Chronic pain due to a cause other than malignancy presents a special challenge to health care workers in terms of its management. This concept stems from the point that chronic pain of non-malignant origin is unpredictable and contributed to by multiple confounding factors (Bonica et al., 2010). Several factors that cut across physiologic, psychologic and social domains influence the symptoms and functional limitations of patients with such kind of pain. As such, the Interdisciplinary Chronic Pain Management (ICPM) aims to collaboratively cover all the biopsychosocial aspects of non-malignancy related chronic pain. Psychological techniques such cognitive therapy, behavioral therapy, biofeedback, relaxation techniques and hypnosis when applied appropriately contribute significantly to the effective ICPM.
Behavior Therapy
Behavior therapy aims at providing treatment through modification of behavior based on the fundamental belief that persistent maladaptive behavior has been conditioned through learning. With regard to management of chronic pain, a number of techniques have been made use of in the management of various conditions. A widely used theory of behavior is the operant conditioning that was proposed by Skinner (Roditi & Robinson, 2011). In the management of chronic pain based on the principles of operant conditioning, it appears that pain behavior such as verbal expression of pain or low level of activity, can grow and eventually evolve into and be maintained as chronic pain manifestations. This comes about as a consequence of positive or negative reinforcement of a given pain behavior as well as punishment of more adaptive, non-pain behavior (Roditi & Robinson, 2011). Depending on the frequency of the reinforcement and the consequences associated, the behavior can be conditioned increasing the proclivity of the behavior being repeated in the future. Therefore, conditioned behaviors occur as a product of learning of the consequences that can either be actual or anticipated of engaging in the given behavior. To put this into perspective, a conditioned behavior such as continued use of medication to relieve the pain can be used as an example. Continued taking of medication as a behavior results from learning through repeated associations that taking medication is followed by removal of an aversive sensation pain. Similarly, pain behaviors exemplified by verbal expressions of pain or low activity levels can transform to conditioned behavior that enhance the occurrence of chronic pain and its sequella. With this theoretical understanding, behavior therapy for chronic pain management aims to extinguish maladaptive pain behaviors through the same learning principles that such behavior might have been established by (Roditi & Robinson, 2011). Specific behavioral techniques have been utilized in the management of chronic pain such as graded activation, time-contingent medication schedules, and fear avoidance (Roditi & Robinson, 2011).. Such measures of behavior therapy have been shown to be effective in treating pain such as those caused by chronic low back pain.
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Cognitive Therapy
Cognitive therapy forms a fundamental component of the psychological interventions useful in interdisciplinary chronic pain management. According to Thorn (2017), the use of cognitive therapy in the management of chronic pain focuses on helping patients to recognize their cognitions and patterns of thinking in order to modify their relationship to the thought or belief. The theoretical model on which the psychological intervention is based on is the cognitive model which holds that thought processes drive emotions, behavior and to a good extent the physical process in the body (Thorn, 2017). Cognitive therapy involves interventions that change the content of a patient’s thought in order making more congruent with reality. The intervention may aim to help the patient understand his/her thought processes and thought content. These will be explained to be just thoughts and therefore let to pass as “just a thought”. This has effect in modifying the patient’s experience of pain (Thorn, 2017). This form of technique is combined with behavior therapy into a cognitive-behavioral therapy and used adjunctively in the management of chronic pain. This is demonstrable through the study by Wetherell et al. (2011) that demonstrated the effectiveness of CBT in the management of osteoarthritis.
Biofeedback
Biofeedback as a psychological intervention plays an important role in the interdisciplinary chronic pain management. According to Sielski et al. (2017), the framework through which the intervention operates is that patients are able to interpret feedback in form of physiological data from their bodies regarding various physiological functions. In biofeedback, the overall objective is to enable a patient achieve control regarding specific physiological processes by initiating self-regulatory processes. In the context of pain management the patient will put to use specific self-regulatory skills in a bid to reduce pain or maladaptive response to stress. Although various types of biofeedback are used based on the disease and the biologic variable whose control is attempted, the overall objective is to provide the subject with feedback that helps them modify physiologic processes that are not usually under voluntary control such muscle tension.
Biofeedback has been shown to be efficacious in the management of various types of chronic pain including headache syndromes, temporomandibular joint dysfunction, and low back pain. According to Sielski et al. (2017), biofeedback results to the improvement on a myriad of pain-related outcomes in the short and long term whether used alone or adjunctively with other interventions. For instance, Roditi & Robinson (2011) through a meta-analysis of 55 studies reveal that biofeedback has significant improvement with regard to frequency of migraine attacks and perceptions of headache management self-efficacy when compared to control conditions. Pain and pain related disability arising from disorders of temporomandibular joint dysfunction have been shown to be significantly improved by use of biofeedback as a psychological therapeutic intervention. Sielski et al. (2017) assert that biofeedback is efficacious in the management of chronic low back pain through modification of pain intensity perception, reduction of muscle tension, depression and cognitive coping. Biofeedback as a psychological intervention has a role in the management of various modalities of chronic pain.
