Psychological approaches to chronic pain management: part 1

Aims and objectives. The aim of this paper is to provide an overview of the theoretical basis and application of psychological interventions used in the management of chronic pain. In doing this, psychological factors mediating pain and disability will also be reviewed. Background. A biopsychosocial model of chronic pain is widely purported and pain management is often based upon cognitive–behavioural principles as psychological factors meditating pain and disability have been found to include emotional, cognitive and behavioural components. Conclusions. This paper provides support for a biopsychosocial model of and for the effectiveness and efficacy of psychological interventions for the management of chronic pain conditions. Relevance to clinical practice. The application of psychological approaches to chronic pain management is reviewed and discussed. The way in which psychological approaches may be integrated specifically into nursing management of chronic pain is discussed in a later paper.     

Moment-by-Moment in Women's Recovery: Randomized controlled trial protocol to test the efficacy of a mindfulness-based intervention on treatment retention and relapse prevention among women in residential treatment for substance use disorder

Although therapeutic treatments exist for substance use disorder (SUD), about half of individuals who enter treatment leave early and relapse to substance use. Early dropout from residential treatment places individuals at risk of relapse, and women in SUD residential treatment represent a vulnerable population. Evidence gaps persist for the use of mindfulness-based interventions (MBIs) among racially and ethnically diverse women with SUDs, especially regarding the efficacy of MBIs adapted to prevent residential dropout and relapse. We previously developed and pilot tested an MBI, Moment-by-Moment in Women's Recovery (MMWR), adapted to support women with SUD during residential treatment. The 12-session MMWR program tested in the present study integrates relapse prevention, addresses literacy level and trauma experiences and mental health problems, and is relevant to issues surrounding treatment- and relapse-related stressors among women. The primary objective of the current Phase II randomized controlled trial is to adequately test the efficacy of MMWR on residential treatment retention and substance use relapse and determine psychosocial and neural mechanisms of action underlying MMWR. Participants are women in residential SUD treatment from a community-based residential site that serves mainly women who are low-income and racially and ethnically diverse. A subgroup of participants from each treatment group also completes functional and structural neuroimaging assessments before and after the intervention to explore possible structural and functional brain correlates of change associated with participation in the MMWR program. Findings are expected to inform the utility of adapting MBIs to improve treatment success among vulnerable women in SUD residential treatment.     

Yoga and pilates in the management of low back pain

Many interventions for the management of low back pain exist, however most have modest efficacy at best, and there are few with clearly demonstrated benefits once pain becomes chronic. Therapeutic exercise, on the other hand, does appear to have significant benefits for managing patients with chronic low back pain (CLBP) in terms of decreasing pain and improving function. In addition, because chronic pain is complex and does not fit a simple model, there have also been numerous trials investigating and demonstrating the efficacy of multidisciplinary pain programs for CLBP. It follows that interventions that treat more than one aspect of LBP would have significant benefits for this patient population. Yoga and Pilates which have, both been gaining in popularity over the last decade are two mind–body exercise interventions that address both the physical and mental aspects of pain with core strengthening, flexibility, and relaxation. There has been a slow evolution of these nontraditional exercise regimens into treatment paradigms for LBP, although few studies examining their effects have been published. The following article will focus on the scientific and theoretical basis of using yoga and Pilates in the management of CLBP.     

Cognitive-behavioral treatments for chronic pain: what works for whom?

Since the introduction of behavioral medicine in the early 70s, cognitive-behavioral treatment interventions for chronic pain have expanded considerably. It is now well established that these interventions are effective in reducing the enormous suffering that patients with chronic pain have to bear. In addition, these interventions have potential economic benefits in that they appear to be cost-effective as well. Despite these achievements, there is still room for improvement. First, there is a substantial proportion of patients who do not appear to benefit from treatment interventions available. Second, although the effect sizes of most cognitive-behavioral treatments for chronic pain are comparable to those in psychopathology, they are quite modest. Third, there is little evidence for differential outcomes for different treatment methods. Fourth, there still is relatively little known about the specific biobehavioral mechanisms that lead to chronic pain and pain disability. One direction is to better match treatment programs to patients' characteristics. This can be done according to an "Aptitude X Treatment Interaction" framework, or from the perspective of the Moderator-Mediator distinction. In this introduction to the special series on what works for whom in cognitive-behavioral treatments for chronic pain, we review existing knowledge concerning both moderating and mediating variables in cognitive-behavioral treatments for chronic pain. We further argue in favor of theory-driven research as the only way to define specific a priori hypotheses about which patient-treatment interactions to expect. We also argue that replicated single-participant studies, with appropriate statistics, are likely to enhance new developments in this clinical research area.     

