer is likely to depend on many factors, such as the severity of the pain, the type of illness, and the methods used. Redeﬁnition may be more effective in relieving chronic pain than distraction is. A study compared these two techniques in reducing the chronic pain of patients who were receiving physical rehabilitation for a variety of medical problems, including arthritis, amputation, and spinal cord injury (Rybstein-Blinchik, 1979). Although both techniques were effective, patients who received redeﬁnition training reported less pain and exhibited less pain behavior than those who were trained in distraction.

Because each behavioral and cognitive strategy we’ve considered can be helpful in treating clinical pain, programs for chronic pain sufferers generally combine different types of methods. One study, for instance, used a program that combined imagery, redefinition, and progressive muscle relaxation training to treat chronic low back pain patients (Turner, 1982). Some people received this program, others received a program of only relaxation training, and a third group served as controls. Compared with the control subjects, the patients in both programs reported much less pain, depression, and disability by the end of treatment, and these improvements were similar for the people in both programs. A followup on the patients in the two programs more than 1¹⁄2 years later revealed that the beneﬁts of the treatments were maintained, as measured by the people’s ratings of pain and reports of health care use. However, the patients who received the program combining cognitive strategies and relaxation also showed a marked improvement in their employment, working 60% more hours per week than those who had the program of relaxation only.

Programs combining behavioral and cognitive methods are at least as effective as chemical methods in reducing chronic tension-type headaches (Holroyd, 2002). What’s more, a review of research and a meta-analysis have shown that cognitive-behavioral programs are effective in treating chronic pain conditions, such as headache, arthritis, and low back pain, but programs with only behavioral methods may sometimes be sufﬁcient (Compas et al., 1998; Morley, Eccleston, & Williams, 1999). To summarize, several behavioral and cognitive methods can help people control acute and chronic pain. These methods include operant techniques, progressive muscle relaxation and biofeedback, and the cognitive strategies of distraction, imagery, and redefinition. Behavioral and cognitive methods are often most helpful when used in combination. (Go to .)

HYPNOSIS AND INTERPERSONAL THERAPY

You may have noticed that the behavioral and cognitive methods we just described for relieving pain sound familiar—and they should. For the most part, they involve psychological procedures derived from the stress reduction techniques we considered in Chapter 5. Because people’s experiences of pain include an emotional component and are stressful, and because behavioral and cognitive methods are effective in reducing stress, psychologists have adapted these techniques to help people control their pain. Other psychological approaches have also been applied to relieve pain. These approaches include hypnosis and interpersonal therapy.

HYPNOSIS AS A TREATMENT FOR PAIN

In the mid-1800s, before ether was discovered, dramatic reports began to appear of physicians performing major surgery on individuals, using hypnosis as the sole method of analgesia (Bakal, 1979; Barber, 1986). In one such case of a woman with breast cancer, a surgeon made an incision halfway across her chest and removed the tumor as well as several enlarged glands in her armpit. During the procedure, the woman conversed with the surgeon and showed no signs of feeling pain. Another physician reported having done hundreds of surgeries with hypnosis as the only analgesic and argued that the patients experienced no pain.

Can Hypnosis Eliminate Acute Pain?

Were all of these operations painless? Probably not— although many patients claimed to feel no pain, some showed other pain behaviors, such as facial expressions, suggesting they were suppressing their agony (Bakal, 1979). Nevertheless, hypnosis can reduce the intensity of acute pain, but it is not highly effective for all individuals (Hilgard & Hilgard, 1983; Patterson & Jensen, 2003; Zeltzer et al., 1997). People vary in their ability to be hypnotized, and those who can be hypnotized very easily and deeply seem to gain more pain relief from hypnosis than those who are less hypnotically susceptible (Freeman et al., 2000; Milling, Levine, & Meunier, 2003).