Relaxation Techniques
Relaxation techniques comprise an integral part of the psychological interventions useful in the interdisciplinary chronic pain management. According to Diezemann (2011), the techniques follow varied objectives which have the overall goals of achieving muscular and vegetative stabilization, serving as a distraction from pain and building an internal focus of control leading to improve pain management. Additionally, Roditi and Robinson (2011) assert that relaxation techniques aim to change the subject exposure and response stress, which are established precipitator and perpetuator of chronic pain. Relaxation techniques reduce both mental and physical tension levels by reducing sympathetic outflow and activating the parasympathetic nervous system outflow and attaining a greater level of awareness for the physiological and psychological states. The effect of the relaxation techniques, which can either be applied singly or in conjunction with other interventions, will therefore be a reduction in pain or to increase the control over pain.
Several relaxation techniques are applicable in different conditions with varied objectives. The progressive muscle relaxation (PMR) technique is an example of a widely applied technique for the control of chronic pain. According to Roditi & Robinson (2011), PMR as a relaxation technique engages subjects in cyclical tension and relaxation of muscles and muscle groups which act through manipulating autonomic responses, increasing opiate activation and production, and optimizing immune function. All these contribute to better pain management for specific types of chronic pains such as neck pains (Mackereth & Tomlinson, 2010). Breathing techniques such as diaphragmatic breathing are other examples of relaxation technique useful in chronic pain management. The technique involves training the subject to maximally and efficiently utilize the diaphragm as a main respiratory muscle, which results to more oxygen consumption. In effect, the hyperventilation helps with anxiety symptoms, reduces muscle tension and as a distraction strategy, all of which have a benefit on chronic pain management.
Hypnosis
The utilization of hypnosis as part of the interdisciplinary chronic pain management makes use of techniques aiming to create a sense of mental ease. According Mazzola et al. (2015), in the management of chronic pain, hypnosis techniques achieve a state of mental ease, dissociation, relaxation to decrease pain and the associated feelings of unpleasantness and stress. The technique aims to strengthen the patient’s ego so as to enhance their competence and mastery to better cope with the pain. The framework for this intervention is that pain in itself is a potent generator of stress and anxiety which in turn heighten the pain perception making the experience of the pain worse. Consequently, hypnotic techniques target to break this vicious cycle by modifying a person’s cognition, beliefs, attention, and anticipation which contribute to the state of mind, which in turn has an effect on pain control.
Hypnosis has been shown to be efficacious in the management of chronic pain of various non-malignant origins. A study by Mazzola et al. (2017), asserted the efficacy of using the technique in the management of chronic migraine. Additionally, the researchers showed that hypnosis had significant impact in management of pain caused by fibromyalgia. Hypnosis has also been shown to be efficacious in the management of chronic pain due to low back pain, pain due to arthritis, pain due to temporomandibular joint dysfunction, and mixed chronic pain problems. Hypnosis sessions conducted through hypnotic induction and hypnotic suggestion procedures plays a fundamental role as a psychological intervention useful in the interdisciplinary chronic pain management.
Chronic pain due to a cause other than malignancy presents a management challenge to health care workers. Given that several factors that cut across physiologic, psychologic and social domains influence the symptoms and functional limitations of patients with such kind of pain, an Interdisciplinary Chronic Pain Management which aims to collaboratively cover all the biopsychosocial aspects of non-malignancy related chronic pain provides the most effective way of managing such pain. As such, psychological techniques such cognitive therapy, behavioral therapy, biofeedback, relaxation techniques and hypnosis when applied appropriately contribute significantly to the effective ICPM.
References
Bonica, j., Fishman, S., Ballantyne, J. & Rathmell, P. (2010) Bonica's management of pain 4 th Ed. Baltimore, MD: Lippincott, Williams & Wilkins.
Diezemann, A. (2011) Relaxation techniques for chronic pain Pub Med 25(4):445-53. doi: 10.1007/s00482-011-1019-2.
Mackereth, P. & Tomlinson, L. (2010) Progressive muscle relaxation Science Direct Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/progressive-muscle-relaxation
Mazzola, L., Calcagno, L. Obdrzalek, A., Pueyrredón, J., Cavanagh S, et al. (2017) Hypnosis for Chronic Pain Management. Physiotherapy Rehabilitation 2:128. doi:10.4172/2573-0312.1000128
Roditi, D. & Robinson, M. (2011) The role of psychological interventions in the management of patients with chronic pain Psychology Research and Behavior Management 4: 41–49 doi: [10.2147/PRBM.S15375]
Sielski,R. , Rief, W. & Glombiewski, J. (2017) Efficacy of Biofeedback in Chronic back Pain: a Meta-Analysis. International Journal of Behavioral Medicine 24(1):25-41. doi: 10.1007/s12529-016-9572-9.
Thorn, B. (2017) Cognitive therapy for chronic pain: a step-by-step guide New York: The Guilford Press
Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, A. J. & Atkinson, J. H. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain , 152(9), 2098-2107.
