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ContinuingEdCourses.Net d/b/a SocialWorkCoursesOnline.com is approved by the California Board of Behavioral Sciences (CA-BBS) to offer continuing education for MFCCs (MFTs) and LCSWs. CA-BBS provider #3311. ContinuingEdCourses.Net d/b/a SocialWorkCoursesOnline.com is approved by the Ohio Counselor, Social Worker, & Marriage and Family Therapist Board (OH-CSWMFT) to offer continuing education for counselors, social workers, and MFTs. OH-CSWMFT provider #RST080501 & #RCX010801.
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This is a beginning to intermediate level course. After taking this course, mental health professionals will be able to:
Many disciplines provide psychological treatment of chronic pain patients. Some examples include psychology, psychiatry, clinical social work, nursing, medicine, and marriage and family counseling. In this online course, the term “pain management clinician” will be used to encompass practitioners in all of these fields.
Working with chronic pain patients requires a special skill set for the pain management clinician. One of the most important issues is to have a good understanding of current pain theories and the nature of the chronic pain syndrome since these form the rationale upon which psychological interventions are justified to the patient. The first chapter will provide an overview of a definition of pain, and different classification systems for pain, as well as outdated and current theories of pain.
Chapter 2 will present the various factors that can influence a patient’s perception of pain and overall level of suffering. The multi-factorial influences on pain will be reviewed including tissue input (nociception), pain sensation, thoughts, emotions, pain behaviors, and the psychosocial environment. Factors impacting the transition from acute to chronic pain will be discussed.
Chapter 3 will review a model for the biopsychosocial assessment of the chronic pain patient. This model is based upon a “targets of assessment” approach developed by Belar and Deardorff (1995, 2008). Methods of assessment for use with the chronic pain patient will also be presented including the clinical interview, questionnaires, patient diaries, psychometric testing, behavioral observation, and the review of archival data. A template for the chronic pain evaluation report will also be discussed.
Chapter 4 will present the most commonly used “direct” psychological treatments for chronic pain including cognitive-behavioral interventions and deep relaxation training.
Chapters 5 and 6 will review two common areas of “indirect” treatment in which the pain management clinician acts as a “consultant” to other healthcare professionals. In working with medical disorders, the pain management clinician must be comfortable interacting with the patient’s other providers (e.g., physician, physical therapist). This chapter will discuss the pain management clinician’s role in medication management and helping to design a physical rehabilitation program based upon behavioral principles.
This chapter will provide an overview of current theories of pain. The material will be presented in a straightforward and concise manner. The goal of this chapter is to provide the practitioner with an overview of the important concepts while also presenting the information in a manner that can be used when working with chronic pain patients. Giving the patient an understanding of the multi-factorial nature of chronic pain is essential to the success of any psychological intervention.
People who suffer from severe, chronic pain know how it can utterly disrupt and damage one’s life. Pain can be cruel, making it hard to enjoy even the simplest daily activities, and certainly making it a challenge to carry out an exercise routine and other healthy activities. Moreover, chronic pain was not previously that well understood. The medical profession used to believe that pain is always a manifestation of an underlying injury or disease. As will be discussed, it was also believed that the amount of pain correlated highly (almost one-to-one) with the amount of tissue damage or injury. As such, doctors focused on treating the underlying cause with the belief that once the injury or disease was cured, the pain would then disappear. If no underlying cause could be found, then the patient was told that very few treatments are available, or worse, “The pain must be in your head.” Unfortunately, some physicians still practice in this manner, having no appreciation for the unique problem of chronic pain, newer theories about pain, and the many factors that influence a chronic pain problem.
The medical community is starting to understand that if pain is no longer a function of a healthy nervous system (signaling that there is a disease or underlying injury), then the pain itself becomes the problem and needs to be treated as the primary pathology.
To successfully treat a chronic pain patient, one must accept that all pain is real. This may seem like an obvious statement, but people with chronic pain are often treated as if their pain is either imaginary or exaggerated. Some of this is perpetuated by the mind-body dualism inherent in the medical model. Unfortunately, this model continues to be alive and well in the medical community. Mind-body dualism espouses the old dichotomy of “functional vs. organic” when evaluating and diagnosing chronic pain. In the model, functional pain is conceptualized to be of purely psychological etiology. A patient is often given this label by the physician if a precise reason for the pain cannot be found (identification of a pain generator). In this scenario, the psychological etiology is a diagnosis by exclusion. Given this situation, it is not surprising that many chronic pain patients feel like they have to prove their pain to their friends, family, and doctors. There are countless patients with stories of being told by doctors that there is no “medical” reason for the pain and therefore “it cannot be that bad.” One of the first tasks for the pain management clinician is to establish with the patient that his reports of pain will be believed. This is especially important since the patient may be hesitant about seeing a “shrink” in the first place. We will discuss this issue further under the initial interview section.
Working in this field is challenging because chronic pain is a somewhat unique medical problem. Pain is a personal experience and cannot be measured like other problems in medicine such as a broken leg or an infection. This causes a frustrating experience for the chronic pain patient in interacting with the healthcare system, family, and friends. Everyone knows that a broken leg can be confirmed by an x-ray and an infection by a blood test measuring the white blood cell count. Unfortunately, there is no medical test to measure pain levels. To make matters more challenging for the chronic pain patient, there may be no solid objective evidence or physical findings to explain the pain. Thus, chronic pain sufferers will go from one doctor to the next searching for medical explanations for their pain (and for a cure). This can lead to unnecessary evaluations and treatments, in addition to putting the patient at risk for actually being harmed or made worse by the interventions.
Pain is not easy to define. In 1979, the International Association for the Study of Pain (IASP) published its first working definition of pain:
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
This definition was reaffirmed in 1994 along with an extensive footnote discussion regarding its implications. The IASP definition acknowledges that, for most people, tissue damage is the “gold standard” by which pain is understood. However, the definition also recognizes that pain may occur in the absence of tissue damage and is impacted by emotional (psychological) factors. In the footnote explaining the definition, the authors point out that pain is not equivalent to the process by which the signal of tissue damage is passed through the nervous system to the brain (this is called “nociception” and will be discussed in detail later); rather, pain is always a psychological state that cannot be reduced to objective signs. In other words, pain is always subjective.
As shall be discussed later, the pain definition takes into account the following research findings:
Since pain is subjective, everyone experiences and expresses it differently. The IASP definition acknowledges research that has demonstrated that individuals with the exact same injury will feel and show their pain in unique ways depending on a number of things, such as:
The newest theories of pain can now explain, on a physiological level, how and why people experience pain differently. The newer pain theories will be discussed in detail later along with clinical and research findings about situational, cognitive, affective, and cultural influences on pain.
Understanding how pain is categorized is critical to providing proper evaluation and treatment. The classification of pain is not a straightforward task and there is no one system that has been universally accepted by clinicians or researchers. As discussed by Gatchel (2004) and others (Turk and Melzack, 1992), there are many ways that pain can be classified, including:
Probably, the most common classification that is used is temporal. As Gatchel (2004) points out, this is likely due to the fact that the temporal classification best helps to understand the biopsychosocial contributors to the pain problem as well as guiding evaluation and treatment. However, it should be kept in mind that a simple temporal classification also has problems since it does not take into account acute recurrent pain (periodic acute pain episodes with pain-free periods in between) and tends to ignore pain conditions associated with a progressive disease process (cancer, COPD). For the purposes of this discussion, we will review the common temporal categories of pain along with modifications to take into account acute recurrent pain and pain associated with a disease process. In this schema, pain can be separated into acute, recurrent acute, and chronic. In addition, there will be sub-categories of chronic pain.
Acute pain is usually indicative of tissue damage and most often serves a protective function for the body by signaling potential physical harm. Acute pain can be defined as follows:
This is the kind of pain that you experience when you cut your finger or stick yourself with a needle. Other examples of acute pain are:
In acute pain, there is likely to be a one-to-one relationship between the amount of tissue damage and the pain experience. In addition, the pain will tend to subside in correlation with tissue healing. Acute pain is often associated with some anxiety that will motivate the individual towards adaptive and self-protective behavior (e.g., resting the injured body part during tissue healing, seeking medical attention).
In acute recurrent pain, the individual suffers from pain episodes with pain-free periods in between. The pain episodes are usually brief (less that 3 months) and associated with an identifiable physical process (such as migraine headache, sickle cell anemia, back sprain, etc.).
In contrast to acute pain, chronic pain is usually less indicative of tissue damage, and generally does not serve a protective function for the body. A temporal definition of chronic pain is as follows:
As discussed previously, this definition emphasizing the temporal component is not completely adequate for all types of chronic pain problems. Even so, the psychological principles of chronic pain assessment and treatment remain the same. There are at least three types of chronic pain problems: (1) chronic pain that is due to a clearly identifiable cause or process, (2) chronic pain that is “nonspecific” and there is no clearly identifiable pain generator that explains the pain, and (3) chronic pain that is due to some type of nerve damage or abnormal nervous system reaction.
In chronic pain associated with a progressive disease, there is an ongoing disease process that is causing the pain. This might include such conditions as cancer, COPD, or muscle spasm in multiple sclerosis. These conditions are often actually categorized by disease state (e.g., cancer pain) which dictates special evaluation and treatment approaches.
Several terms have been developed for chronic pain in which a specific disease process or pain generator either cannot be identified or does not account for the level of pain and suffering being reported by the patient. These include chronic pain, chronic benign pain, chronic non-cancer pain, and chronic nonspecific pain. For the purposes of this discussion, we will simply use the term “chronic pain.” In this type of pain, the problem may have started with an acute injury or trauma (e.g., back injury) and developed into a chronic pain problem of more than 6 months duration such as chronic nonspecific low back pain or fibromyalgia.
It appears that pain can set up a pathway in the nervous system and, in some cases, this becomes the problem in and of itself. In this type of chronic pain, the nervous system may be sending a pain signal even though there is no ongoing tissue damage, or the tissue injury (pain generator) is less than what would be expected given the patient’s pain experience. The nervous system itself misfires and creates the pain. As we shall discuss, the pain signal from the peripheral nervous system is enhanced by higher-level central nervous system processes. In such cases, the pain is the disease rather than a symptom of an injury.
Neuropathic pain has only been investigated relatively recently; it seems to involve some type of direct injury to the nerves. In most types of neuropathic pain, all signs of the original injury are usually gone and the pain that one feels is unrelated to an observable injury or condition. With this type of pain, certain nerves (that have been injured or irritated) continue to send pain messages to the brain even after the initial tissue damage has healed.
Neuropathic pain (also called nerve pain or neuropathy) is very different from pain caused by an underlying injury. While it is not completely understood, it is thought that injury to the sensory or motor nerves in the peripheral nervous system can potentially cause neuropathy. Neuropathic pain is placed in the chronic pain category, but it has a different feel then chronic pain of a musculoskeletal nature.
Neuropathic pain feels different from musculoskeletal pain, and is often described with the following terms — severe, sharp, lancing, lightning-like, stabbing, burning, cold, ongoing numbness, tingling, and/or weakness. It may be felt traveling along the nerve path from the spine down to the arms/hands or legs/feet. Different types of neuropathic pain conditions include reflex sympathetic dystrophy (or Complex Regional Pain Syndrome), trigeminal neuralgia, postherpetic neuralgia, and radiculopathy.
Unfortunately, many physicians still treat all pain as acute pain, using a unilateral medical model. Medical evaluation of acute pain might involve extensive diagnostic testing such as MRI, CT, and diagnostic nerve blocks to determine the cause of the pain (or “pain generator”). Treatment often includes medications, physical immobilization, invasive procedures, and surgery to try to correct the source of the pain. The medical approach is generally quite appropriate in acute pain cases (e.g., repair the bone fracture, torn muscle, herniated disc). However, this strictly biomedical approach can be exactly the wrong thing to do in cases of chronic nonspecific pain. In fact, treating nonspecific chronic pain as if it were acute pain will likely make the patient worse since it reinforces the sick role and subjects the patient to iatrogenic problems. Treating other types of chronic pain problems (progressive disease, neuropathies) strictly from a medical model is inappropriate. It is important to keep in mind that any type of chronic pain problem (and acute pain problem for that matter) is susceptible to the influence of psychosocial factors.
It is critical for the physician and patient to have an understanding of the difference between acute and chronic pain. Evaluation and treatment approaches will be different depending upon the type of pain problem.
René Descartes proposed one of the original theories of pain in 1664. He proposed that a specific pain system carried messages directly from pain receptors in the skin to a pain center in the brain. He suggested that it is like a bell-ringing mechanism in a church wherein a man pulls the rope at the bottom of the tower and the bell rings at the top. In this model, there is a one-to-one relationship between tissue injury and the amount of pain a person experiences. For instance, if you stick your finger with a needle, you would experience minimal pain whereas, if you cut your hand with a knife, you would experience much more pain. Thus, the specificity theory proposes that the intensity of pain is directly related to the amount of tissue injury. The specificity theory underwent modifications throughout the 19th and early 20th centuries, but its basic assumptions were unchanged (see Melzack and Wall, 1973, for a discussion of other pain theories including Muller’s doctrine of specific nerve energies, 1842; Von Frey’s theory, 1894; pattern theories from various theorists from 1894 through the mid-1950’s; Livingston’s central summation theory, 1943; and Noordenbos’ sensory interaction theory, 1959).
The specificity theory is generally accurate for acute pain, but it does not explain many types of chronic pain. Unfortunately, variations on the specificity theory are still taught (or at least emphasized) in many medical schools, and a majority of doctors still ascribe to it in practice. The theory assumes that if surgery or medication can eliminate the alleged “cause” of the pain, then the pain will disappear. In chronic pain cases, this is very often not true. If a doctor continues to apply the specificity theory to a chronic pain problem, the patient is risk for having surgeries, medicines and procedures that will not work as the search for the “source of the pain” presses on. Ultimately, the validity of the patient’s pain complaints will be challenged if reasons cannot be found and the “treatments” do not work.
Several research findings and clinical observations have proven the specificity theory to be inadequate; these can be summarized as follows (see Wall & Melzack, 1973 and Turk & Gatchel, 2002 for more detailed discussions):
The meaning of the situation influences pain. Dr. Henry Beecher worked with severely wounded soldiers during World War II. To his surprise, Dr. Beecher observed that only one out of three soldiers carried into a combat hospital complained of enough pain to require morphine. Most of the soldiers either denied having pain from their significant injuries or had so little pain that they declined medication. These soldiers were not in a state of shock, and were able to feel pain inasmuch as they complained when the IV lines were placed.
When Dr. Beecher returned to his practice in the United States after the war, he noticed that trauma patients with wounds similar to the soldiers he had treated required morphine at a much higher rate to control their pain. In fact, four out of five patients required morphine for pain from wounds similar to those he had seen in the combat soldiers. Dr. Beecher concluded that this evidence demonstrated there was not a direct relationship between the wound and the amount of pain experienced. He believed the meaning attached to the injuries in the two groups explained the different levels of pain. To the soldier, the wound meant thankfulness to escape alive from the battlefield and to be going home. Alternatively, the injury to a civilian often meant major surgery, loss of income, loss of activities, and many other negative consequences.