Mind-Body Interventions in the Management of Chronic Cancer Pain

ObjectivesTo describe mind-body interventions used in the management of chronic cancer pain including their mechanisms of action, dosing, and delivery methods based on available evidence to date.Data SourcesPeer-reviewed publications.ConclusionFurther high-quality research is needed to establish the effectiveness and mechanisms of actions for mind-body interventions in chronic cancer pain management.Implications for Nursing PracticeMind-body interventions for chronic cancer pain management are generally safe and well-accepted by individuals with cancer. Nurses need to be knowledgeable about these interventions to explain their level of effectiveness and any safety issues with patients.     

Moderators of Mindfulness Meditation,Cognitive Therapy,and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain: A Test of the Limit,Activate, and Enhance Model

This study examined psychosocial pain treatment moderation in a secondary analysis of a trial that compared cognitive therapy (CT), mindfulness-meditation (MM), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP). The Limit, Activate, and Enhance (LA&E) model of moderation provided a framework for testing a priori hypotheses. Adult participants (N = 69) with CLBP completed a pretreatment assessment of hypothesized moderators: pain catastrophizing, brain state as assessed by electroencephalogram, mindful observing, and nonreactivity. Outcomes were pain interference, characteristic pain intensity, physical function, and depression, assessed at pre- and post-treatment. Moderation analyses found significant interaction effects, specifically: 1) higher and lower baseline pain catastrophizing was associated with greater improvement in pain intensity in MM and MBCT, respectively; 2) higher baseline theta power was associated with greater improvement in depression in MBCT and interfered with response to CT; 3) lower baseline nonreactivity was associated with greater improvement in physical function in MM while higher nonreactivity was associated with greater improvement in MBCT. The findings support the possibility that different patients are more or less likely to benefit from various treatments. Theory-driven moderation research has the capacity to inform the development of patient-treatment matching algorithms to optimize outcome.PerspectiveThis study presents preliminary findings from theory-driven tests of the moderators of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain. The results of such analyses may inform the understanding of for whom various evidence-based psychosocial pain treatments may engender the most meaningful benefits.     

Isn't There Room for Music in Chronic Pain Management?

Chronic pain with its comorbidities, such as depression, insomnia, and social deprivation, is a major cause of disability and health-economic burden. Insufficient response to pain medication and potentially serious adverse effects have led the majority of chronic pain patients to seek relief from non-pharmacological remedies. Along with this trend, pain research has paid increasing interest in critical evaluation of various complementary treatments. Music-based treatments have emerged as an efficacious and safe means to enhance the management of acute and chronic pain. We review the current position of music-based interventions in the treatment of chronic pain and present explanations for the analgesic effects of music through modulation of the primary nociception and discuss the contribution of the mesolimbic dopaminergic system to the affective component of pain perception. We propose ways to translate the novel theoretical understanding into clinical practice in different health care settings, primary health care in particular, and discuss the preconditions of successful implementation. We argue that music interventions provide low-cost, easily applicable complementary pain treatments not requiring heavy utilization of health care resources. Finally, we provide research and quality improvement frameworks and make suggestions to cover the gaps of existing evidence.PerspectiveThis article addresses the current evidence for analgesic effects of music interventions, discusses its neurobiological basis and evaluates potential use of music in treating chronic pain patients in different health care settings. We also propose directions for future research to cover shortages in the currently published data.     

Psychologic interventions for chronic pain

As a biopsychosocial understanding of chronic pain has become more sophisticated during recent decades, a variety of psychologically based treatment approaches have been developed and empirically validated for helping people better manage their pain. These approaches to pain management have much to offer persons with chronic pain in terms of enhancing quality of life and pain-related coping, as well as reducing disability and pain-related interference with functioning. Although some treatments, like hypnotic analgesia, may require referral to a specialized provider, several of the principles of other psychologically based treatment approaches for pain management (eg, operant behavioral therapy, cognitive-behavioral therapy, motivational interviewing) can easily be integrated into work with persons with pain in a rehabilitation setting. Rehabilitation providers who are interested in incorporating these treatment strategies into their clinical work who do not have prior exposure to these approaches are encouraged to review the suggested references and to seek out related training opportunities.     

