Cognitive-Behavioral Therapy (CBT)
Psychoeducational approaches are the simplest mind-body strategy.
Patients with chronic illness, including chronic pain, may benefit
from information about the disorder. Pain education programs are
considered to play an important role in the treatment of both
chronic pain (Glajchen, 2001) and cancer pain (Thomas, 2000).
Educational programs may include a review of the basic anatomy
and physiology involved in a particular pain condition, or
information about helpful ways of dealing with pain. They may
include stress management techniques and a discussion of
realistic expectations for pain management and improvement in
quality of life. The information can be helpful in removing
misconceptions and fears, helping patients understand the causes
of their pain, and managing pain more effectively.
CBT has proven to be effective in reducing pain and
disability when it is used as part of a therapeutic
strategy for chronic pain. CBT addresses the psychological
component of pain, including attitudes and feelings, coping
skills, and a sense of control over one's condition. It can
provide educational information and diffuse feelings of fear
and helplessness. It can help a patient look at ways in which
their attitudes contribute to inaccurate and unrealistic
expectations, and can help them find a more realistic and balanced
view of the problem. CBT may include training in various types of
relaxation approaches, which can help people in chronic pain lower
their overall level of arousal, decrease muscle tension, control
distress, and decrease pain, depression and disability (Barkin, 1996).
Relaxation imagery or pain-management imagery may also be taught to
promote relaxation and changes in pain intensity or quality
(Fernandez, 1989). Finally, CBT may include the teaching of
life skills and coping skills that can assist the patient in
productive problem solving and the prevention or minimization of
future pain episodes.
CBT has been found to be effective as part of a treatment
regimen for a variety of pain conditions including episodic
migraine and chronic daily headache (Lake, 2001), chronic
musculoskeletal pain (Haigh, 1999), pain in the well elderly
(Manetto, 1996), chronic cancer pain (Thomas, 2000), rheumatoid
arthritis and osteoarthritis (Bradley, 2002), fibromyalgia
(Berman, 1999), myofascial temporomandibular disorders
(Sherman, 2001), chronic low back pain (van Tulder, 2001),
carpal tunnel syndrome pain (Feuerstein, 1999), and chronic
pelvic pain (Reiter, 1998). It has been suggested to benefit
patients with chronic fatigue syndrome, irritable bowel
syndrome (Kroenke, 2000), and anxiety (Ketterer, 1999).
Although research into the use of CBT in children is in the
early stages, it holds promise for reducing pain-related
distress in children (Chen, 2000).
Biofeedback
Biofeedback is the use of electronic monitoring instruments
to provide patients with immediate feedback on heart rate,
blood pressure, muscle tension, or brain wave activity. This
allows the patient to learn how to influence these bodily
responses through conscious control and regulation.
Electromyographic (EMG) biofeedback, for example, can teach
patients how to relax a particular muscle or how to achieve more
generalized relaxation for stress reduction. Biofeedback has been
shown to be effective in the management of migraine headaches,
fibromyalgia, temporomandibular disorders, and rheumatoid arthritis
(Barkin, 1996), Raynaud's disease, tension headaches (DePalma, 1997),
headaches in children (Serration, 2000) and the pain associated with
irritable bowel syndrome (Leafy, 1998). Many other applications of
biofeedback continue to be studied.
Hypnosis
Hypnosis is a highly relaxed, trance-like state in which
the conscious or rational part of the brain is temporarily
tuned out through a focus on relaxation and non-attention
to distracting thoughts. During hypnosis, changes like
those found in meditation can occur, such as a slowing of
the pulse and respiration, and an increase in alpha brain
waves. The person may become more open to specific suggestions
and therapeutic goals such as pain reduction. In the
post-suggestion phase, the continued use of the new
behavior after the hypnosis session is reinforced.
Medical hypnosis has been shown to be helpful in reducing
both acute and chronic pain (Holyroid, 1996). A National
Institutes of Health panel found hypnosis to be effective
in alleviating the pain associated with cancer (NIH, 1996).
A 1997 review of the literature on hypnosis in pain control,
which evaluated all controlled scientific studies comparing
hypnosis to other psychological interventions for pain,
showed hypnosis to be equally or more effective in reducing
suffering and possibly even reducing pain sensation
(Holyroid, 1996). Other studies have shown effectiveness
of hypnosis for pain associated with burns, cancer, and
rheumatoid arthritis (DePalma, 1997) (Sellick, 1998) and
pain and anxiety reduction related to surgery (Lang, 2000).
Clinical evidence supports the use of hypnosis in reducing
pain in a wide variety of acute and chronic pain conditions
for a substantial number of patients.
Imagery
Imagery is the use of imagined pictures, sounds, or
sensations for generalized relaxation or for specific
therapeutic goals, such as the reduction of pain. These
images can be initiated by the patient or guided by a
practitioner. The sessions in which imagery is used
can be individual or group.
More than half the studies of imagery for pain--postoperative pain,
cancer pain, chronic low back pain, burns, and migraine
headache--report significant relief from the procedure
(Eller, 1999). In a review of laboratory research on coping
strategies for pain control, imagery was the most effective
in relieving pain (Eller, 1999). Many of these studies,
however, evaluate imagery together with other interventions
such as hypnosis, cognitive-behavioral therapy and relaxation
techniques. Nonetheless, the limited evidence suggests the
usefulness of guided imagery in reducing the sensory and emotional
components of pain. The Agency for Health Care Policy and Research
recommends the use of imagery for reduction of pain intensity and
distress for cancer pain and for the management of mild to severe
acute pain (AHCPR, 1992).
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