Pain after healing of an injury. Another finding that discounted the specificity theory was that of phantom limb pain. Many times, patients who undergo the amputation of a limb continue to report sensations that seem to come from the amputated limb. This might include feeling that the limb is still there, or it may be a sensation of pain. Of course, the sensations cannot be actually coming from the limb since it has been removed from the person’s body. The specificity theory cannot account for these findings since there is no ongoing tissue injury in the missing limb.
Injury without pain and pain without injury. Injury without pain can occur in a variety of situations including individuals who are born without the ability to feel pain. These patients must learn to avoid damaging themselves severely since there is no “protective function” from pain. The following is just such a recent case (as reported on CNN.com Health, November 1, 2004):
If 5-year-old Ashlyn's chili is scalding hot, she'll gulp it down anyway. On the playground, a teacher's aide watches Ashlyn closely, keeping her off the jungle gym and giving chase when she runs. If she takes a hard fall, Ashlyn won't cry. Ashlyn is among a very small group of people in the world known to have congenital insensitivity to pain with anhidrosis, or CIPA -- a rare genetic disorder that makes her unable to feel pain. The untreatable disease also makes Ashlyn incapable of sensing extreme temperatures -- hot or cold -- disabling her body's ability to cool itself by sweating. The genetic mutation that causes CIPA only disrupts the development of the small nerve fibers that carry sensations of pain, heat, and cold to the brain.
Another fairly common situation is a person being distracted when injured such that pain is not felt. In this case, it is not unusual to hear stories of accident victims presenting to the emergency room stating they were injured (including major lacerations of the skin and fractured bones) but did not experience pain until minutes or hours afterwards.
Pain without injury or after the point of complete tissue healing can occur in a number of medical conditions such as central neuropathic pain after a stroke, reflex sympathetic dystrophy (complex regional pain syndrome), phantom limb pain, and post-herpetic neuralgia.
Hypnosis for anesthesia. The specificity theory cannot explain how hypnosis can be used for anesthesia during surgery. Certain people under hypnosis can withstand high levels of pain that would normally cause them to cry out. Surgery has been done on almost every part of the body using only hypnosis for anesthesia. Obviously, significant tissue damage is occurring during the surgery but the patient under hypnosis is not experiencing any pain. This finding dealt the specificity theory its final blow.
Due to the findings listed above, a new theory of pain was developed in the early 1960’s that could explain these results. It is called the gate control theory of pain, and it was developed originally by Melzack and Wall (1965). The gate control theory changed the way in which pain perception was viewed. The original theory is very complex and a detailed discussion is beyond the scope of this presentation. However, it is valuable to present an overview of the theory in language that can be used with patients. Explaining the basics of this theory to patients can help establish the credibility of psychological pain management interventions. It will also demonstrate to the patient that the psychological intervention can actually change (decrease) the experience of pain on a physiological level.
The gate control theory attempts to explain the experience of pain (including psychological factors) on a physiological level. Based upon subsequent challenges and findings, the original gate control theory has undergone some reformulation and revision, but the basic tenets hold true. It has been able to explain a variety of pain phenomena and has had enormous heuristic value in stimulating further research (Turk and Flor, 1999).
In the gate control theory, pain is divided into two components that are processed separately by the body. These are:
Pain messages flow along the peripheral nerves to the spinal cord and proceed to the brain. In the spinal cord, there are “nerve gates” (in the dorsal horn substantia gelatinosa) that can inhibit (close) or facilitate (open) nerve impulses going from the body to the brain. These nerve gates are influenced by a number of factors including the diameter of the active peripheral fibers converging in the dorsal horns as well as “instructions” coming down from the brain.
The relative excitatory activity in the afferent large-diameter (myelinated) and small-diameter (unmyelinated) nociceptor fibers is thought to influence the spinal gates. The activity in the A-beta (large diameter) is thought to primarily inhibit transmission (close the gates) whereas the A-delta and C (small diameter) activity are thought to primarily facilitate transmission (open the gate). When the gates are more open, a person experiences more pain since the messages flow freely. When the gates close, the pain is decreased or may not be experienced at all. The specifics of each part of the pain system are discussed in the following paragraphs. These are important concepts because they explain why certain treatments are effective.
This will be a brief review of your graduate course in psychophysiology. Sensory nerves bring information to the spinal cord from various parts of the body. These nerves are specialized to detect pain, heat, cold, vibration, and touch. At least two types of small diameter nerve fibers are thought to carry the majority of pain messages to the spinal cord:
As discussed earlier, the activity of the A-delta and C fibers tend to facilitate transmission of the nerve impulse (“open” the spinal nerve gates). In addition, they result in a different pain sensation. A good example of how these different nerve fibers work is when you strike the “funny bone” in your elbow (actually the ulnar nerve). You may notice that the first sensation is a sharp, tingling pain followed by a second sensation of achiness. The first sensation is the activation of the A-delta nerve fibers followed by the activation of the slower C fibers. The activation of different nerve fibers can produce different qualities of pain sensation.
Also, you may have noticed that when you strike your elbow or hit your head, rubbing the area seems to provide some relief. This is because you are activating other sensory nerve fibers. These nerve fibers carry pressure and touch messages to the spinal cord:
These speeding messages can reach the spinal cord and brain to override some of the pain messages carried by the A-delta and C fibers. When this overriding occurs, the pain messages are decreased and you experience less pain. The action of these differing nerve fibers can explain why many treatments for pain are effective. Treatments such as massage, heat, cold, TNS (transcutaneous nerve stimulation), or acupuncture can change a pain message due to some of these differences in nerve fibers.
The pain message travels along the peripheral nervous system until it reaches the spinal cord. At this point, an extremely complex system can:
As discussed previously, the gate control theory proposes that there are gates on the bundle of nerve fibers in the spinal cord between the peripheral nerves and the brain. These spinal nerve gates can either open to allow pain impulses to move freely from the peripheral nerves to the brain, or they can close to stop the pain signals from reaching the brain. Many factors determine how the spinal nerve gates will manage the pain signal including:
Once the pain signal reaches the brain, a number of different things can happen. Certain parts of the brain stem can inhibit or muffle incoming pain signals by the production of endorphins, which are naturally occurring morphine-like substances. Stress, excitement, and vigorous exercise are among the things that may stimulate the production of endorphins. This is why athletes may not notice the pain of a fairly serious injury until the “big game” is over. This is also why regular aerobic exercise can be an excellent method to help control chronic pain.
In addition, pain messages may be directed along different pathways in the brain. For instance, a fast pain message is relayed by the spinal cord to specific locations in the brain—the thalamus and cortex. A fast pain message reaches the cortex quickly and prompts the individual to take action to reduce the pain or threat of injury.
In contrast, chronic pain tends to move along a “slow pain” pathway. As discussed above, slow pain tends to be perceived as dull, aching, burning, and cramping. Initially, the slow pain messages travel along the same pathways as the fast pain signals through the spinal cord. Once they reach the brain, the slow pain messages take a pathway to a different portion of the brain, the hypothalamus, and the limbic system. The hypothalamus is responsible for the release of certain stress hormones in the body. The limbic system is the brain area where emotions are processed. As shall be discussed later, this is one reason why chronic pain is often associated with stress, depression, and anxiety. The slow pain signals are actually passing through brain areas that control these experiences and emotions.
As discussed earlier, the brain also controls pain messages by attaching meaning to the situation in which the pain is experienced. This occurs in the cortex, which is a higher level of the brain where thinking takes place. As reviewed previously, soldiers who were wounded in combat displayed much less pain then similarly wounded civilians who had been involved in a trauma such as a car accident. The meaning that the brain attached to the situation seemed to be the important difference. The brain also gives meaning to the pain signal; this occurs in the cortex. Depending on how the messages are received and other factors related to the situation, the brain might pay close attention to the pain signal, or choose to ignore it altogether.
So far, we have primarily focused on factors that influence the pain signal as it travels from the periphery to central structures (afferent input). In addition to these influences, the pain signal can be influenced by efferent neural impulses that descend from the brain. In other words, the brain can send signals down the spinal cord to open and close the nerve gates. At times of anxiety or stress, the descending messages from the brain may actually amplify the pain signal at the nerve gate as it moves up the spinal cord. On the other hand, the descending message from the brain can “close” the nerve gate in the spinal cord and the message will be stopped at the closed nerve gate (no pain experienced by the brain). This can occur in situations such as being in battle, playing competitive sports, being under hypnosis, or being distracted.
In working with chronic pain patients, it is important to carefully explain the gate control theory of pain along with providing examples. This creates an excellent foundation for discussing what factors can open and close the spinal nerve gates. The following presentation can be helpful for patients:
Let's look at a number of other things that can open or close the pain gates as messages move up and down the spinal cord. These can be divided into sensory, cognitive, or emotional areas.
Sensory factors include things that are related to your actual physical being and activities.
Cognitive factors are those things that are related to your thoughts. This might include your memories, your interpretation of a current situation, or your predictions about the future.
Emotional factors are those things related to your emotions or feelings. Emotions are being happy, sad, mad, or glad.
Factors that open the pain gates and cause more suffering are:
Sensory factors are such things as injury, inactivity, long-term narcotic use, poor body mechanics, and poor pacing of your activities.
Cognitive factors are focusing on the pain, having no outside interests, worrying about the pain, remembering bad things associated with the pain, and thinking that your future is a catastrophe.
Emotional factors include depression, anger, anxiety, stress, frustration, hopelessness, and helplessness.
Factors that close the pain gates and cause less suffering are:
Sensory factors can include increasing your activity, short-term use of pain medication, relaxation training and meditation, and aerobic exercise.
Cognitive factors include outside interests, thoughts that help you cope with the pain, and distracting yourself from the pain.
Emotional factors that can close the pain gates include having a positive attitude, decreasing depression, being reassured that the pain is not harmful, taking control of your pain and your life, and stress management.
The following illustration is helpful for patients to understand the gate control
theory of pain.
The following examples can be presented to patients to help illustrate two things—(1) how the brain can selectively block out sensations it perceives as non-threatening, and (2) the gate control theory in action:
You may notice that when you first get dressed, you can feel the physical sensations that result from the clothing. This is especially true for the typically tighter fitting items such as underwear and shoes as they press against your body. After you have had your clothes on for even a brief period of time, the physical sensations are not noticeable at all unless you specifically pay attention to them. This is an example of how the brain blocks out sensations that it knows are not dangerous.
The next two examples relate directly to pain problems. Imagine that a tight clothespin has been placed on your arm and you are instructed to leave it there for the entire day. For those of you with masochistic tendencies, go ahead and try this experiment for yourself rather than just using your imagination. The initial pain from the tight clothespin might be quite severe as it compresses your skin and surface muscles. Peripheral nerve fibers sense this pressure and transmit a pain signal to the spinal cord and on to the brain. At first, you'll notice a fast pain, but after a while you may notice a slow pain. The pain is initially experienced as fairly proportional to the amount of pressure applied. Everyone would agree that this is acute pain.
After a short while, the pain messages coming from the clothespin will begin to be decreased by the closing of the spinal nerve gates. This is because the brain begins to view the pain signals as non-harmful and not a threat. The pressure from the clothespin may be painful at first, but it is not injuring you in any way. As time goes on, the pain message is given less priority by the brain and your awareness of it decreases greatly. The brain knows that the clothespin will be there all day long and it is not causing any injury. Therefore, the brain gradually “turns the volume down” on the pain message to the point of it being barely noticeable after about thirty minutes. The compression on your skin is still occurring, but it is now perceived as either a mild discomfort or not noticed at all.
The last example is one that occurs at our spine institute almost on a daily basis. Just recently, a female patient came in convinced that her back pain was due to a spinal tumor. A thorough physical examination and medical history was entirely normal except for the onset of the back pain after a recent period of extreme stress. The stress involved the patient’s elderly father who had recently been diagnosed with (you guessed it) a spinal tumor. The patient reported that her father’s symptoms had also initially been back pain. Upon questioning, it became quite clear that the patient had an extreme fear that she also was suffering from a spinal tumor. This belief was creating intense suffering which, in turn, made the back pain worse. An MRI was obtained and shown to be negative, and the diagnosis above, stress related back pain, was made. After experiencing tremendous relief that the back pain was not the result of a tumor (in addition to one or two jumps of joy), the patient’s symptoms began to dissipate rather rapidly, and she returned to normal activities.
Not all pain that persists will turn into chronic pain. Pain is experienced very differently for different people. Likewise, the effectiveness of a particular treatment will often differ from person to person. For example, a certain medication or injection for a herniated disc may provide effective pain relief for some people but not for others.
Not all patients with similar conditions develop chronic pain, and it is not understood why some people will develop chronic pain and others will not. In addition, a condition that appears relatively minor can lead to severe pain, and a serious condition can be barely painful at all.
As pain moves from the acute phase to the chronic stage, factors other than tissue damage and injury come more into play. Also, influences other than tissue input become more important as the pain becomes more chronic. These include such things as ongoing “pain” signals in the nervous system even though there is no tissue damage, as well as thoughts and emotions. This can be a difficult concept for chronic pain patients to accept. A common retort is, “But my pain is real.” Remember, as we discussed at the beginning of this section, all pain is real and physically experienced. However, the gate control theory establishes that pain can be affected by a variety of factors other than tissue input. After a discussion of the gate control theory and some of these examples, patients are often more open to accepting the idea of psychological pain management treatment.
“Those who have something better to do don't suffer as much.” – W. Fordyce, Ph.D.
Many things can increase or decrease a patient’s perception of pain. These influences on pain perception are explained by the gate-control theory. This section will be a further discussion of these issues, as it is a commonly neglected topic in traditional approaches to chronic pain. These factors are well known to the research and academic communities but rarely acknowledged in general practice. The concepts presented in this chapter are excellent to discuss with chronic pain patients.
As explained by the gate control theory of pain, there is not a one-to-one relationship between tissue damage and pain. Rather, many factors influence chronic pain, disability, and suffering. Thus, a person can have severe pain with minimal physical findings and minimal pain with horrendous physical findings. The “onion” model pictured subsequently describes in a simple format what is currently known about aspects of chronic pain. The model makes common sense given the examples discussed in the previous chapter such as hypnosis and phantom-limb pain. In using this model with patients, the importance of addressing all aspects (or “layers”) of the chronic pain problem can immediately be understood. The following are definitions of the various "layers" of pain in the model:
This diagram depicts the pain system and the various influences on chronic pain. Tissue damage is only one of many factors determining how much pain will be experienced. This pain system model is excellent for use in working with chronic pain patients.