How does hypnosis reduce pain? Although the mechanisms underlying pain relief from hypnosis are not clear, part of the answer seems to involve physiological changes that occur in the brain and spinal cord of people who are highly suggestible when they are hypnotized (Patterson & Jensen, 2003). Other factors may involve the deep relaxation people experience when hypnotized—as we saw earlier, relaxation can relieve pain—and cognitive factors, such as by producing states of heightened attention to internal images (Barber, 1986; Turk, Meichenbaum, & Genest, 1983). Studies have shown that hypnosis and cognitive-behavioral methods produce similar pain relief and that combining these methods does not enhance their effects (Liossi & Hatira, 1999; Milling, Levine, & Meunier, 2003).

Hypnosis is a dramatic and unusual phenomenon. Laboratory research on acute pain, induced by cold-pressor or muscle-ischemia procedures, has found that (Barber, 1982):

When hypnotized, the people who gain the most pain relief from suggestions of analgesia tend to be those who are highly responsive to other suggestions, such as that their arm is becoming light.
Whether under hypnosis or not, individuals who are told to try not to feel pain tend to use distraction and redeﬁnition techniques.
Contrary to the common myths about hypnosis, people usually show as much pain reduction using cognitive strategies, such as imagery and redeﬁnition, as they do under hypnosis.

It may be that some patients who were supposedly hypnotized actually were not, and they may have applied cognitive strategies to reduce the pain.

Can Hypnosis Relieve Chronic Pain?

Hypnosis can reduce chronic pain. Although most relevant studies have tested patients with recurrent headache, some have shown that hypnosis also helps with other pain conditions, such as low back pain and cancer pain (Patterson & Jensen, 2003). In general, hypnosis is about as effective as relaxation therapy, and, interestingly, regardless of which of these therapies people receive, their pain relief is greatest if they are high in hypnotic suggestibility. These ﬁndings lead to an important question: What is it about being highly suggestible that helps people apply psychological methods to control their pain?

INTERPERSONAL THERAPY FOR PAIN

Interpersonal therapy uses psychoanalytic and cognitive-behavioral perspectives to help people deal with emotional difﬁculties, such as adjusting to chronic pain, by changing the way they interact with and perceive their social environments (Davison, Neale, & Kring, 2004). The underlying theory is that people’s emotional difﬁculties arise from the way they relate to others, particularly family members. Therapy sessions involve discussions to help clients gain insights into their own motivations and how their behavior toward other people affects their own emotional adjustment. In the case of chronic pain patients, the insights often relate to feelings they and their families have about the pain condition, how they deal with pain behavior, and changes that have developed in the interpersonal relationships of these people.

An example of this approach involves showing patients how their pain behavior is part of “pain games” they play with other people (Szasz, cited in Bakal, 1979). In these games, individuals with chronic pain seem to take on roles in which they continually seek to conﬁrm their identities as suffering persons, maintain their dependent lifestyles, and receive various secondary gains, such as attention and sympathy. These patients are probably not aware of what is actually happening in these games, and the purpose of this psychotherapeutic approach is to make them aware. The assumption is that once patients gain an insight into how their behavior patterns are affecting their lives, they can give up the games if they want to and are shown how.

Therapies leading to insight can also help chronic pain patients and their families understand the problems they experience in their relationships within the family system (Flor & Turk, 1985; Kerns & Payne, 1996). For instance, when a spouse suffers from chronic pain, both spouses experience feelings of frustration, anger, helplessness, and guilt that they often do not communicate openly to each other. These feelings can result from changes in their roles, general style of communication, and sexual relationship. The following excerpt shows how a therapist was able to help a pain patient, John Cox, and his wife gain insights about their feelings and behavior. The three of them were discussing a pain episode John had had while he watched TV with his wife, and the therapist (T) asked the wife how she reacted when she realized he was in pain:

Mrs. Cox: I really felt sorry for John, but I didn’t know what to do. I just tried to watch the show and not say anything to him. At those times I feel . . . so helpless.