Non-institutional treatment of chronic pain by field management: an outcome study with comparison group

Field management, through the use of specially trained field consultants, is a mechanism by which interdisciplinary interventions can be implemented in non-institutional settings. Management of the real environmental determinants (home, work, social) of pain and disability should improve the effectiveness of behaviorally based interventions and make these treatments more accessible. Over a 6 year period, 261 patients having various chronic somatic complaints (e.g., pain, fatigue, gastrointestinal complaints) underwent interdisciplinary outpatient treatment based on medical and behavioral sciences. Comparison of patients having field management with patients receiving office-based treatment found a significantly greater reduction in disability with field management. 84% of field managed patients had a successful outcome as defined by: (a) return to regular work, or (b) reduced limitations on work, exercise, and daily living activities, depending on functional status at assessment. Only 61% of patients with office-based treatment were successful. Compliance, defined as the frequency with which treatment was mutually terminated, was significantly higher with field management. The availability of long-term disability benefits was highly predictive of a poorer outcome. However, field management remained effective for improving functional status regardless of the availability of benefits. Finally, determination of the cost of non-institutional treatment indicated that field management is a cost-effective modality. Implications of these findings for the treatment of disability in chronic pain and other chronic illness syndromes are discussed.     

Transforming pain medicine: Adapting to science and society

The field of chronic pain medicine is currently facing enormous challenges. The incidence of chronic pain is increasing worldwide, particularly in the developed world. As a result, chronic pain is imposing a growing burden on Western societies in terms of cost of medical care and lost productivity. This burden is exacerbated by the fact that despite research efforts and a huge expenditure on treatment for chronic pain, clinicians have no highly effective treatments or definitive diagnostic measures for patients. The lack of an objective measure for pain impedes basic research into the biological and psychological mechanisms of chronic pain and clinical research into treatment efficacy. The development of objective measurements of pain and ability to predict treatment responses in the individual patient is critical to improving pain management. Finally, pain medicine must embrace the development of a new evidence‐based therapeutic model that recognizes the highly individual nature of responsiveness to pain treatments, integrates bio‐psycho‐behavioural approaches, and requires proof of clinical effectiveness for the various treatments we offer our patients. In the long‐term these approaches will contribute to providing better diagnoses and more effective treatments to lessen the current challenges in pain medicine.     

Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism

Low back pain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic. Eighty five percent of chronic low back pain (CLBP) disorders have no known diagnosis leading to a classification of 'non-specific CLBP' that leaves a diagnostic and management vacuum. Even when a specific radiological diagnosis is reached the underlying pain mechanism cannot always be assumed. It is now widely accepted that CLBP disorders are multi-factorial in nature. However the presence and dominance of the patho-anatomical, physical, neuro-physiological, psychological and social factors that can influence the disorder is different for each individual. Classification of CLBP pain disorders into sub-groups, based on the mechanism underlying the disorder, is considered critical to ensure appropriate management. It is proposed that three broad sub-groups of CLBP disorders exist. The first group of disorders present where underlying pathological processes drive the pain, and the patients' motor responses in the disorder are adaptive. A second group of disorders present where psychological and/or social factors represent the primary mechanism underlying the disorder that centrally drives pain, and where the patient's coping and motor control strategies are mal-adaptive in nature. Finally it is proposed that there is a large group of CLBP disorders where patients present with either movement impairments (characterized by pain avoidance behaviour) or control impairments (characterized by pain provocation behaviour). These pain disorders are predominantly mechanically induced and patients typically present with mal-adaptive primary physical and secondary cognitive compensations for their disorders that become a mechanism for ongoing pain. These subjects present either with an excess or deficit in spinal stability, which underlies their pain disorder. For this group, physiotherapy interventions that are specifically directed and classification based, have the potential to impact on both the physical and cognitive drivers of pain leading to resolution of the disorder. Two case studies highlight the different mechanisms involved in patients with movement and control impairment disorder outlining distinct treatment approaches involved for management. Although growing evidence exists to support this approach, further research is required to fully validate it.     