Nociception is defined as mechanical, thermal (heat or cold), or chemical energy acting on specialized nerve endings that send an impulse, or "signal," into the nervous system that negative events are occurring. The “transduction” of tissue trauma into neural signal depends upon sensory end organs known as nociceptors (Chapman, Nakamura, & Flores, 1999). Nociceptors are sensory neurons found throughout the body. As discussed previously, these nociceptors consist of:
Both of these types of fibers are distributed widely in skin and deep tissues. These nociceptors are usually the beginning point of the "pain" message. Pain is produced by repetitive stimulation of these receptors. It might include an impact or trauma (mechanical, such as cutting yourself), an injury involving temperature (thermal, such as burning yourself), or an injury involving chemical changes (chemical, such as an irritant). Nociception is what occurs at the site of injury that usually leads to pain being experienced. For instance, if you have ever hit your finger with a hammer or struck your toe on a table, you may have noticed that the pain signal can take a brief moment to reach your brain and be experienced.
In the simplest terms of this model, pain is the actual perception that occurs in the brain after the nerve signal (due to nociception) travels from the periphery to the central nervous system. Pain sensation is experienced in the brain, while nociception occurs at the site of injury. However, it must also be kept in mind that a pain sensation can be experienced without nociception as discussed in the last section on phantom limb pain. In addition, there may be no pain sensation even with extensive nociceptive input (e.g., the severely wounded soldier or surgery under hypnosis).
Cognitions or thoughts occur in higher brain centers and are an assessment of the pain-sensation signal coming into the nervous system as well as events surrounding it. These thoughts can be conscious or unconscious and will greatly influence how the pain signal is perceived. For instance, general body aches and stiffness are perceived as "good pain" when these occur after a vigorous exercise session, whereas they are perceived as "bad pain" when related to a medical condition, such as fibromyalgia. The level of actual input to the nervous system may be the same, but the thoughts about the input cause the pain in the patient with fibromyalgia to be perceived as much more distressing.
Another example was experienced by this author. As a teenager he was struck in the face by a door, causing a significant injury with profuse bleeding that required forty stitches. Interestingly, no pain was experienced until the extent of the injury was realized by seeing the reaction of others and looking in the mirror. After that, the pain became quite intense. These examples illustrate how thoughts (conscious and unconscious) impact pain perception and suffering. The thoughts were generally of the nature, "Oh, this must be very serious!" which made the pain worse.
In the case of chronic back pain (and other chronic pain conditions), a similar assessment of the situation occurs in the patient. Many patients are convinced that their chronic pain represents serious damage even though physical findings are minimal. They believe that hurt equals harm, and are totally guided and controlled by the pain. In these people, suffering is very great. Alternatively there are people (a smaller group by far) who have very severe findings on their diagnostic tests (e.g., MRI, CT of the spine) yet who don't seem to be bothered by the pain. They perceive their pain as benign or not dangerous. They live their lives regardless of the pain, and overall suffering is thereby diminished. Thus, these differences in pain sensation can be explained by differences in thoughts and attitudes about the pain.
Changing a patient’s thoughts about her chronic pain is one of the most powerful psychological treatment tools; this will be discussed in the chapter on cognitive behavioral interventions.
The emotional aspect of pain is a person’s response to thoughts about the pain. If you believe the pain is a serious threat (thoughts), then emotional responses may include fear, depression, or anxiety. Conversely, if you believe the pain is not a threat, then the emotional response will be negligible. Consider again the previous example of a strenuous workout. The day afterward, the person may show grimacing, slow movements, and other "pain behaviors." Even so, the thoughts about the pain will be positive ("Boy, what a good workout that was last night") and the emotions will follow similarly (e.g., feeling good about having worked so hard). The thoughts and subsequent emotional response would be quite different in the case of a fibromyalgia flare-up even though the nociceptive input and pain behaviors are similar. We will discuss the emotional aspects of pain in more detail later in this chapter.
Suffering is very closely tied to the emotional aspect of pain. In general, it is triggered by aversive events, such as loss of a loved one, fear, or a threat to one's well being. Suffering very often occurs in anticipation of a possible perceived threat even though the threat may not actually exist. A very good example of this last scenario was presented in the previous section (the back tumor example). A patient with severe headaches was firmly convinced she had a brain tumor. Her husband had recently died of a brain tumor that had started with simple headaches. Her suffering was very high because she was anticipating her headaches were a sign of a very serious condition that could lead to death. After the MRI, it was confirmed that she did not have a tumor and that her headaches were likely due to muscle tension. Her suffering decreased significantly, as did her pain. This illustrates extreme suffering in response to a threat that never actually existed. It also illustrates how a patient’s level of suffering can change even when the nociceptive input and pain sensation do not.
Pain behaviors are defined as things people do when they suffer or are in pain. The behaviors that others observe as typically indicating pain include:
Pain behaviors are in response to all the other factors in the pain system model (tissue damage, pain sensation, thoughts, emotions, and suffering). Pain behaviors are also affected by previous life experiences, expectancies, and cultural influences in terms of how the pain is expressed. Interestingly, pain behaviors are also affected by the outside environment, as will be discussed in the next section.
Psychosocial environment includes all of the environments in which we live, work, and play. Research has consistently shown that these environments influence how much a person will show pain behaviors. One might also expect that pain behaviors will vary across the different psychosocial environments of the patient. Chronic pain can affect all aspects of a person's life including relationships, work activity, sexual functioning, and recreational pursuits. Exactly how these environments can affect the patient’s pain and suffering are important to evaluate since this can help guide the treatment intervention.
As we discussed in the previous section, pain can generally be divided into acute and chronic phases based upon the length of time in pain and how fast the tissues are expected to heal. It is very important to understand that as pain moves from the acute to the chronic stages, the influences of other factors in the pain system (aside from tissue damage) come more into play. Gatchel (1991, 1996, 2004) has characterized this progression from acute to chronic pain as a three-stage model. This is illustrated in the following figure:
This model can be applied to a number of chronic pain problems, especially those of a musculoskeletal nature. As can be seen in this model, as the pain goes on longer and longer, factors other than tissue input become more influential. This can be a difficult concept for patients to understand, and the common retort is, "But I have real pain." Again, as a reminder, the pain is absolutely real and is physically experienced. It is simply being supported and increased by factors other than the tissue damage. Another conceptual model of the various factors influencing acute versus chronic pain is as follows:
As we discovered in the pain system model, thoughts, emotions, and suffering are an integral part of any chronic pain experience. In this section, we will further investigate how emotions influence pain and vice-versa. These emotions include depression, anxiety, fear, and anger.
Comorbid psychiatric disorders commonly occur in chronic pain patients and, among these, depression is frequent. Chronic pain and depression are two of the most common problems that health professionals encounter, yet only a handful of studies have investigated the relationship between these conditions in the general population (Currie and Wang, 2004). For instance, major depression is thought to be four times greater in people with chronic back pain than in the general population (Sullivan, Reesor, Mikail & Fisher, 1992). In research studies on depression in chronic low back pain patients seeking treatment at pain clinics, prevalence rates are even higher. These range from 32 to 82 percent of patients showing some type of depressive problem, with an average of 62 percent (Sinel, Deardorff & Goldstein, 1996). In a recent study of chronic disabling occupational spinal disorders in a large tertiary referral center, the prevalence of major depressive disorder was 56% (Dersh, Gatchel, Mayer et al., 2006). In another study, it was found that the rate of major depression increased in a linear fashion with greater pain severity (Currie and Wang, 2004). It was also found that the combination of chronic back pain and depression was associated with greater disability than either condition alone.
Depression is more commonly seen in chronic back pain problems than in those pain problems of an acute, short-term nature. The development of depression in these cases can be understood by looking at the host of symptoms often experienced by the person with chronic spine pain. Explaining this process to the patient can be very useful since it demystifies the etiology of the depression and dispels the idea that being depressed is somehow related to a “weak will.” We will often tell patients that clinical depression goes beyond normal sadness, and is characterized by the following symptoms from the DSM-IV:
It is often quite impactful to go over this list with the chronic pain patient since it can help develop a therapeutic alliance in treating the depression.
Chronic pain often results in difficulty sleeping which leads to fatigue and irritability during the day. During the day, the chronic pain patient often has difficulty with most activities (moving slowly and carefully) as well as spending most of the time at home away from others. This leads to social isolation and a lack of enjoyable activities. Due to the inability to work, there may be financial difficulties that begin to affect the entire family. Beyond the pain itself, there may be gastrointestinal distress caused by anti-inflammatory medication and a general feeling of mental dullness from the pain medications. The pain is distracting, leading to memory and concentration difficulties. Sexual activity is often the last thing on the person’s mind; this causes more stress in the relationships. Understandably, these symptoms accompanying chronic pain may lead to feelings of despair, hopelessness, and other indicators of a major depression.
A recent study by Strunin and Boden (2004) investigated the family consequences of chronic back pain. Patients reported a wide range of limitations on family and social roles including physical limitations that hampered patients’ ability to do household chores, take care of the children, and engage in leisure activities with their spouses. Spouses and children often took over family responsibilities once carried out by the individual with back pain. These changes in the family often lead to depression and anger among the back pain patients, and to stress and strain in family relationships.
Several psychological theories about the development of depression in chronic back pain focus on the issue of control. As discussed previously, chronic back pain can lead to a diminished ability to engage in a variety of activities such as work, recreational pursuits, and interaction with family members and friends. This situation leads to a downward physical and emotional spiral that has been termed “physical and mental deconditioning” (as depicted in the previous Figure; see Gatchel and Turk, 1999). As the spiral continues, the person with chronic back pain feels more and more loss of control over his or her life. The individual ultimately feels totally controlled by the pain, leading to a major depression. Once in this depressed state, the person is generally unable to change the situation even if possible solutions to the situation exist.
The heading above is not a typo. We first discussed chronic pain leading to depression, and now we will now cover the idea that depression can predispose a patient to chronic pain.
For quite some time, clinical researchers have known that chronic back pain can lead to major depression (see Worz, 2003 for a review). Newer studies are now looking at how psychological variables such as depression and anxiety may be linked to the onset of a back and other pain problem. For example, Atkinson, Slater, Patterson, Grant, and Garfin (1991), in a systematic study of depressed male Veterans Administration chronic pain patients, found that 42% of patients experienced the onset of depression prior to the onset of pain, whereas 58% experienced depression after the pain began. Polatin et al. (1993) reported that 39% of the chronic low back pain patients they evaluated displayed symptoms of preexisting depression. More recently, in a review of research studies in this area, Linton (2000) found that ,in 14 of the 16 reviewed studies, depression was found to have increased the risk for developing back pain problems.
As we have seen, many chronic pain patients will experience clinical depression. In addition, these patients will also be faced with the option of elective surgery in an attempt to help the pain. Having some understanding of the impact of depression on surgery is important. The following material will briefly address this issue relative to back pain and spine surgery; however, the conclusions are generalizable to other chronic pain states.
Research has clearly demonstrated that nonphysical variables such as depression, anxiety, thought patterns, and personality style can influence a spine surgery outcome (see Block, Gatchel, Deardorff & Guyer, 2003 for a review). Unfortunately, it appears that in many cases, having a major depression may not bode well for the outcome of a spine surgery. For instance, as discussed by Block et al. (2003), spine surgery patients who are clinically depressed preoperatively may continue to display depressive symptoms post-operatively; moreover, this can negatively affect the surgery outcome. Particular symptoms that may impede postoperative recovery include such conditions as low motivation, sleep disturbance, slower healing time, difficulty with physical rehabilitation and inability to perceive improvements (Block et al, 2003; Deardorff and Reeves, 1997).
Block et al. (2003) discuss that, in looking at the issue of depression and spine surgery outcome, it is important to consider if the individual is experiencing a “reactive depression” or shows a pre-injury history of more chronic depression. A reactive depression is defined as depressive symptoms in response to the chronic back pain and associated problems (loss of work, friends, etc.). Reactive depression occurs in back pain patients who have no previous history of depression. However, many chronic back pain patients have a history of problems with depression even before the onset of the back pain. As reviewed previously, individuals with chronic depression may be at greater risk for developing a low back pain condition. It is also likely that this same group is at greater risk for a poorer outcome to spine surgery (Block et al., 2003).
If you are working with a chronic pain patient with significant depression who is facing an “elective” surgery for her pain problem, you may want to recommend (to patients and surgeon) that consideration be given for postponing the surgery until the depression can be treated. Treatment for depression is often part of a preparation for spine surgery program (see Block et al., 2003; Deardorff and Reeves, 1997).
One of the biggest problems in treating major depression in the patient with chronic pain is missing the diagnosis. This occurs for two reasons—the chronic pain patient often does not realize he is also suffering from a major depression, and the doctor is not looking for it. Chronic pain patients will often define their problem as strictly medical and related to the pain. This is supported by a recent study, which found that individuals with chronic pain and depression went to their physicians 20% more often than a comparison group of non-depressed medical patients. In addition, depressed chronic back pain patients were 20% less likely to see a mental health specialist than medical patients without a pain problem (Bao, Sturm, & Croghan, 2003).
The depressive symptoms may be downplayed by the chronic pain patient who believes that, “just get rid of this pain and I won’t feel depressed,” or that acknowledging depression is a sign of weakness in dealing with the pain. When the diagnosis of major depression in the chronic pain patient is missed or ignored, treatments strictly directed at the pain are much more likely to fail. As concluded by Ohayon and Schatzberg (2003), the presence of a chronic pain physical condition increases the duration of depressive mood; chronic pain patients seeking medical consultation should be routinely screened for a major depression.
Treatment of depression associated with chronic pain requires a specialized approach. It is generally accepted that the pain and the depression should be treated simultaneously in a multidisciplinary fashion. The treatment of clinical depression most often includes psychological interventions (e.g., counseling, relaxation training) and antidepressant medication. In a recent review of the research from 1980 though 2000 looking at treatment of depression, it was found that the combined treatment approach (medication and psychotherapy) yielded better outcomes than either of the interventions alone (Pampallona et al., 2004). Simultaneous treatment directed at the chronic pain is critical. It has been found that chronic pain may interfere with depression improvement; this makes common sense. Treatment for the chronic pain might include such things as physical rehabilitation aimed at restoration of function, trying to “normalize” one’s life as much as possible even with the pain, and appropriate medication management. Multidisciplinary treatment of the chronic pain and major depression will ultimately give the patient more of a sense of control over the pain, and start a “positive spiral” toward physical and mental reconditioning.
In most cases, anxiety about the pain is more likely in the subacute stage while depression prevails with chronification. The subacute phase occurs after the acute phase but before the chronic stage. It usually occurs at about the three- to six-month range. At the acute stage, the patient with pain generally feels a reasonable sense of hope that the pain will resolve within the near future. In the subacute phase and at the beginning of the chronic phase, one's thoughts and emotions about the pain begin to change. It is not uncommon for the person to begin to wonder, "Will this pain ever go away?" "This must be something serious," and "I'll never get better." These types of thoughts lead to anxiety.