T:: Perhaps? MR.COX:Well maybe she did know how I was feeling,

but I felt upset that she didn’t tell me. (Turk, Meichenbaum, & Genest, 1983, pp. 244–245)

Insights such as these help family members understand each others’ feelings and points of view, and this understanding can help to break down the long-standing confusion and conﬂicts that have developed over time. Improvements in family relationships can enable the therapist to enhance the cooperation of each member in the treatment process (Kerns & Payne, 1996). Also, interpersonal therapy appears to be useful in treating depression, a common problem among pain patients (Davison, Neale, & Kring, 2004).

In summary, hypnosis and interpersonal therapy offer promising techniques in the treatment of chronic pain. Thus far in our discussion of methods for reducing pain we have considered a variety of medical and psychological techniques. In the next section, we will see how physical therapy and certain skin stimulation methods can also play important roles in controlling pain.

PHYSICAL AND STIMULATION THERAPIES FOR PAIN

Anthropologists and medical historians have noted that most, if not all, cultures in recorded history have learned that people can “ﬁght pain with pain” (Melzack & Wall, 1982). One pain can cancel another—a brief or moderate pain can cancel a longer-lasting or stronger one. For example, you might reduce the pain of an injection by pressing your thumbnail into your foreﬁnger as the shot is given. Reducing one pain by creating another is called counter-irritation. People in ancient cultures developed a counter-irritation procedure called cupping to relieve headaches, backaches, and arthritic pain. In this procedure, one or more heated glass cups are inverted and pressed on the skin. As the air in the cup cools, it creates a vacuum, causing the skin to be bruised as it is drawn up into the cup. This method is still used in some parts of the world today (Melzack & Wall, 1982).

The principle of counter-irritation is the basis for present-day stimulation therapies for reducing pain. After examining these pain control methods, we will discuss the important role other physical approaches can play in reducing pain.

STIMULATION THERAPIES

Why does counter-irritation relieve pain? One reason is that people actively distract their attention from the stronger pain to the milder one. Another explanation comes from gate-control theory. Recall that activity in the peripheral ﬁbers that carry signals about mildly irritating stimuli tends to close the gate, thereby inhibiting the transmission cells from sending pain signals to the brain. Counter-irritation, such as massaging a sore muscle, activates these peripheral ﬁbers, and this may close the gate and soothe the pain.

This gate-control view of how counter-irritation works led to the development of a pain control technique called transcutaneous electrical nerve stimulation (TENS). This technique involves placing electrodes on the skin near where the patient feels pain and stimulating that area with mild electric current, which is supplied by a small portable device. Anecdotal evidence suggests that TENS can reduce acute muscular and postoperative pain (Chapman, 1984; Hare & Milano, 1985). For example, a 9-year-old boy began receiving TENS while still unconscious after kidney surgery and then awoke, not feeling any pain. He thought the surgery had not occurred and that the hospital staff was not telling the truth when they said it did. When

asked why it couldn’t be true, he asserted

conﬁdently, “Because I haven’t got any bandages.”

We asked him to feel his belly, since his hands

were outside of the bedclothes. When he did, an

expression of astonishment came over his face.

(Chapman, 1984, p. 1265)

Then, he claimed to feel pain and began to cry. Despite this dramatic anecdote, evidence today indicates that TENS is not effective in reducing acute pain (Johnson, 2001). And its success in treating chronic pain is unclear. When TENS does relieve discomfort for some chronic conditions, such as phantom limb pain, its effects are often short-lived (Hare & Milano, 1985; Zeltzer et al., 1997).

Another stimulation therapy that is used today for reducing pain is acupuncture, a technique in which ﬁne metal needles are inserted under the skin at special locations and then twirled or electrically charged to create stimulation. Acupuncture has been used in China for at least the past 2,000 years and was originally based on the idea that pain occurs when the life forces of yin and yang are out of balance (AMA, 2003; Bakal, 1979; CU, 1994). Although acupuncturists do not necessarily believe this rationale any longer, many, but not all, still determine the placement of the needles on the basis of charts that show hundreds of insertion points on the body. These acupuncturists believe that stimulation at several speciﬁc points relieves pain in associated parts of the body. On the nose and ear, for example, certain points are associated with the small intestine, whereas other points are associated with the kidney, or heart, or abdomen.