L’hypnose médicale dans la gestion de la douleur chronique

Interest in hypnosis for chronic pain management has increased in recent years and several studies have indicated that hypnosis interventions produce a significant decrease in chronic pain. However, there are a number of basic research weaknesses throughout most of these reports. First, there was a lack of standardization of the hypnotic interventions. Second, no data were available to determine precisely a clinical profile of responders to hypnosis. Third, the efficacy of self-hypnosis benefits has poorly been investigated. However, there are few data about the positive effects of hypnosis beyond pain reduction and so continuous research will be needed to fully evaluate the efficacy of hypnosis in chronic pain management.     

Verbally reinforcing pain reports: an experimental test of the operant model of chronic pain

Effective treatments for chronic pain have been based on the operant model for chronic pain, which holds that pain behaviours can be operantly controlled by various reinforcers. Support for the operant model comes primarily from treatment/outcome studies which report significant reductions in pain behaviours in chronic pain patients, but fail to demonstrate the underlying operant thesis that various reinforcers play a significant role in the establishment and maintenance of pain behaviours. In an experimental test of this hypothesis, the pain reports of forty-six healthy undergraduate students were measured over two sets of fifteen trials, in which the pressure from a blood-pressure cuff applied to their arm either remained stable or decreased over time. Half of the subjects received positive verbal reinforcement from the experimenter after each trial if their report of pain intensity exceeded that of the previous trial. Overall, the mean pain reports of reinforced subjects were significantly greater than those of the non-reinforced subjects both when the intensity of the cuff was stable over trials, and when it decreased, as expected. These results provide support for the operant model of chronic pain. The clinical and theoretical implications of these results for the operant model of chronic pain are discussed, and suggestions for future research are made.     

The Role of Resilience in the Clinical Management of Chronic Pain

Chronic pain affects more individuals than does cancer, heart disease, and diabetes combined. Yet, our treatment options remain remarkably limited. Often, highly effective psychotherapeutic approaches are limited by many barriers such as access, reimbursement, and acceptability; however, resilience-based positive activity interventions could offer a promising alternative. These interventions are engaging, non-stigmatizing, and do not require a mental health professional for their provision. This article reviews the new, but limited, research exploring the use of positive activity interventions for the treatment of patients with chronic pain. The related psychological and biological mechanisms are addressed, as are suggestions for more systematically evaluating the potential for positive activity interventions to become an adjunct to or stand-alone intervention strategy for patients with chronic pain.     

AAPT Diagnostic Criteria for Chronic Sickle Cell Disease Pain

Pain in sickle cell disease (SCD) is associated with increased morbidity, mortality, and high health care costs. Although episodic acute pain is the hallmark of this disorder, there is an increasing awareness that chronic pain is part of the pain experience of many older adolescents and adults. A common set of criteria for classifying chronic pain associated with SCD would enhance SCD pain research efforts in epidemiology, pain mechanisms, and clinical trials of pain management interventions, and ultimately improve clinical assessment and management. As part of the collaborative effort between the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks public-private partnership with the U.S. Food and Drug Administration and the American Pain Society, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy initiative developed the outline of an optimal diagnostic system for chronic pain conditions. Subsequently, a working group of experts in SCD pain was convened to generate core diagnostic criteria for chronic pain associated with SCD. The working group synthesized available literature to provide evidence for the dimensions of this disease-specific pain taxonomy. A single pain condition labeled chronic SCD pain was derived with 3 modifiers reflecting different clinical features. Future systematic research is needed to evaluate the feasibility, validity, and reliability of these criteria.

Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis

Acceptance-based interventions such as mindfulness-based stress reduction program and acceptance and commitment therapy are alternative therapies for cognitive behavioral therapy for treating chronic pain patients. To assess the effects of acceptance-based interventions on patients with chronic pain, we conducted a systematic review and meta-analysis of controlled and noncontrolled studies reporting effects on mental and physical health of pain patients. All studies were rated for quality. Primary outcome measures were pain intensity and depression. Secondary outcomes were anxiety, physical wellbeing, and quality of life. Twenty-two studies (9 randomized controlled studies, 5 clinical controlled studies [without randomization] and 8 noncontrolled studies) were included, totaling 1235 patients with chronic pain. An effect size on pain of 0.37 was found for the controlled studies. The effect on depression was 0.32. The quality of the studies was not found to moderate the effects of acceptance-based interventions. The results suggest that at present mindfulness-based stress reduction program and acceptance and commitment therapy are not superior to cognitive behavioral therapy but can be good alternatives. More high-quality studies are needed. It is recommended to focus on therapies that integrate mindfulness and behavioral therapy.     

Exercise-Induced Hypoalgesia in Pain-Free and Chronic Pain Populations: State of the Art and Future Directions

Exercise is considered an important component of effective chronic pain management and it is well-established that long-term exercise training provides pain relief. In healthy, pain-free populations, a single bout of aerobic or resistance exercise typically leads to exercise-induced hypoalgesia (EIH), a generalized reduction in pain and pain sensitivity that occurs during exercise and for some time afterward. In contrast, EIH is more variable in chronic pain populations and is more frequently impaired; with pain and pain sensitivity decreasing, remaining unchanged or, in some cases, even increasing in response to exercise. Pain exacerbation with exercise may be a major barrier to adherence, precipitating a cycle of physical inactivity that can lead to long-term worsening of both pain and disability. To optimize the therapeutic benefits of exercise, it is important to understand how EIH works, why it may be impaired in some people with chronic pain, and how this should be addressed in clinical practice. In this article, we provide an overview of EIH across different chronic pain conditions. We discuss possible biological mechanisms of EIH and the potential influence of sex and psychosocial factors, both in pain-free adults and, where possible, in individuals with chronic pain. The clinical implications of impaired EIH are discussed and recommendations are made for future research, including further exploration of individual differences in EIH, the relationship between exercise dose and EIH, the efficacy of combined treatments and the use of alternative measures to quantify EIH.PerspectiveThis article provides a contemporary review of the acute effects of exercise on pain and pain sensitivity, including in people with chronic pain conditions. Existing findings are critically reviewed, clinical implications are discussed, and recommendations are offered for future research.     

Cognitive-Behavioral Therapy fOr Clinical Pain Control: A 15-Year Update and its Relationship to Hypnosis

Since Tan's (1982) review of cognitive and cognitive-behavioral methods for pain control was published 15 years ago, sigruficant advances have been made in cognitive-behavioral therapy for pain. The scientific evidence for its efficacy for clinical pain attenuation is now much more substantial and is briefly reviewed. In particular, cognitive-behavioral therapy for chronic pain was recently listed as one of 25 empirically validated or supported psychological treatments available for various disorders. A number of emerging issues are further discussed in light of recent developments and research findings. The relationship of cognitive-behavioral therapy to hypnosis for pain control is briefly addressed, with suggestions for integrating hypnotic and cognitive-behavioral techniques.     

Personalized pain management: Is it time for process-based therapy for particular people with chronic pain?

Background and Objective

Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling and distressing pain. At the same time, improvements in the effectiveness of these treatments appear to be at a standstill. This may be due to an inherent lack of generalizability from aggregated group data to the individual, limited utility of our current schemes for categorizing people with pain conditions, faced with their inherent heterogeneity, our relatively coarse categories of treatment types and focus on treatment packages rather than individual methods, and our current failures to find adequate predictors of outcome, or to assign people their best-suited treatment methods, based on group data. In this review, it is argued that the development and examination of truly personalized treatment is a next logical step to create progress and improve the results people achieve.

Methods

Key research studies pertaining to psychological treatments, treatment outcome, heterogeneity in chronic pain, prediction of treatment outcome, subtyping and treatment tailoring are reviewed.

Results and Conclusion

It is suggested that development of future treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, based on contextually sensitive ongoing assessment. Knowledge and practical solutions needed to make process-based therapy for chronic pain happen are discussed.

Significance

Psychological approaches to chronic pain have been highly successful in the past but improvement in the effectiveness of these over time is slow to nonexistent. It is argued here that this has happened due to a failure to adequately consider the individual. Future psychological treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, grounded in ongoing contextually sensitive assessment.