Anxiety can occur at different intensities, all the way from nervousness to full panic attacks. We explain to patients that clinical anxiety is generally characterized by the following:
Although most patients believe that their anxiety will subside "when the pain goes away,” the anxiety is very often causing a significant increase in pain perception. This results in a vicious cycle of pain, anxiety, more pain, and more anxiety. As an example of this, this author recently evaluated and treated a seventy-two-year-old woman who had been scheduled to undergo spine surgery. She was clearly a good candidate for the surgery given all appropriate factors. As one part of her pain problem, she had a significant amount of generalized anxiety. She had been involved in a few sessions of psychological preparation for surgery, which we will often do with anxious or depressed patients. Approximately two weeks prior to the scheduled surgery, the patient's leg pain completely disappeared! Her findings on the MRI continued to be abnormal. The surgeon could only explain it under the category of "an act of nature one does not want to argue with." Given this experience, the patient expected that her anxiety and depression would also abate shortly thereafter. To her dismay, this did not occur. She continued to be emotional and began to address those issues in psychotherapy.
This is certainly an unusual and rare example, but it does illustrate that removal of the pain does not necessarily mean emotional issues will also then resolve. For the patient to wait until the chronic pain is gone before addressing emotional issues is a trap that will prevent a return to a normal life.
Recent research suggests that fear may be a significant component in many types of chronic pain. This is usually focused on the fear of further injury, increased pain, or both. This fear is often closely linked with the anxiety discussed in the previous section.
Fear in chronic pain is unreasonable when it is either not appropriate to the situation or is beyond what it should be, given the nature of the situation. This might include being fearful of reinjury when there is no indication that this will occur. When fear is at these levels and interferes with normal functioning, it is considered a phobia. A phobia is defined as an irrational fear of an object, activity, or situation causing the person to avoid the object, activity, or situation (e.g., movement).
A new area of scientific investigation in many types of chronic pain is “kinesophobia,” or fear of movement. In our clinical practice, we see kinesophobia quite routinely. These patients have guarded, slow, and deliberate movements, as well as extreme cautiousness. This is often due not to the pain but rather to a phobia of injury, reinjury, or acute exacerbation. The following case example illustrates this condition:
The patient was a forty-two-year-old man who was a very successful lawyer. He had one episode of fairly severe back pain, somewhat localized, which lasted for quite some time. He attributed the onset of the pain to "moving a certain way" while getting out of his car. This had occurred about four months prior to the patient coming to our clinic. In that time, he had been seen by several specialists, at least one of which had recommended spine surgery. The patient came in with extremely slow, almost robot-like movements in an attempt to keep his spine as straight as possible. Out of fear of making the pain worse, he would not bend. He had developed a very structured ritual in order to get dressed each morning. This included putting his underwear and pants on the floor, stepping into them, and then gradually working them on with the help of a reaching device. He had developed similar rituals for putting his shoes on, driving, working at his desk, and interacting with his children. We ultimately involved him in an aggressive physical therapy program for reactivation and mobility as well as psychological pain management to address his kinesophobia. We even employed such unusual techniques as having him do a type of obstacle course through the gym with a time clock so that he could not focus on his fear of the pain. There was no medical reason for him to fear the pain or to be a surgical candidate. The patient responded very well to the program with a return to normal activities.
Kinesophobia can cause great problems over the long term. The fear of movement results in the patient attempting to move as little as possible. This guarding behavior causes the muscles in the back to fall into a state of disuse and atrophy. The muscles become weak and tight (shortened) due to lack of use. Any attempt to increase activity will then cause an increase in pain due to the weak and tight muscles. This scares the patient into not doing anything. Working through this period of increased pain under supervision with reassurance is critical to recovery from the pain problem.
Development of the disuse syndrome and physical/mental deconditioning due to fear of injury and pain. The cycle causes more and more pain to occur as can be seen in the Figure.
Anger is frequently an integral component of chronic pain problems. It is helpful to explain to patients that anger may be felt and expressed directly or indirectly. We are all familiar with the direct expression of anger. This might include such things as a short temper, irritability, and explosive behavior. Indirect anger may be expressed in a number of ways. For instance, depression has been defined as "anger turned inward" and may, in some cases, be a type of indirect anger. We often see chronic pain cases where there is no overt anger but an increase in self-destructive behaviors, such as increased smoking, coffee intake, risk taking, and substance abuse (alcohol and/or medicines). These patterns can indicate indirect anger. Another expression of indirect anger is passive aggressiveness. This is anger expressed outwardly but in a passive, indirect manner. It is important to investigate how the patient might be using pain and disability in a passive aggressive manner. An example of this includes an increase in pain (or pain behaviors) in response to someone with whom the patient is actually angry. We commonly see this pattern in marital or family relationships. Usually, the person with chronic pain who is expressing anger through increased pain does so unintentionally and is not aware of the pattern. Consider the following case example:
We once treated a man with chronic low back pain who had not responded to the usual conservative interventions. As part of the multidisciplinary program, he became involved in pain management treatment with a psychologist. As part of these treatment sessions, the spouse is often brought in to help determine how the family is responding to the pain problem. Initially the couple stated that they "rarely fight" and that the pain problem had not really bothered them that much. This was in the face of also reporting that the man had been disabled from work, they had not had sex in over six months, and that she had had to get a job to help support the family due to his disability.
As the treatment progressed, it became clear that there was a high degree of anger in both of them that was not being expressed directly. The husband would show an increase in pain behaviors in response to any possible area of conflict in the marriage. For instance, the wife once attempted to discuss their financial status in the session. He eventually started having more and more trouble with his back pain as the discussion progressed, to the point of having to stand up and walk around the clinic. He also felt, that, whenever she did bring up the topic of finances, she was implying that he was bringing all this misery to the family on purpose. In contrast, she stated she was simply trying to "brainstorm" about how to realistically manage their finances. She would also express her anger at the situation indirectly. At first, she was very supportive in helping with more responsibilities around the house due to his pain problem. However, as the pain went on and on, she became more frustrated with the situation. She started to spend more and more time away from home, and away from him. He began to respond to this by unconsciously showing more pain behaviors in order to try to get her attention once again. Of course, this drove her farther away. The cycle was becoming worse and worse until the issue was openly discussed in the pain management sessions.
Another aspect of anger in chronic pain is that of entitlement. This is a term for the feeling that "somebody or something owes me something for the pain that I am experiencing”. We often see this sense of entitlement in cases where the chronic pain has started as the result of a work-related injury, or car accident. People commonly feel they are "entitled" to a pain-free existence and that any limitation of normal activities due to pain is unacceptable. They feel that if their lives are disrupted or limited in any way due to pain, then "somebody should pay." Although in a legal sense this might in part be accurate, from a psychological perspective this attitude can be very self-destructive.
When a patient has excessive focus on what she is "entitled to" due to the pain, it will generally prevent her from taking responsibility for getting better. When there is litigation involved, the situation becomes even more complex, as we shall see in the next section. Even when there is not litigation involved, human beings will naturally look for a place to "put the blame" for their pain. We do this in an attempt to explain the pain and to direct our anger at something. This blaming may be directed at a spouse, at doctors who were unable to find a reason for the pain or provide a cure, "the guy who hit me," "the idiot who left a slippery floor for me to fall on," or "God, for putting me in this painful situation." Focusing on blaming is a form of entitlement, and it is not healthy for a recovery from chronic pain.
The most important thing to remember about entitlement is that it is a natural response to extended pain and disability; but if it is not adequately addressed and resolved it can completely interfere with recovery.
In working with chronic pain patients, it is important to be aware of other factors that can influence pain, suffering, and disability. These primarily involve behavioral factors, as originally identified by Fordyce (1988).
Pain behaviors are the actions that help us communicate to others around us that we are experiencing pain. These might include such behaviors as talking about the pain, taking pain medicine, yelling out, grimacing, groaning, moving slowly, and/or being very silent. It is only through these types of behaviors that others can try to gauge our level of pain experience. Pain is an individual experience that cannot be directly measured, so we use pain behaviors to communicate our distress.
Any behavior that we exhibit can be reinforced by those around us. Further, any behavior that is reinforced, by definition, will increase in frequency. For example, research studies have shown that if you get a classroom of students to pay attention to the teacher each time he moves to the left side of the classroom and to ignore him when he is on the right side, after a while he will be teaching the entire class from the left side of the room. Even more interesting is that the teacher will not be aware that this reinforcement of being on the left side of the classroom is even occurring. Other examples of behaviors that are reinforced throughout the day include working for a paycheck, recreational activities, and family interactions.
As with any behavior, pain behavior can also be reinforced by the environment around the patient; this most commonly occurs in the family setting. Thus, it is very important for the pain management clinician to get a good understanding of how the family system is responding to the patient’s display of pain behaviors. Reinforcement of pain behaviors can be very direct and obvious, such as:
These are examples of direct attention (reinforcement) for pain behaviors. Reinforcement can also be quite subtle, as can be seen in the following example given by Dr. Fordyce, the pioneer in this area of pain research:
The pain-ridden wife walks across the room without displaying pain and her paper-reading husband does not look up. When she limps, holds her back, or gasps while walking, his attention is diverted to her, and he watches and perhaps makes a solicitous comment.
In this next case, Dr. Fordyce also gives an extreme but not uncommon example of how powerful direct reinforcement can be:
The patient was a man in his forties who had been incapacitated for nearly twenty years. His wife worked to supplement his disability income. The husband was completely deactivated, spending most of his time in bed watching TV. She would prepare dinner for him in the evenings and bring it to the bedroom. When he would make an attempt to get out of bed to eat in another room or socialize with friends, his wife would chastise him for taking such risks. Her nurturing behavior was actually being reinforced by his decrease in pain behaviors each time she attended to him. In addition, his pain behaviors were continually reinforced by her attention to them. It is similar to parents who indulge a whining child. The indulgent behavior is reinforced by the temporary cessation of the child's whining while the whining is reinforced over the long term by continued attention from the parents.
Direct reinforcement of pain behaviors can increase both disability and suffering, which in turn increase one's perception of pain. It is important to note that direct reinforcement of pain behaviors (as with the other influences to be discussed next) are most likely to have influences in the chronic pain stages, after most tissue-healing has occurred. This is usually considered important four to six months after the onset of pain, consistent with Gatchel’s model of transitioning from acute to chronic pain.
Behavior can also be influenced by what has been termed avoidance learning. This is behavior that we engage in to keep away from consequences that are negative or aversive. In this way, those behaviors are actually being reinforced. Avoidance learning can also influence pain behaviors; behaviors will be reinforced in an attempt to avoid the pain. Dr. Fordyce gives the following examples:
A certain limp or posture is found to be effective in being more comfortable and in avoiding the pain. Thus, it is reinforced each time it is rehearsed, and becomes part of the person's usual behavior.
Bed rest is found to decrease the pain. Thus, in order to avoid any pain, the person spends more and more time in bed. Any time an increase in activity is attempted, the pain increases more and more due to weakening of muscles and other factors. Attempts at becoming more active are punished by increased pain, and bed rest is reinforced by avoidance learning.
A patient may know that walking more than three hundred yards has resulted in increased pain in the past. Therefore, whenever this goal is approached, the expectation for increased pain occurs. The patient will then avoid coming near the three hundred-yard mark in the walking program.
Early in the history of a pain problem, a limp is reinforced by avoiding pain. After some time, the limp itself leads to reinforcing from family members and others (e.g., "Let me help you," "I'll take care of that," and "Don't walk all that way; I'll drive you" ). At this point, it may not be necessary for pain to occur for the person to limp. It is an independent behavior in and of itself.
These examples illustrate in simple terms what is actually a complex and subtle process. Another area that has received great attention in research recently is avoidance learning as it relates to job dissatisfaction and lack of recovery from back pain. In the Boeing Study, researchers at the University of Washington found that one of the strongest predictors of whether a worker would have prolonged back injury disability was job dissatisfaction. One would think it might be something like heavy work, bending, problems with one's spine, or some other "physical" explanation. This was not the case.
It is important to underscore the fact that the person who is experiencing the pain, as well as his family members, is usually completely unaware of these influences of reinforcement and avoidance learning.
Dr. Fordyce also points out that the medical community can actually foster pain behavior and disability in the following ways:
The first of these factors is fairly straightforward. It simply entails the attention that one receives from the medical community when seeking treatment for a chronic pain problem. We have treated many chronic pain patients who clearly obtain a type of nurturance from their relationships with various aspects of the medical community. This might include such factors as seeing the physical therapist a few times per week for hot packs and massage, visiting the doctor on a frequent basis, or going into the hospital occasionally for management of a pain "flare-up." We will often see this pattern of reinforcement in patients who have very few other areas of reinforcement. An example of this might be the person who has lost his job due to pain, has few supportive family relationships, and no recreational interests. In this scenario (which we see often), the pain problem and its treatment is virtually the center of the person's life.
The use of pain medications can be a powerful reinforcer for pain behavior. This topic is more fully explored in Chapter 5, and will only be briefly mentioned here. Pain medications are often prescribed on a "pm" (as needed) basis. Under this prescription, pain medications are given when the person is experiencing pain (showing pain behaviors) and are not given when there are no pain behaviors. This method would appear to make common sense, but it can actually set up strong influences over pain behavior. Pain medication provides pain relief as well as an improved sense of emotional well being. This improved sense of well being might include such things as relief from anxiety, a general sense of relaxation, or improved energy and sleep in the person who is depressed. Given the fact that pain medicine can be very reinforcing, pain behaviors can quickly come under their influence. This occurs because the person must usually demonstrate pain behaviors in order to justify the request for pain medicines. The pain medicines are then taken, reinforcing the pain behaviors. As the pain becomes more chronic, the likelihood of pain behaviors being reinforced by pain medicine use becomes greater and greater. Physicians will often play a role in this process as apparent solutions to the pain problem become fewer and fewer. A common response by the chronic pain patient is, "Do something!" which unfortunately often results in the physician throwing more pain medications at the problem.
The medical community can also inadvertently reinforce chronic pain behaviors by how it manages bed rest and activity. For instance, in treating musculoskeletal and other chronic pain problems, the prescription for extended bed rest is common. This is often followed by the admonition to "let the pain be your guide" in terms of activity. In the majority of cases, the pain becomes more chronic and this type of approach will actually make the entire problem worse, not better. This medical advice simply reinforces the entire sick role in both the patient and those around her. It also creates much of the unnecessary disability we see with chronic pain sufferers.
As Dr. M. Scott Peck has stated so eloquently and succinctly in his book, The Road Less Traveled, "Life is difficult." In some cases of chronic pain, the multidisciplinary assessment will reveal that part of the pain problem relates to the patient not being able to cope with being well. This is not a conscious decision on the part of the patient. Rather the stress of coping with being well is more negative than focusing on the chronic pain and being in the sick role. Thus, the chronic pain actually shelters the patient from stress, responsibility demands, and other aspects of normal everyday life. In these cases, it is important to assess the "cost" (in psychological, physical, and emotional terms) for the person to actually get better. The following example will help illustrate this point:
Mr. T. was a fifty-three-year-old railroad conductor who injured his back while attempting to throw a large railroad track switch. He had been through the usual course of physical therapy, but his back pain continued. He had an MRI that revealed a slight disc bulge, but the doctors did not think these findings accounted for his level of pain. He had been disabled from work for approximately twelve months at the time of our assessment. As with the previous doctors, the physical evaluation revealed little that would account for his pain. However, the psychological evaluation revealed several things that helped explain his pain. First, he had been experiencing more and more stress in the work setting just prior to the injury. He had a new boss who was constantly "on" him. The patient was very concerned about his ability to do the job given his age and the number of younger people who were ready to take his place. He feared his new boss was trying to "get rid” of him. In addition, the railroad disability program allowed him to collect 80 percent of his full pay while he was disabled. He might also be eligible for early medical retirement or retraining if the back pain did not resolve.