Does acupuncture work? Its ability to produce high levels of analgesia for acute pain in some individuals has been clearly and dramatically demonstrated; for instance, surgeons have performed major surgery on patients with only acupuncture anesthesia. But research ﬁndings point to several conclusions about its effects and its limitations (Bakal, 1979; Chapman, 1984; Melzack & Wall, 1982):

Even in China, physicians perform only a small percentage (less than 10%) of surgeries with acupuncture analgesia, and these operations are straightforward ones with little likelihood of complications.
Patients must volunteer for the procedure, and then their physicians select appropriate candidates very carefully and make sure these patients are well indoctrinated.
Acupuncture is rarely effective for surgical patients in Western cultures.

Laboratory studies have shown that acupuncture produces only mild analgesia in most people.
The degree of analgesia acupuncture produces depends on the intensity of the stimulation, and not on its being applied at the exact points described on acupuncture charts.
Pain patients who beneﬁt most from acupuncture tend to be those who are also easily and deeply hypnotizable.

Acupuncture does not provide long-term relief for most chronic pain patients, but some evidence indicates that it is useful in treating headache and low back pain (Mayer, 2000; Zeltzer et al., 1997).

It is tempting to conclude from these ﬁndings that acupuncture works simply through suggestion or distraction effects, but this seems unlikely because the technique also produces analgesia in animals, such as monkeys and mice (Melzack & Wall, 1982). Psychological factors cannot provide a full explanation. Gate-control theory provides two plausible reasons for the effects of acupuncture: stimulation from the needles may close the gate by activating peripheral ﬁbers or the release of opioids, such as endorphins (Bakal, 1979; Zeltzer et al., 1997).

PHYSICAL THERAPY

Physical therapy is an important rehabilitation component for many medical conditions—for instance, after injury or surgery, patients perform exercises to enhance muscular strength and tissue ﬂexibility to restore their range of motion. Physical therapists have a variety of techniques they can incorporate into individualized treatment programs to help patients who suffer from acute and chronic pain conditions. Exercise is a common feature in these programs (AMA, 2003; Zeltzer et al., 1997).

The therapist and patient generally plan the program together, setting daily or weekly goals that promote very gradual but steady progress. The progress is tailored to the patient’s needs, being fast enough to promote a feeling of accomplishment but slow enough to prevent overexertion, reinjury, or failure. In cases of acute injury, such as serious damage to the knee joint, the exercise program might span a year or two. The rationale for using exercise to control pain depends on the type of health problem the patient has. With arthritis, for instance, exercise helps by maintaining the ﬂexibility of the joints and preventing them from becoming deformed (Minor & Sanford, 1993). Other approaches in physical therapy, such as massage, traction, and applying heat or cold to the painful area of the body, seem to provide temporary pain relief (Tunks & Bellissimo, 1991). The spinal manipulation treatment people get from chiroproactic and osteopathic specialists, especially for neck and lower back pain, is not generally considered to be physical therapy, but it appears to relieve back pain (Andersson et al., 1999; Bove & Nilsson, 1998).

Physical therapy programs are widely used in treating two highly prevalent chronic pain conditions, arthritis and low back pain (Minor & Sanford, 1993; Moffet et al., 1999). For both of these conditions, exercise is probably the most important physical therapy approach for achieving long-term pain relief. For instance, programs for low back pain that gradually increase exercise produce substantial improvements in self-reports of pain and ability to perform physical activities, such as standing and lifting weights (Alaranta et al., 1994; Moffet et al., 1999). Sometimes physical therapy is combined with behavioral methods in treating chronic pain to gain the beneﬁts of each approach, and treatments for low back pain provide a good example again. A study compared the beneﬁts of two 10-week programs—one with physical therapy, the other with behavioral and cognitive methods—for adults with chronic low back pain (Heinrich et al., 1985). Both groups experienced similar reductions in pain across many months, and each group showed improvements that were speciﬁc to the programs they received. At the end of the programs and at followup, subjects in the physical therapy group showed better physical functioning, and those in the behavioral-cognitive group showed better psychosocial adjustment. Other research has combined these methods and found that low back pain patients show less pain behavior, disability, and self-reported pain with both physical and behavioral-cognitive therapy than with either approach alone (Turner et al., 1990).

In this chapter we have described many different types of treatment, including medical, psychological, and physical therapies, and we have seen that each method can help to alleviate clinical pain. Some methods seem to be more effective than others, especially for particular pain conditions. Typically, no single approach is sufﬁcient by itself. Therefore, specialists who provide treatment in pain clinics often apply several methods in combination. (Go to .)

muscle or ligament strains, lack of proper exercise, should people do when they develop backaches? and normal wear and tear on facet joints. These Medical advice in the past called for getting lots of problems tend to increase with age for many rea-bed rest and taking aspirin. But this advice has sons—for instance, people’s muscular conditioning changed as a result of new research (Deyo et al., usually declines as they get older, the effects of wear 1991; USDHHS, 1994). Most backaches resolve and tear accumulate, and the disks gradually dry out themselves in a few days or weeks with or without and provide less cushioning for the vertebrae. Peo-medical attention. Physicians today recommend ple whose jobs require frequent heavy lifting are that the person become active as soon as possible— more likely than other workers to develop low back walking and exercising cautiously—even if it hurts a pain (Kelsey & Hochberg, 1988). Exercise can help little. People with back pain should consult their protect people from back problems, but it needs to doctor when the pain is: consist of proper activities. People who do the wrong

• Linked to a known injury, such as from a fall.

kinds of exercises do not get this protection, and those who overexert themselves can precipitate • Severe enough to disable the sufferer and awaken back pain.

him or her at night.

What kinds of physical activity can help protect • Not relieved by changing position or lying down. against back problems? Proper exercise involves a

• Accompanied by nausea, fever, difﬁculty or pain in program of back-strengthening and stretching activurinating, loss of bladder or bowel control, numb

ities, along with abdominal exercises. Many differ-ness or weakness in a leg or foot, or pain that

ent exercises are available for these purposes, and shoots down the leg.

Figure 12H–1 presents a few easy ones. What

PAIN CLINICS

Before the 1970s, if a person’s pain lingered, and physicians could not determine its cause or ﬁnd a remedy for the discomfort, that patient was left with virtually no reasonable treatment alternatives. In desperation, such people often tried extreme medical approaches that could lead to drug addiction or irreversible nerve damage, or they may have turned to charlatans. Although many people with chronic pain still use ill-conceived, desperate measures to gain relief from their discomfort, effective alternatives are available today, as we have seen. Effective pain control treatments can now be obtained through pain clinics (or pain centers), which are institutions or organizations that have been developed speciﬁcally for the treatment of chronic pain conditions.

The concept of having special institutions for treating pain originated with John Bonica, an anesthesiologist who founded the ﬁrst pain clinic at the University of Washington Medical School (Fordyce, 1976; Melzack & Wall, 1982). Soon other professionals followed suit, and by the late 1990s there were perhaps a thousand pain clinics in the United States alone (Turk & Stacey, 2000). The structure, methods, and quality of pain clinics vary widely. Many pain clinics are private organizations, whereas others are afﬁliated with medical schools, university departments of behavioral medicine, and hospitals. Many provide inpatient treatment, and others focus on outpatient care; and many incorporate a variety of treatment methods, whereas others provide basically one approach, such as acupuncture, hypnosis, biofeedback, or TENS (Follick et al., 1985; Kanner, 1986; Turk & Stacey, 2000). Pain centers accredited by the Commission on Accreditation of Rehabilitation Facilities in Tucson, Arizona, typically offer high-quality treatment (Chapman, 1991).