This example clearly indicates that the "cost" for this patient to get better was to return to a job that was becoming more and more stressful, return to a job from which he might be fired, lose the possibility of retraining, and give up 80 percent of his pay for being in a less stressful (albeit painful) situation. It should be clearly understood that this situation does not show malingering or faking. It is just a situation of many pressures operating on this person's chronic pain problem. The pain situation protected him from another situation that, for him, was even worse. Another less extreme example follows:
Sharon is a thirty-year-old woman who has been rather "sickly" since childhood. She had back pain that seemed to "come out of nowhere" and had been with her for the past two years. She had been through a variety of evaluations and treatment approaches, which were of little help. She would consistently report some relief at the beginning of treatment, but the pain would eventually return to its usual levels. Our evaluation revealed that Sharon had a very inconsistent work history, a number of failed relationships, and little in the way of social involvement. The last two years had been almost entirely focused on her back pain problem in terms of going to doctors, therapists, and other healers. It was clear that the back pain was helping to distract her from other very stressful aspects of her life and sheltering her from the demands of normal functioning. The cost for her to become well would have been very great without help in other areas of her life. Although she was very depressed and anxious in her chronic back pain problem, the other prospects were certainly no better. Until she was able to focus on these issues, her back pain would not resolve.
In thinking about a patient’s chronic pain problem, it is important to assess whether the pain is being influenced by any of the factors discussed above. To summarize, these include factors such as nociception, thoughts, emotions, pain sensation, suffering, pain behaviors, and the psychosocial environment. It is important to acknowledge the power that emotions can have on a patient’s chronic pain, including:
The longer the pain lingers, the more likely one or more of these emotions is increasing the pain. The influence of nonphysical factors on chronic pain, disability, and suffering must be acknowledged. Very few physicians will take all of these aspects into account, even though recent research indicates they may be among the most important in chronic pain cases. These factors include:
If any of these influences are part of the chronic pain problem, they need to be addressed or the problem will not be likely to resolve. Getting the patient to be aware and accepting of these factors is the first step in teaching effective pain management skills.
As discussed by Turk and Monarch (2002), chronic pain should be assessed from a biopsychosocial perspective. This is consistent with the gate control and pain system models discussed previously. The biopsychosocial perspective takes into account biologic, affective, cognitive, behavioral, and sociocultural influences on pain.
The clinical health psychology assessment model developed by Belar and Deardorff (1995, 2008) is useful in completing a biopsychosocial assessment of chronic pain. The following is adapted from Belar and Deardorff, Clinical Health Psychology in Medical Settings, Second Edition (APA Books, Washington D.C., 2008).
In the biopsychosocial assessment of chronic pain, there are various “targets” of assessment that should be addressed. The target groups form a 4 X 4 assessment grid (domain of information by unit of assessment). The domains of information include biologic or physical, affective, cognitive, or behavioral. The units of assessment include patient, family, health care system, and sociocultural context. The following table shows some examples of the kinds of information that might be collected. For a more detailed example, see Belar & Deardorff (1995, 2008).
|
Environments |
||||
|
Patient |
Family |
Healthcare System |
Sociocultural |
|
|
Biologic |
age, race, sex, physical appearance, symptoms, health, vital signs, lab data, medications, genetics |
home setting, economics, family size, family illness |
treatment setting, medical procedures, prosthetics |
social services, financial issues, social networks, occupational, health hazards |
|
Affective |
mood, affect, feelings about treatment and other aspects of chronic pain, history of affective disorder |
family feelings about patient, illness, and treatment |
providers’ feelings about patient, illness, and treatment |
sentiment of the culture about patient, illness, and treatment |
|
Cognitive |
cognitive style, thought content, intelligence, education |
knowledge about illness, attitudes and expectations |
provider knowledge, provider attitudes |
current state of knowledge, cultural attitude |
|
Behavioral |
activity level, interactions with others |
involvement in care |
provider skills, education, and training |
employer, laws, customs |
Each block also has an associated developmental or historical perspective that could be critical to a full understanding of the patient’s present condition. In each area, the clinician should attempt to understand the patient's (a) current status, (b) changes since onset of the pain, and (c) past history. The focus of the assessment should not be based solely on identification of problems but also on the delineation of assets, resources, and strengths of the patient and his environment.
The patient targets of assessment include biological, affective, cognitive, and behavioral. In many ways, these targets of assessment coincide with the “layers” of the pain system model as presented previously (e.g., nociceptive input, pain sensation, cognitive, affective, pain behaviors, psychosocial environment)
The most obvious biological targets are the patient's age, race, sex, and physical appearance. In addition, the clinician needs to gain a thorough understanding of the patient's current pain and other physiological symptoms, and how they are similar or dissimilar to past symptoms. Recent changes in the pain condition or treatment are particularly salient to the assessment because they are often the precipitating events that elicit the referral (e.g., increased pain, decreased function, contemplation of surgery). The clinician will want to obtain information on the specifics of the pain problem—nature, location, and frequency of symptoms; current treatment regimen; and general health status or other medical problems. Other sources of biological information include the physical exam, current and past vital signs, results from relevant laboratory tests, medications, and use of illicit drugs. Furthermore, a history of the patient's constitution and general health including previous illnesses, relevant genetic information, injuries, and surgeries should be obtained.
Depending on the type of pain problem, biological targets might also include variables associated with the autonomic nervous system or musculoskeletal activity (e.g., electromyographic (EMG) recordings or peripheral temperature readings) obtained in both resting and stress-related conditions. For example, a psychophysiological profile involving lumbar paraspinal EMG activity under relaxed and stressed conditions, in addition to various postures, could be obtained on a patient suffering from chronic low back pain.
As will be discussed subsequently, the use of a pain questionnaire and a pain activities diary can be very helpful in assessing biological and other targets.
The assessment of affective targets involves understanding the patient's current mood and affect, including their contextual elements and historical features. In addition, an assessment would be incomplete without having obtained information about the patient's feelings about her pain problems, treatment, health care providers, future, social support network, and, of course, self. Again, it is helpful to obtain data that allow for comparison between current affective states and those of the past, in that it is often the contrast that has prompted the referral.
Assessment of the patient's cognitive functioning involves gathering information about the patient's knowledge, perceptions, and attitudes, as well as the content and pattern of thinking. It is imperative that the clinician be aware of cognitive abilities and limitations of the patient, from both current and developmental perspectives. Cognitive targets include general intelligence; educational level; specific knowledge concerning the pain problem and treatment; attitudes toward health, illness, and health care providers; perceived threat of illness; perceived control over psychological and physical symptoms; perception of costs and benefits of possible treatment regimens; and expectations about future outcome. Another important target is the perceived meaning of the chronic pain problem (and resulting loss of function) to the patient. The clinician should be aware of the patient's general cognitive style and philosophy of life, including religious beliefs. Assessment of the patient’s religious and spiritual beliefs is an area of assessment and intervention that is very often neglected. Research indicates this is one of the most important areas to patients but the least often addressed by health care providers (see Deardorff and Reeves, 1997, for a review).
Behavioral targets include what the patient is doing (the action) and the manner in which he does it (the style). In assessing pain behaviors, the following actions are often evaluated:
The style of behavior can also be evaluated such as flamboyant, hesitant, age-appropriate, hostile, restless, and passive. The pain management clinician will want to understand the patient's overall level, pattern, and style of activity in areas of self-care and interpersonal, occupational, and recreational functioning, as well as specific behavioral targets related to the reason for referral. Other important behavioral targets in chronic pain include medication seeking, exercise, activities of daily living (ADLs), sexual functioning, and compliance with treatment regimens.
Of special interest is the patterning and nature of the physician-patient relationship, as well as whether the patient senses any type of control over the pain problem. Once again, a historical perspective is important because past behavior is often the best predictor of future behavior.
Extremely significant in pain psychology is the assessment of current and previous health habits (e.g., smoking, exercise, eating patterns, and alcohol usage) and health care utilization. The clinician should be able to answer the following questions about the patient—(a) What are the nature, frequency, and pattern of past contacts with health service providers, and (b) what have been the antecedent stimuli and consequences of these contacts (i.e., history of previous help-seeking and treatments)?
Finally, an assessment would be incomplete without information concerning the patient's current and past history of compliance or adherence to treatment regimens, with specific reasons for noncompliance noted whenever it has occurred. Areas of assessment here include medication usage as prescribed, history of keeping appointments, and follow-through on previous recommendations.
The pain management clinician also needs to assess aspects of the various environments within which the chronic pain patient interacts. These include (a) the family unit, (b) the health care system with its various settings and providers, and (c) the sociocultural environment, including social network, occupational setting, and aspects related to ethnicity and cultural background. As with assessment of the individual patient, environmental targets of assessment include physical, affective, cognitive, and behavioral domains, with a focus on relevant demands, limitations, and supports.
Family environment. In assessing the physical domain of the family environment, it is important to know about available economic resources and perhaps even physical characteristics of the home setting, depending on the problem being assessed (e.g., chronic low back pain). The family's developmental history, size, and experience of recent changes are all important aspects to consider. The clinician should also be aware of other illnesses and pain problems in family members and familial models for various symptoms (e.g., a parent who has been disabled due to chronic pain).
In the affective domain, it is important to understand family members' feelings about the patient, the patient's pain problem, and the treatments rendered. Assessment of past or present affective disorders in the family is essential.
In the cognitive domain, the clinician must assess the family's attitudes, perceptions, and expectations about the patient, the patient's pain problem and treatment, and the future. Family members' intellectual resources, as well as knowledge that they possess about health and the pain problem, should be understood.
In the behavioral domain, the clinician will want to know whether there have been any changes within the family since the onset of the chronic pain problem. An example would be a shift in roles and responsibilities of family members due to the chronic pain patient’s lack of ability to function (e.g., at home and at work). It is also important to find out to what degree family members participate in the patient's care. As discussed under the pain system model, reinforcement contingencies can have a powerful effect on pain behavior. The clinician should investigate how the patient’s pain and illness behaviors are being reinforced by the family members to the exclusion of wellness behaviors. Pain behaviors might be positively reinforced (e.g., nurturing and “supportive” help for the patient) and negatively reinforced (e.g., removing the patient from stressful responsibility demands, family members taking over the household chores and ADLs). Consider the following example based on an actual case referred for psychological pain assessment:
Mr. Smith had been disabled from his job for one year after a low back work injury. The patient had undergone a variety of diagnostic tests; these had not identified likely pain generators. Although the patient complained of extreme pain, the physical findings simply did not explain his level of suffering and disability. Prior to his injury, he had been working two jobs -- neither of which he enjoyed – to support the family. After the injury, he was receiving disability payments, and his wife had returned to work to help support the family. Mr. Smith spent virtually all of his time at home, in bed. Mr. Smith was on a significant amount of pain medicine and his doctor was able to get the insurance company to buy Mr. Smith a hospital bed for his home. The family put the bed in the living room so that Mr. Smith could interact more with his children, who were very helpful in taking care of him. So far, a myriad of physical treatments had provided no relief.
As can be seen, assessment of behaviors of family members that could influence the patient's pain behavior or physical adaptation is crucial. For example, families might model chronic pain behavior, punish patient attempts at self-help, or be secretive in a manner that increases patient anxiety.
Health care system. The health care system should also be assessed across physical, affective, cognitive, and behavioral domains. For example, in the first domain the clinician needs to know the physical characteristics of the setting in which the patient is being assessed or treated (e.g., chronic pain program, surgeon’s practice, multiple doctors). In addition, the pain management clinician must understand the physical characteristics of the diagnostic procedures and the treatment regimen to which the patient has been, is being, or will be exposed. This is why it is important for the clinician to be familiar with the type of chronic pain problem that is being treated. As an example, anyone who works with spinal disorders and resulting pain problems should be familiar with the common diagnostic tests (e.g., MRI, CT, CT-myleogram, discogram, bone scan, EMG, NCS) and common medical treatments (e.g., physical therapy, medications, epidural and nerve root blocks, and the various spine surgeries).
In the affective domain, one must be aware of how health care providers feel about the patient and about the patient's chronic pain problem. In addition, the attitudes of providers themselves toward the health care system within which they work can enhance or detract from overall health care. Chronic pain patients who are on disability and not showing any significant response to various medical treatments can become frustrating to healthcare providers who are continuing with a strictly medical model approach (e.g., medications, surgery, physical modalities). After awhile, one might see a certain passive-aggressiveness by the healthcare providers towards the patient as frustration mounts. Of course, the symptoms of the chronic pain patient will often worsen due to attempts to “prove” the severity of her ongoing symptoms and need for treatment.
In the cognitive domain, the clinician needs to have some understanding of how knowledgeable health care providers are about the patient's pain problem and treatment. As discussed earlier, one often observes that all pain problems are treated as if they are “acute” in the medical community. Of course, this is not the appropriate intervention for chronic pain problems. One needs to assess healthcare providers’ attitudes and expectations about these issues as well as about the patient's future. Furthermore, it is helpful to be aware of the community standard of care for the problem. When assessing the "behavior" of the overall health care system, the clinician needs to be aware of policies, rules, and regulations that will affect the patient and her treatment (e.g., staffing patterns at the treatment center, appointment schedules, medication refill policies). It is also important to understand which specific behaviors health care providers might be displaying that could influence patient behavior. An example of this would be transmitting information about the pain problem. I have heard countless stories of chronic back pain patients being told by their physician, “you have the spine of an 80-year old.” Of course, this type of information significantly influences the patient’s belief system and expectation regarding future recovery (or lack thereof).
Sociocultural environment. Physical aspects of the patient's sociocultural environment include both (a) the physical requirements and flexibilities of the patient's occupational and work setting, and (b) the social and financial resources/services available to the patient. In addition, the clinician should be aware of the nature of the patient's social network (including size, density, and proximity) and the frequency of the patient's contact with it. This is an extremely important area of assessment in chronic pain. It is not uncommon for a chronic pain patient to be referred for psychological pain management near the end of the treatment cycle. By that time, the patient has often been on disability from work for quite some time, is in financial trouble, and is almost completely isolated from previous social support networks outside of the home. All of these factors act as significant barriers to recovery.
In the affective and cognitive domains, the clinician should understand cultural sentiments, attitudes, and expectations as impacted by the patient's race, gender, ethnicity, lifestyle, religion, pain problem, and treatment (e.g., sentiments about a chronic pain problem and disability in a person who was previously the primary breadwinner of the household). The clinician should be able to answer the following questions: What are the cultural attitudes towards the pain problem and disability? What is the health belief model of the culture itself? Are there prevalent religious beliefs that could impact the patient's willingness to obtain treatment?
In terms of the behavior of large sociocultural systems, the clinician might need to know specific employment policies related to the pain problem being assessed (e.g., regulations regarding return to work for patients with back problems). In addition, legislation regulating health care provision and health habits is relevant (e.g., The Americans with Disability Act, state Workers’ Compensation Laws) Finally, the clinician should be aware of ethnic customs that could be related to symptom reporting (or underreporting) and health care use.
It becomes clear from a review of the targets for assessment that these "blocks" are interrelated, and that the nature or relative importance of information obtained in one block is often affected by information found in another. For example, type and location of the pain problem can affect perceived meanings of the physical symptoms because of the special psychological significance of certain body parts (face, back, pelvic, or extremity pain may carry different meanings for the patient).
Integrating assessment information is critical in the evaluation of a chronic pain patient. It is also important to gather accurate information across as many “blocks” of assessment data as possible. This is because a chronic pain patient is often being treated by more than one provider. It is not uncommon to have a patient who is being treated by a pain management physician, physical therapist, internist, pain management clinician, surgeon, and others. Patient self-report and questionnaires are only two data sources, and the information may or may not be entirely accurate. For instance, patients often do not know the medical diagnosis for their pain problem, do not remember or know the details of their medication regimen, or do not understand the surgeries they are facing (or have undergone). In addition, a patient may be reluctant to discuss a past history of medication abuse, but this information would likely be available elsewhere. Of course, the results of any psychological testing would be impacted by such things as medication use, level of concentration, substance abuse, and the ability to tolerate the pain and maintain focus while taking a lengthy test such as the MMPI-2. As can be seen, information gathered across assessment blocks should be compared and contrasted to determine consistencies and inconsistencies.
In conducting an assessment, it is important to understand that the data obtained could be influenced by the type of setting in which the assessment occurs. For example, low-back-pain patients often walk with greater or lesser flexibility depending on who is watching them and in what setting they are being observed. The pain management clinician should be collecting all observational data that is available (examples include the patient walking from the parking lot to the office, the patient sitting in the waiting room, the patient interacting with staff). Consider the following example:
A low-back-pain patient in an inpatient, chronic pain program was repeatedly observed ambulating with a walker by program personnel. However, on one occasion, when the patient was unaware that he was being observed, he was seen casually carrying his walker over his shoulder while ambulating with appropriate body posture and gait.
Patient expectations about the purpose of the assessment clearly influence the data obtained. For example, the demand characteristics for patients seeking a spine surgery that he believes will “cure” the pain will clearly impact how the pain evaluation is approached. When evaluating a chronic pain patient, it is imperative to take into account the reason for the evaluation. Various evaluation purposes include:
The patient who is undergoing a psychological pain evaluation in pursuit of treatment will likely respond very differently from the one that is being assessed for disability or litigation issues. The purpose of the evaluation should be clearly discussed with the patient at the beginning as part of the informed consent process.
The presence of other people, their roles, and their behaviors can also affect responses during assessment. For instance, one might witness the emotional breakdown of a chronic pain patient only a few moments after the patient assured his physician that he was doing “fine” or felt ready for some type of proposed treatment or surgery. Or, one might see the reluctance of patients to reveal even significant physical symptoms because of the perception of their physician as being too rushed. The pain management clinician working with chronic pain patients will often be able to obtain much more information than the treating physician will. This underscores the importance of communication amongst treating professionals.
The following are more examples of relationships that influence the interpretation of information obtained during assessment:
In performing the chronic pain evaluation, numerous methods can be used. Many of these give information about one or more targets in the assessment model. The choice of methods depends on the target being assessed, the purpose of the assessment, and the skill of the clinician.
There are probably as many different approaches to the evaluation of chronic pain as there are clinicians involved in this field. It is not so much the individual methods used as long as the important targets of assessments are addressed in a valid manner. The issue of validity will be discussed in detail shortly. The critical issue is that any psychological testing results, mental status examination, or other data must be interpreted within the context of the chronic pain problem and symptoms.
One should not be wedded to any one particular technique, as each has its strengths and weaknesses. However, it is safe to say that a good clinical interview is the core assessment method. Belar and Deardorff (1995, 2008) endorse a multiple-measurement model and a convergent-divergent, hypothesis-testing approach to clinical assessment. A detailed description of all the specific methods available to assess the chronic pain patient is beyond the scope of this presentation. The following is an approach that I have found useful and is similar to what other clinicians in the field might do. The Suggested Resources at the end of the online course provides excellent references for further study in this area. The methods of assessment discussed are interview, questionnaires, diaries, psychometrics, observation, and archival data.
The clinical interview is perhaps the most common method of gathering information. It has the capacity to elicit current and historical data across all domains (i.e., physical, affective, cognitive, and behavioral information regarding the patient and her family, health care, and sociocultural environments). The interview is also a means of developing a supportive working relationship with the patient. It permits the acquisition of self-report and observational data from the patient, family members, significant others, employers, and health care providers. Understanding one's own stimulus value is crucial to the interpretation of interview data.
Content and style of individual interviews vary depending on the assessment question and purpose. The formality of the interview process (unstructured, semistructured, or structured) often depends on the personal preference of the clinician as well as the setting and time constraints. Specific intervention programs (e.g., a chronic pain rehabilitation program) commonly use structured interviews. Probably the best approach is a combination of the structured and unstructured interview approaches. This helps to avoid interviewer bias and to remain open to exploring areas not immediately recognized as important.
In the majority of situations, it is most useful to develop one's own structured/semi-structured interview for a specific pain patient population (especially if you are specializing in one chronic pain group over another). For instance, if you find yourself working with mostly spinal pain problems, you might develop an interview specific to that patient population. Although there will be a great deal of overlap, interviews for other pain problems (e.g., complex regional pain syndrome, craniofacial pain, neuropathy, pelvic pain) might be slightly different.
The first few minutes of contact with the patient can be critical in completing a valid and comprehensive chronic pain evaluation. Prior to being referred to the pain management clinician, chronic pain patients have often been very involved in medical evaluations and treatments. Thus, the referral to a pain management clinician can be threatening and misunderstood. At the beginning of the interview, it can be useful to ask the patient the name of the referring physician and the patient’s understanding of why she was referred (the response will often be, “I don’t know”). Initially, a very brief explanation of the role of pain psychology can be helpful. After that, explain to the patient that you are going to gather a lot of information about their pain problem (and other aspects of their lives) to determine if pain management techniques might be helpful. Hopefully, at that point, some rapport has already been established. After the introductory comments, the next segment of the interview should be very focused on the pain and medical issues. It is useful to start with gathering more “medical” information since the patient will be comfortable with this interaction and not be placed on the defensive. Later, the interview can focus on “psychological” data gathering after more rapport and credibility with the patient is established. After gathering the medical information, one can usually move into the other areas without much resistance (e.g., psychosocial, work, psychiatric histories, mental status examination).
An example of a pain evaluation report template that illustrates the important elements of information gathering from all available sources (e.g., the clinical interview, psychological testing, medical records review, and discussions with family and healthcare providers) appears later in this chapter. Elements of the clinical interview often include the pain and medical history, psychosocial histories (family, work, educational), current psychosocial status, and the mental status examination (MSE).
Not every clinical interview will assess all categories outlined previously but there should be certain common components to every clinical interview. For instance, every clinical interview should include some elements of the Mental Status Examination. How extensive an MSE is completed will depend on the presenting symptoms and preliminary findings. Elements of the MSE should include at least the following sections:
(1) Appearance, Attitude, and Activity;
(2) Mood and Affect;
(3) Speech and Language;
(4) Thought Process, Thought Content, and Perception;
(5) Cognition; and
(6) Insight and Judgment.
The MSE commonly yields information that has not been previously assessed by another health care professional. Many of the areas of assessment (e.g., sexual functioning, drug- and medication-use history, and suicidality) are uncomfortable areas for other providers to explore, but they are of great concern to the patient. For instance, in asking about the impact of a pain problem on sexual functioning, the following response is not uncommon, "I am glad someone finally asked me about that! I've been very concerned. . . ."
An excellent mental status exam resource is The Psychiatric Mental Status Examination (Trzepacz & Baker, 1993). There are also many MSE structured formats available.
Clinician-developed, problem-focused, information-gathering questionnaires are very useful in the assessment of a chronic pain problem. Depending upon the purpose of the interview, the questionnaire may be mailed to the patient before the first visit and reviewed at the time of interview. This method is a considerable time-saver in the evaluation of chronic pain patients since the amount of information that needs to be gathered from the patient tends to be quite extensive. Chronic pain patients also appreciate the ability to fill out these questionnaires at home since sitting tolerance and endurance are often an issue (precluding having the patient being able to complete the forms in the waiting room at the time of the interview). Of course, if the purpose of the evaluation is related to disability or is medical-legal, the questionnaires and psychological testing must be completed in a controlled environment.
The interviewer may review questionnaire data with the patient but can focus more time on areas needing further clarification and on more general psychological issues. Reviewing some questionnaire information with the patient is important since it demonstrates the value of the data to the clinician and helps to establish rapport. Questionnaires are also a mechanism for the systematic recording of data that can facilitate clinical research and subsequent program evaluation.
A sample intake questionnaire for use with chronic pain patients follows:
PAIN QUESTIONNAIRE INSTRUCTIONS
The following questionnaires are designed to provide you with the most comprehensive evaluation possible. The questionnaires will give us valuable information about the impact your medical problem has had on your life.
Depending on which questionnaires are included, the assessment will take between 20 minutes and 1 1/2 hours to complete. Questionnaires might include any combination of the following, depending on the purpose of the assessment:
Pain Patient Questionnaire
Minnesota Multiphasic Personality Inventory (MMPI-2)
Battery for Health Improvement (BHI-2)
The Multidimensional Pain Inventory (MPI)
Beck Depression Inventory (BDI-2)
These questionnaires are commonly used in pain clinics throughout the world. Please read the following instructions carefully.
1. It is very important to fill out the questionnaires alone and not to discuss your answers with anyone. If, for some reason, you cannot complete the questionnaires without assistance, please let us know.
2. It is important to answer ALL of the questions. Please do not leave any blank. Answer all of the questions as accurately and honestly as possible. Please read the instructions for each questionnaire carefully.
It is important to understand that all patients being evaluated get the same questionnaires. Many of the questions will apply to your situation and many will not. In fact, you may not understand why some of the questions are even being asked. Answering all of the questions is essential as we evaluate a wide variety of complex pain problems. Therefore, we have everyone answer all of the same questions. Thank you for your cooperation. We will go over the results of the evaluation at its completion.
INSTRUCTIONS. PLEASE READ AND ANSWER ALL OF THE QUESTIONS. PRINT YOUR ANSWERS CLEARLY. IF YOU NEED MORE SPACE FOR ANY OF YOUR ANSWERS, YOU MAY WRITE ON THE BACK OF THE PAGE.
Today’s Date:_______________________________
Name: ________________________________________________ Age:________
Address: ___________________________________________________________
City State Zip: _______________________________________________________
Phone: ________________________________________
Briefly describe your pain problem:________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Choose a number between 0 (no pain) and 100 (the most intense pain imaginable) which describes the level of your pain at its:
Highest intensity……………………………………………. __________________
Usual intensity……………………………………………… __________________
Lowest intensity……………………………………………. __________________
Your pain level at this very moment……………………….. __________________
Choose a number between 0 (no interference) and 100 (continuous interference) which describes how much your pain interferes with the following activities:
Work………………………………………………….. ______________________
Family chores…………………………………………. ______________________
Play, recreation……………………………………….. ______________________
Sex…………………………………………………….. ______________________
What is the percentage of time that you are in pain (0 to 100): _________
What makes your pain worse?
_______________________________________________________________________
_______________________________________________________________________
What eases or reduces your pain?
_______________________________________________________________________
_______________________________________________________________________
Use the figures below to indicate (1) Where the pain is located, (2) How much area is involved, and (3) Whether there is more than one location.
Do your sensations spread? If so, show where they spread by writing an “X” at the main area of pain and draw arrow to show how the symptoms spread.
WHAT OTHER MEDICAL PROBLEMS DO YOU HAVE?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please complete the table below for any surgeries you have had:
|
Date of Surgery |
Type of Surgery |
Age |
Complications (if any) |
List all of your current medications. Continue on the back if necessary.
|
Current Medications |
Dose |
# of pills per day |
Times of day taken |
Side Effects? |
List all of the doctors involved in your medical care:
|
Doctor’s Name |
Specialty |
Type of Treatment |
Dates of Treatment |
Do you have any history of drug/alcohol abuse problems? YES NO
How much of the following do you take in a day?
|
coffee ________ cups/day |
tobacco ________ cigarettes/day |
|
cola _________ glasses/day |
beer _________ 12 oz. cans/day |
|
wine _________ glasses/day |
liquor _________ ounces/day |
Please list any psychiatric or psychological care you have had in the past or now:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
On the lines below, and on the back of this page if necessary, please list any questions or other information about your pain problem that you think is important for us to know as part of your evaluation. Also, provide any concerns that you have about the spine surgery so that we can address them with you.
In the thousands of patients who have been asked to complete various versions of this questionnaire, refusal has been almost nonexistent. However, given the initial defensiveness of many patients to seeing a pain management clinician, it is important to limit questionnaire items to variables related to sociodemographic features and the chief complaint, leaving broader psychological exploration to the interview.
Questionnaires can also be developed for significant others and health care providers. The form and content of the questionnaire will depend, of course, on the theoretical orientation of the clinician. Questions can be forced choice, open ended, simple ratings, checklists, or pictorial in nature (e.g., pain maps). Clarity and ease of response are important features. However, the clinician must take care not to use questionnaire techniques in a fashion that would substitute for the development of a quality professional relationship with either the patient or the referral source.
Patient diaries are commonly used to record behaviors, both overt (e.g., activities, pain medication use, “down time”) and covert (e.g., thoughts, feelings, pain intensity). They are used as baseline measures and as an intervention to foster learning about antecedents, consequences, and the relationships among internal and external behaviors (i.e., to promote psychological and physiological insights). Diaries are also used to measure the effectiveness of treatment programs. Although there are controversies about the reliability and validity of diary data, they continue to be an excellent source of clinically useful data.
To improve compliance (and the validity of the data collected), diaries should be easy to use, brief, and non-intrusive. Training patients in how to use a diary is important. The use of cues as reminders to record information can increase compliance.
There are many sample patient diaries used in the evaluation and treatment of chronic pain. The diary should be custom-made to collect the type of information that is important to the treatment of the specific pain problem. The following is an example of a pain-activity-medication diary that is commonly used:
This pain diary, along with a number of other patient materials, is available from the American Pain Foundation (201 N. Charles St., Suite 710, Baltimore, MD, 21201-1111, www.painfoundation.org).