MULTIDISCIPLINARY PROGRAMS

A theme that has appeared more than once in this chapter is that no single method for treating chronic pain is likely to succeed. In fact, one physician has advised avoiding clinics that focus on applying a single approach, such as biofeedback or nerve block methods (Kanner, 1986). Multidisciplinary pain clinics (or centers)—those that combine and integrate several effective approaches—are likely to succeed for the largest percentage of patients and provide the greatest pain relief for each individual. Clinics that use multidisciplinary programs generally use assessment and treatment procedures for each patient that involve medical, psychosocial, physical therapy, occupational therapy, and vocational factors and approaches (Follick et al., 1985; Turk & Stacey, 2000).

Assessment procedures are used in determining the factors that are contributing to the patient’s condition, identifying the speciﬁc problems to address in the program, and customizing the program to match the needs of the patient (Chapman, 1991; Turk & Stacey, 2000). Although the goals and objectives of different multidisciplinary programs vary, they typically include:

Reducing the patient’s experience of pain.
Improving physical and lifestyle functioning.
Decreasing or eliminating drug intake.
Enhancing social support and family life.
Reducing the patient’s use of medical services.

Multidisciplinary programs generally integrate speciﬁc treatment components to achieve each goal (Follick et al., 1985). These programs include, for example, procedures to decrease the patient’s reliance on medication and physical exercises to increase the person’s strength, endurance, ﬂexibility, and range of motion. They provide counseling to improve family relationships and to enable the patient to ﬁnd full-time employment when possible. And they offer a range of psychological services to reduce the experience of pain, decrease pain behavior, and improve the patient’s psychological adjustment to the pain condition.

EVALUATING THE SUCCESS OF PAIN CLINICS

How effective are multidisciplinary pain clinics? To answer this question, we’ll start by examining the procedures and results of two pain programs. Each program (1) was conducted by a hospital-afﬁliated pain clinic, (2) provided treatment on an inpatient basis for 4 weeks with weekends off, (3) treated several patients at a time with a variety of treatment techniques, and (4) had staff to provide medical, psychological, physical, and occupational therapy. Each program also used a medication reduction procedure, physical therapy, relaxation and biofeedback training, cognitive-behavioral group therapy, family involvement and training, and other methods.

In the ﬁrst of these programs, the patients were men and women who had suffered intractable pain from known injuries or diseases, such as arthritis, for at least a year and were unemployed because of their pain conditions (Cinciripini & Floreen, 1982). All subjects received the full program. The researchers assessed the patients’ behavior and functioning at the start and at the end of the program, and in followups 6 and 12 months after. By the end of this program, the patients’ activity levels had increased and their pain experiences, pain behaviors, and drug use had decreased sharply. Indeed, 90% of the patients were now free of analgesic medication. The subjects who participated in the followup assessments reported that they continued to be active, and about half were employed. Moreover, their pain continued to diminish: before treatment their average pain rating was 4.6 on a 10-point scale; by the end of the program it was 2.2, and after a year it was 1.2.

The second program compared a treatment group that completed the program with a control group that met all the criteria for acceptance into the program but declined to participate solely because they lacked insurance coverage (Guck et al., 1985). Followup assessments comparing the treatment and control subjects 1 to 5 years later revealed impressive outcomes: the treatment group reported experiencing far less pain, less evidence of depression, and less interference from pain in various activities, such as household chores, socializing, sexual relations, exercise, and sleep. Almost two-thirds of the treatment group and only one-ﬁfth of the controls were employed, and far fewer treatment subjects used painkilling drugs.

Meta-analyses of dozens of studies have shown that people suffering with chronic pain who receive treatment at multidisciplinary pain centers report much less subsequent pain and are far more likely to return to work than individuals who have standard pain treatment (Cutler et al., 1994; Flor, Fydrich, & Turk, 1992). What’s more, the cost of the treatment is only a small fraction of the medical and disability payments patients would receive for a year (Stieg & Turk, 1988). Other research has found evidence indicating that reductions in pain helplessness and catastrophizing during multidisciplinary treatment lead to later decreases in pain severity and anxiety (Burns et al., 2003). Of course, not all pain patients beneﬁt from this treatment, but most do.

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