In general, two kinds of psychometric techniques are used in the assessment of chronic pain problems, general tests that are adapted to use in this population (e.g., MMPI-2, BDI-2) and tests constructed specifically for use with medical/pain patients (e.g., BHI-2, MPI). To get even more specific, there are also tests developed just for specific pain problems. For this overview discussion, tests designed for specific pain disorders will not be reviewed.
It is beyond the scope of this presentation to review all of the psychological tests that are used with pain patients (for that purpose the reader is referred to such volumes as Gatchel, Andersson, Deardorff, et al., 2001; Gatchel, Deardorff et al., 2006; Gatchel and Weisberg, 2000; Turk and Gatchel, 2002; and Turk and Melzack, 1992). The following reviews examples of commonly used tests; these are of both the “adapted-for-use” type and the specifically designed type:
The original MMPI was the most commonly used standardized personality test with chronic pain patients. The original MMPI was revised and released as the MMPI-2. Similar to its predecessor, it is likely that the MMPI-2 will also be the most commonly used personality test with chronic pain patients. Some of the strengths in using the MMPI-2 with chronic pain patients are:
The identification of psychopathology and personality disorders
There is a high prevalence of psychiatric and personality disorders among chronic pain patients. Identifying these psychopathological disorders is extremely important in the management of a chronic pain problem.
The identification of personality and behavioral characteristics of chronic pain patients differs from the identification of psychopathology. Examples of pain patient personality characteristics that might be identified by the MMPI -2 include dependent personality trends, passive aggressiveness, and obsessive-compulsive behavior. Identification of these characteristics by the MMPI-2 can help in treatment planning with chronic pain patients.
Another strength of the MMPI-2 is that the scores are standardized. The experienced MMPI-2 user will compare a chronic pain patient's profile not only with the normative reference group but also with other chronic pain patient profiles and subgroups developed though statistical means.
Many users of the MMPI-2 use it to make predictions regarding patient behavior, including response to treatment and treatment outcome. Many studies have shown that MMPI-2 profiles of chronic pain patients can be reliably classified into three or four major subgroups. The subgroups have been found to differ reliably from one another on such variables as pain intensity, medication use, functional disability, employment status, and surgery outcome.
The MMPI-2 is one of the only instruments that has several sophisticated mechanisms to check for response bias by the patient. In addition, the vast majority of the items are not face valid. Therefore, the clinician can generally tell if the patient answered the questions with a response bias (for whatever reason) that might affect the final profile results.
Anyone using the MMPI-2 to assess the personality characteristics of chronic pain patients must be aware of its strengths and weaknesses and avoid inappropriate use of the instrument. Critical areas of which to be aware include:
The MMPI-2 contains 567 true-false questions. For the chronic pain patient to complete the test, it can take several hours and may have to be completed over several sessions. Some clinicians believe that, although the MMPI-2 might yield useful information, the amount of time required to complete the test does not make it cost effective. Another common complaint of pain patients taking the MMPI-2 is its item content. Pain patients are particularly sensitive to psychological assessment since they believe the clinician may be implying the pain is "imaginary." This issue always has to be managed carefully by the referring physician and the pain clinician doing the assessment. The method in which the MMPI-2 is introduced to the patient is critical.
It has been argued that the results of the MMPI-2 profiles are invalid when used with chronic pain patients due to the inclusion of items that reflect features shared by psychiatric disturbance and chronic illness such as long-term pain. Scales 1 (Hypochondriasis) and 3 (Hysteria) contain a number of items reflecting a general medical or physical condition. Research has shown that elevations on Scales 1 and 3 can be reflective of disease rather than psychological status. This must be taken into account when interpreting MMPI-2 results.
For a clinician who is not extremely familiar with the use of the MMPI-2 with pain patients, there is a high risk of misinterpretation of the results. The risk of misinterpretation is due to several factors including the standardization sample, the contamination of certain scale items with physical symptoms, and the "outdated" scale names that purport to measure something they do not. A test interpreter who is not aware of these issues is likely to make a serious mistake in the MMPI-2 interpretation.
The Battery for Health Improvement-2 (BHI-2) is a 217-item, self-report, multiple-choice instrument designed for the psychological assessment of medical patients. The purpose of the test is to provide relevant information and treatment recommendations to professionals who treat injured patients in a variety of settings, including physical rehabilitation, vocational rehabilitation, and general medicine. The BHI-2 has 18 scales organized into five domains: Validity scales, Physical Symptoms scales, Affective scales, Character scales, and Psychosocial scales. The BHI-2 was designed for patients, 18-65 years old, who are being evaluated or treated for an injury. The test was designed for patients with at least a 6th grade education and takes approximately 35 to 40 minutes to complete.
Unlike many psychological tests that have been adapted for use with medical patients, the BHI-2 was designed specifically for this clinical population. As discussed in Battery for Health Improvement-2 Manual (Disorbio and Bruns, 2002), self-report psychological tests tend to “overpathologize” what might actually be normal or expected for the average medical or rehabilitation patient. Thus, traditional psychological tests must be used with caution, and interpreted accordingly by a qualified individual.
As documented in the manual, research relative to the development of the test has been extensive. This has included establishing normative values, demonstrating reasonable reliability (internal, test-retest), and assessing validity by correlating BHI-2 scales with scales from other established instruments (e.g., MMPI-2, MCMI-III). One potential problem with the BHI-2 that the user should be aware of is that there does not seem to be much clinical research yet available outside of that done by the authors during test development.
The SCL 90-R consists of only 90 items that are rated on the five-point scale (0 to 4). The instructions and questions are very straightforward; most patients can complete the test within 15 to 30 minutes. The results yield nine scale scores: Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety Paranoid Ideation, and Psychoticism. There are also three global measures of psychological distress: Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total. The SCL 9O-R has become one of the most commonly used measures of psychological distress among chronic pain patients.
Similar to the MMPI, one of the important uses of the SCL 90- R is the identification of psychopathology. The SCL 9O-R has been used extensively in medical settings as a screening tool and outcome measure. The SCL 90-R is a good instrument for screening for global psychological distress in medical patients. It is brief, easy to score, and generally well tolerated by patients.
Like the MMPI, the SCL 9O-R yields standardized scores. This allows the clinician to compare the individual profile of the pain patient against the normative sample and other groups. The test has been standardized using non-psychiatric and psychiatric normative samples. Although the SCL 9O-R measures various psychological problems, the item wording on the SCL 90-R seems to be less objectionable to most patients compared to the MMPI.
The SCL 90-R has shown reasonable convergent validity with MMPI scales and subscales. Thus, an argument can be made for the use of the SCL 9O-R in place of the MMPI when one wants a measure that is brief as well as simple to administer and score. Alternatively, some pain centers will first use the SCL 9O-R as a screening tool and then administer the MMPI only to those patients who show elevated scores on the SCL 90- R.
The problems with the SCL 9O-R are somewhat similar to those leveled at the MMPI. First, the SCL 9O-R was originally designed to be used on psychiatric patients. Critics contend that using the SCL 9O-R with pain patients causes significant problems due to unsuitability of norms, questionable relevance of clinical signs, and the misinterpretation of results. Thus, any understanding of results much take into account the effect of the patient’s report of physical symptoms in elevating certain scales.
Another criticism is that, like most of the other instruments except the MMPI-2, the items on the SCL 90-R are very face valid. In addition, there is no scale or means of checking for response bias or conscious manipulation of test results by the patient.
The original Beck Depression Inventory (BDI) is a 21 multiple-choice item test reflecting specific behavioral signs of depression that are weighted in severity from 0 to 3. The total score is obtained by adding the weighted values for each response endorsed by the patient. Scores of 0-9 are considered normal, the 10-15 range is seen as mild depression, 16 to 19 represents mild to moderate severity, 20-29 is judged as moderate to severe, and 30+ represents severe depression. The instrument was originally standardized using psychiatric patient populations.
The BDI is very easy to administer and score. It takes a patient between 5 and 10 minutes to complete the questionnaire, and the questions are very straightforward. The BDI has been shown to be a reliable and valid index of the severity of depressive symptoms in chronic pain patients.
The BDI has been slightly revised to the BDI-2. The BDI-2 has essentially the same questions as the original BDI except it has been divided into two subscales: physical and cognitive (or mood). This allows the clinician to see which factors are responsible for an elevated score. This can help minimize false positives in a pain patient population in which a patient has an elevated score due to physical symptoms but is not depressed.
The BDI is a very face-valid instrument. Thus, if a patient desires to present an inaccurate clinical picture of his emotional status, the BDI is easily manipulated. This generally does not occur and, if suspected, the BDI results can be correlated against additional clinical data such as the initial interview, history, and other test measures.
The Brief Battery for Health Improvement-2 (BBHI-2) was developed to serve as a tool for assessing medical patients who may be experiencing problems with pain, functioning, somatization, depression, anxiety or other factors relevant to rehabilitation and recovery (Disorbio and Bruns, 2002). The BBHI-2 is a shortened version of the BHI-2; it is a 63-item, self-report, multiple-choice instrument. The purpose of the test is to provide relevant information and treatment recommendations to professionals who treat injured patients in a variety of settings including physical rehabilitation, vocational rehabilitation, and general medicine. The BBHI-2 has six scales that cover three content areas: validity (defensiveness), physical symptoms (somatic complaints, pain complaints, functional complaints), and affective symptoms (depression and anxiety). The BBHI-2 was designed for patients, 18-65 years old, who are being evaluated or treated for an injury. The test is intended for patients with at least a 6th grade education and takes approximately 7 to 10 minutes to complete. The BBHI-2 is especially useful for tracking patient progress and response to treatment.
The problem with the BBHI-2 is the same as that of the BHI-2 in that there is not much research outside of the development studies. The brevity of the BBHI-2 makes it most useful as (1) a screening tool to identify patients in need of further assessment, (2) a test-retest measure of progress and response to treatment, and (3) a test to be used in conjunction with more comprehensive psychological testing.
A number of more relevant measures have been developed for use specifically with chronic pain patients. These can be very useful depending on the targets of assessment chosen. Among these are:
The MPI is a 56-item measure comprised of three sections. The first section includes items assessing (1) pain severity and suffering, (2) interference of functioning due to pain, (3) perceived life control, (4) affective distress, and (5) support from spouse or significant other. The second section assesses the patient's perception of how much the spouse or significant other is displaying solicitous, distracting, or punishing responses to pain or suffering behavior. The third section assesses the patient's level of activity in areas of household chores, outdoor work, activities away from home, social activity, and general activity level. The length of the MPI is well tolerated by patients, taking only about 15 to 20 minutes to complete.
The computer scoring generates a scaled T-score, and classifies the case into one of three empirically derived prototypic profiles: "Dysfunctional" (high pain severity, affective distress, and life interference with low life control and activity levels); "Interpersonally Distressed" (low levels of support from significant others); and "Adaptive Coper" (the opposite of Dysfunctional, with low levels of pain severity, affective distress, and life interference, and higher levels of life control and activity).
The MPI was specifically developed for pain patient assessment. The standardization and normative data are all derived from populations of pain patients. The MPI is theoretically linked to a cognitive-behavioral perspective of chronic pain and health assessment. Because the MPI was developed for use with pain patients, the items are relevant to the experience of the person with chronic pain. Therefore, patients generally do not question why the questionnaire is being used to assess their problem.
The MPI was designed to be a brief measure of specific characteristics of pain patients. As such, it does not yield any detailed information about such topics as depression, anxiety, or somatization. It also is not designed to screen for psychopathology that might impact chronic pain treatment. Therefore, the MPI might be best used in conjunction with another instrument such as the SCL 9O-R or MMPI-2.
The CSQ is a 50-item self-report instrument originally designed to assess six cognitive (diverting attention, reinterpreting pain sensation, coping self-statements, ignoring pain sensation, praying or hoping, and catastrophizing) and two behavioral (increasing activity level and increasing pain behaviors) coping strategies. This instrument also includes two items that ask patients to report their perceived control over pain and their ability to decrease pain.
The psychometric properties of the CSQ are good, and it has received a great deal of clinical research attention in terms of comparing reported use of coping strategies to indices of patient functioning and treatment outcome. For example, one major association between the CSQ factors and adjustment to chronic pain is that patients who report catastrophizing thinking styles and who view themselves as ineffective at controlling their pain appear to be more disabled and depressed at initial assessment as well as at follow-up assessment. Results such as these speak highly of the clinical utility of the CSQ with pain patients.
Factor analytic studies of the CSQ have failed to reveal a reliable factor structure, thus indicating the empirical difficulty of identifying distinct dimensions of coping. This suggests the need for additional research evaluating the "active ingredients" of patients' self-reported coping responses. Although this suggests a theoretical shortcoming in the CSQ with regard to the structure of coping strategies, it does not distract from its clinical utility.
The CPCI is a recently developed instrument comprised of 64 items that yields scores on eight main subscales measuring coping strategies that are frequently the target of treatment in multidisciplinary programs -- Guarding, Resting, Asking for Assistance, Relaxation, Task Persistence, Exercising, Stretching, Coping Self- Statements, and Seeking Social Support.
The CPCI was developed specifically for use with chronic pain patients, and attempts to overcome shortcomings of other coping measurement tools. Most coping measures assess primarily cognitive coping strategies (e.g., the Coping Strategies Questionnaire) to the exclusion of behavioral strategies. The CPCI was designed to assess behavioral coping strategies. Because the CPCI is so new, there is a limited amount of research available; thus, it is unknown how the CPCI results relate to such issues as treatment planning and prediction of outcome.
Obviously, this listing is not exhaustive. I cannot overemphasize the need for the psychologist to be aware of the reliability and validity issues specific to each measure for each usage. Failure to recognize the limits of interpretation of test results is contrary not only to good clinical practice but also to ethical standards.
Observation of the chronic pain patient is one of the most fundamental methods of assessment, and can provide the clinician with information applicable to many of the target areas described in the model. Observation can be unstructured or highly structured, and can be made directly by the clinician, by family members, or by health care providers. Furthermore, these observations can be audiotape or videotape recorded.
In most instances, the source of observational data will be during the clinical interview, as well as in the office setting or outpatient clinic (e.g., waiting room, walking to and from the office). If the patient is being assessed on an inpatient basis, observation can be made on the unit. Another important source of observational data is the interaction between the patient and significant others. It can be very helpful to have family members available to be interviewed as part of the evaluation. This can give the clinician a sense of how family members are reacting to the pain behaviors of the patient.
Observations can be quantified through rating methods, content analyses (e.g., somatic focus), frequency scores (e.g., pill counts to determine compliance), and other methods. The clinician can also collect impressions in an effort to generate hypotheses for more precise testing. It is especially useful to compare direct observation of behavior with others, perceptions of the behavior, or the patient’s own perception of his own behavior (e.g., the "demanding patient”). Reasons for the lack of correlation could be clinically very meaningful, and thus help target areas for intervention.
Archival data might include the patient’s medical chart, literature reviews relating to the pain condition, and employment records. Literature reviews of the chronic pain condition including cause, symptoms, course, prevention, treatment, and psychological components can provide archival data that is useful in the assessment process. Having a familiarity with the pain problem before assessing the patient can be very helpful in assisting the clinician in obtaining the more relevant information as efficiently and effectively as possible. It also helps to establish the credibility of the clinician with the patient. If you are referred a pain patient who has a condition with which you are unfamiliar, a quick Internet search of a reputable medical website (e.g., Medscape or WebMD) can provide useful information prior to the initial evaluation.
Reviews of previous medical and psychiatric charts are very valuable sources of information in the assessment of the chronic pain patient. The data from these archival sources can be compared and contrasted with those collected elsewhere (e.g., patient self-report, psychological testing). Although these records are not always easily obtained, the clinician will find the information contained within them most useful in providing a historical perspective of the patient, her problem, and aspects of help-seeking behavior.
It might also be necessary to consult archival data when assessing the potential impact of various environmental variables on the problem, such as the health care system and the sociocultural environment. Hospital policies, insurance coverages, legislation relating to disability, laws regulating the practice of health care provision, and employers' policies need to be understood to develop an adequate conceptualization for intervention. This is especially true when working with chronic pain patients who are part of a workers’ compensation or other disability system (e.g., Social Security).
According to Belar and Deardorff (1995, 2008), at the end of the assessment process, the clinician should have an understanding of:
(a) the patient in her physical and social environment,
(b) the patient's relevant strengths and weaknesses,
(c) the evidence for psychopathology,
(d) the nature of the disease and treatment regimen, and
(e) the coping skills being used by the patient.
After integrating relevant information, the clinician should be able to answer the seven questions listed below. These questions were derived by Belar and Deardorff (1995, 2008) from Moos (1977) who delineated these areas as the major adaptive tasks for any patient with a medical illness (including chronic pain). The relative importance of answers to each question in determining the overall status of the patient will vary, dependent on the understandings developed through assessment of the previously mentioned targets.
In conclusion, the purpose of the psychological pain evaluation is to understand the patient and her problem in order to arrive at a treatment strategy or a management decision. One need not be wedded to a particular theory or assessment strategy; rather, flexibility in this regard is an asset. However, the biopsychosocial conceptual framework should form the foundation of any chronic pain evaluation or treatment strategy.
Once the pain management clinician has an “understanding” of the chronic pain patient this information is usually recorded in an evaluation report. A template for the pain management evaluation report follows. Depending upon the setting and other issues, the report template can certainly be modified. For instance, very few physicians (and no surgeons) will take the time to read a lengthy evaluation report (the kind that psychologists are very good at producing). In many cases, it is appropriate to send only a very brief summary of important points to the other health care providers. The more lengthy report is often necessary when the patient is part of a comprehensive pain program, med-legal evaluation, or disability assessment.
Pain Management Evaluation
Identifying Information:
Presenting Problem and Review of Available Medical Records:
Work History:
Educational History:
Legal History:
Military History:
Other Medical Problems:
History of Work/Other Injuries:
Interviewer Observations and Mental Status Examination:
This is a summary of interviewer observation and a mini-mental status examination. A formal mental status examination was not necessary.
Attitude:
Pain Behaviors:
Mood/Affect:
Crying Spells:
Sleep:
Appetite and weight changes:
Energy level:
Memory and concentration abilities:
Suicidal ideation, plan, previous attempts:
Sexual functioning:
Symptoms of generalized anxiety or panic:
Thought Process:
Orientation:
Psychosocial Situation:
Psychiatric Treatment History:
Substance Use:
Medications:
Pain and Psychological Assessments:
Pain and Functional Ratings:
The numerical pain ratings assess the patient’s pain intensity and fluctuations. The functional ratings assess the patient’s self-perception of how the pain is affecting physical abilities across a number of domains.
Pain Drawing:
The pain drawing assesses the patient’s report of sensory distribution of pain and other symptoms
Battery for Health Improvement-2:
The BHI-2 is a comprehensive self-report instrument designed for the psychosocial assessment of medical patients (Bruns and Disorbio, 2002). The purpose of the test is to provide assessment information and treatment recommendations for injured patients in a variety of settings.
Multi-Dimensional Pain Inventory:
This comprehensive self-report instrument evaluates the impact of diverse chronic pain syndromes on multiple dimensions of a patient’s life (Turk and Melzak, 1992).
Beck Depression Inventory-2:
The BDI-2 is a self-report measure of depression. It is not used to diagnose depression in a patient; rather, it is designed to provide a measure of the intensity of depression in a patient who is found likely to be “depressed” by other measures (e.g., clinical interview). The BDI-2 helps to assess the chronic pain syndrome.
Impressions:
Symptoms of a Chronic Pain and Disability Syndrome:
Contribution of Operant/Cognitive/Affective Factors:
Strengths and Assets:
Suicidal Risk:
Substance Abuse Potential:
Potential Problems Related to Compliance with Treatment Recommendations:
Propensity Toward Side effects to Medications or Treatment:
Appropriateness for Antidepressant Medication Evaluation and Treatment:
Psychosocial Barriers to Recovery:
Appropriateness for Multidisciplinary Treatment:
Conclusions and Recommendations:
The two most common types of direct psychological treatment of chronic pain include cognitive behavioral interventions and relaxation training. These approaches are often used together to provide simultaneous interventions at cognitive and physical levels.
The cognitive behavioral model is excellent for treating many aspects of a chronic pain problem. It is beyond the scope of this discussion to review all of the intricacies of the cognitive behavioral model. For that discussion, the reader is referred elsewhere (see Bradley, 1996; Gatchel, 2004; Turk, 2002). This section will present an overview of the cognitive behavioral approach with a special emphasis on using it in treating chronic pain.
Turk (2002) provides an excellent overview of cognitive-behavioral treatment of chronic pain patients. Much of that detailed discussion will be reviewed subsequently, along with information from other sources. As discussed by Turk (2002), “According to the C-B model, then, it is the pain sufferer’s perspective, based on his or her idiosyncratic beliefs, appraisals, and unique schemas, that filter and interact reciprocally with emotional factors, social influences, and behavioral responses, as well as sensory phenomena. Moreover, patient’s behaviors elicit responses from significant others (including health care professionals) that can reinforce both adaptive and maladaptive modes of thinking, feeling, and behaving” (page 140). Turk goes on to summarize the five assumptions that characterize the cognitive behavioral treatment approach, and discusses them relative to chronic pain:
In the pain system model, an individual is seen as an active processor of the pain sensation including attaching meaning to it (e.g., threatening or non-threatening) and interpreting it based upon past experience and cultural influences. This active processing influence on pain becomes more and more significant as the pain goes on.
In the pain system model, a person’s thoughts about the pain will directly influence such things as affective state, pain behavior, and physiological arousal. For instance, chronic pain is often associated with depression; this is characteristically preceded by “depressionogenic” thoughts (“I’ll never get better,” “I have no control,” etc.). In addition, pain behaviors such as limiting activities are clearly related to one’s thoughts about the pain (“If I am active, I will injure myself”). Lastly, physiological arousal will follow such thoughts as, “I won’t be able to stand this pain much longer” and “What if the surgery doesn’t work?”
In the pain system model, a patient’s pain behavior will be influenced by the individual’s beliefs (thoughts) about the pain and by the reaction of the psychosocial environment (positive and negative reinforcement of the pain behavior).
As pain becomes more chronic, maladaptive patterns become more firmly entrenched. These patterns often include becoming more ensconced in the sick role with concomitant maladaptive changes in thoughts (how the patient views herself), affective status (depression) and behavioral patterns (pain and disability behaviors).
The gate control theory of pain posits that individuals can employ various pain management techniques to change the level of pain sensation and suffering.
As can be seen, the cognitive behavioral assumptions fit nicely within the conceptualization of the pain system discussed earlier.
The steps for preparing the chronic pain patient for the cognitive behavioral approach, and psychological pain management in general, include:
Introducing the cognitive behavioral model into treatment requires some preparation of the patient. In working with chronic pain patients, the pain management clinician must always be careful not to imply that “the pain is all in your head” or not believable. It can be helpful to present the psychological pain management techniques as methods to help the person manage the pain more effectively, improve his quality of life, and improve his mood even though the pain will still be there.
The next step is to carefully go over the gate control theory of pain and the “pain system” model as discussed previously. These concepts form the foundation upon which the multifaceted intervention will be justified to the patient. It is important for the patient to be actively involved in the psychological pain management treatment or it is doomed to fail. Part of preparing the patient includes explaining how psychological pain management techniques differ from the many medical treatments the patient has likely undergone. In contrast to medical treatments, the patient must be actively involved in any type of self-management and rehabilitation approach. He cannot simply be the passive recipient of a treatment (as in injections, massage, medication, surgery, etc.).
After explaining the gate control theory of pain to the patient, and the need for active patient involvement in the treatment, the cognitive behavioral approach can be discussed as one component of the chronic pain management treatment.
The patient can be told that the cognitive behavioral model (and the method for changing one’s thoughts) has been termed the “ABCDE” model, and that it can be a very useful tool in dealing with chronic pain. The specifics of the ABCDE model will be discussed shortly, but it is important for the patient to have an understanding of how thoughts and emotions operate. This was reviewed previously in more technical terms; a manner in which these concepts can be presented to patients follows.
We would all agree that we constantly have thoughts and images going through our head related to evaluating the world around us. In addition, we are continually evaluating the sensations that are going on inside of us as well. These thoughts have been termed “automatic” thoughts because they often occur automatically, almost out of our awareness. Automatic thoughts have the characteristics of being very fast, virtually out of awareness or unconscious, and highly believable. As we shall see shortly, automatic thoughts have great power over our emotions and behaviors. At first, the nature of the automatic thoughts may not be readily apparent even though they are influencing your emotions and your body's health.
Many of the cognitive researchers have observed that individuals under stress have a tendency to engage in negative automatic thoughts. Negative automatic thoughts, or “self-talk,” have the following characteristics:
Chronic pain can be a particularly stressful event, easily resulting in a cascade of negative automatic thoughts. Based on these findings, the ABCDE model was developed for chronic pain management. ABCDE stands for :
A is the Activating Event or Antecedent Event, which is simply the event to which you are responding. This could be an outside event, such as sitting in a traffic jam, or an internal event, such as a severe back spasm.
B is your automatic thought or Belief about the activating event. For instance, your belief about being in the traffic jam might be, "Oh no, this is awful. I will never make the meeting in time. I should have left earlier." Alternatively, your belief might be "There's nothing I can do about this traffic jam. I'll take this time to listen to the radio and be as relaxed as possible. I'll leave earlier in the future." In the back-pain example, your automatic thoughts might be, "I'll never get better. My back is getting worse and worse. I'll end up a cripple." On the other hand, your thoughts about the back pain might be "This pain doesn't mean I'm getting worse. This is usually a temporary thing. I am getting better overall. This pain is nothing to be frightened of."
In each of the above examples the first set of thoughts are negative automatic thoughts, and the second set of thoughts are coping or rational thoughts, The difference in the makeup of these thoughts can certainly be seen, and will be discussed more fully in a later section.
C is the Consequent Emotion that results from the automatic thoughts. Most people think that A causes C, but in reality, C is caused by B. A person's emotional response to a situation is caused by his beliefs about the situation and not by the situation itself
D is the Disputing Thoughts that are used to change automatic negative thoughts. These are used to help change the way a person thinks about stressful situations (such as back pain) from a negative standpoint to a coping standpoint. In working with patients on this exercise, we like to term this process the power of realistic thinking.
E is the Evaluation part of using the disputing thoughts to challenge the negative automatic thoughts. This process will be discussed further.
The following examples will help the patient understand just how the ABCDE model operates.
EXAMPLE 1
Activating Event: You experience a mild increase in your heart rate and feel "uncomfortable and jittery."
Belief: I'm having a heart attack!!!
Consequent Emotion: Fear, anxiety, panic.
Resulting Behavior: Call doctor or go to emergency room.
In this situation, the symptoms are being interpreted as a possible heart attack. The subsequent emotions and behavior follow from this belief. Suppose an alternative belief was that, "I just drank four cups of coffee and the caffeine is causing the symptoms." With this explanation, the emotions and resulting behavior would be entirely different.
EXAMPLE 2
Activating Event: You hear a noise at the bedroom window in the middle of the night.
Belief: There is an intruder trying to get in.
Consequent Emotion: Fear, panic.
Resulting Behavior: Call police, hide, and grab a weapon.
Again, in this example, the emotions and behavior follow from the belief that there is danger. Alternatively, if the belief was that the noise was caused by the wind blowing a tree branch against the window, the emotional response and behaviors would be entirely different. It should be noted that in each of these examples, the situations prompting the beliefs are exactly the same. The only difference is how the information is interpreted by the person in terms of beliefs. These beliefs are what caused the emotional response and behavior, not the situation itself.
We often see a similar occurrence in back pain cases. Take, for instance, the following example:
EXAMPLE 3
Activating Event: Back or neck pain
Beliefs: "There is something seriously wrong with my spine."
"My spine is weak and fragile."
"My pain is going to get worse and worse."
"I can't cope with this pain."
"I will never get better."
"I will always have pain."
"I should be better by now."
"I should never have let this happen."
"My back pain is all their fault."
"Nobody really understands my pain."
"If I move the wrong way, I'll do myself in."
Consequent Emotion: Hopelessness, helplessness, anxiety, fear, depression, anger
Resulting Behavior: Bed rest; social isolation; irritability; physical deconditioning; decreased sex drive; disability from work; use of pain medicines; groaning, moaning, and grimacing; slow, robotic movements
These examples illustrate how our thoughts influence our emotions and behavior. But how can we use this information to help with chronic pain? This is done through the use of the "three-column" and "five-column" techniques. The power in using this approach comes from changing the negative automatic thoughts to "realistic, coping, and nurturing" thoughts. By changing the thoughts about the chronic pain, the patient can change his emotional responses and behaviors.
The ABC and ABCDE models can be utilized in a three- or five-column technique. A three-column worksheet can be seen in following figure.
The Three-Column Technique
|
Activating Event |
Beliefs |
Consequent Emotions |
|
Sitting at work. Supervisor gave me too much to do. I’m noticing worse pain in my back and neck. |
“There is something seriously wrong with my back.” |
Fear |
|
“I’ll never lead a normal life.” |
Helplessness |
|
|
“There is nothing I can do about this pain.” |
Hopelessness |
|
|
“My back pain is all their fault.” |
Anger and Entitlement |
|
|
“I should be better by now.” |
Guilt |
The three columns represent the A, B, and C events discussed previously. It is useful to make several copies of a blank ABC worksheet in order to practice identifying activating events, beliefs, and consequent emotions. The three-column technique is a tool that enables the patient to run the automatic negative thoughts in slow motion. The patient can use the three-column technique to analyze thoughts and feelings whenever a stressful situation presents itself. An activating event can be any stressor, such as pain, a situation, a memory, or an interaction with another person. At first it can be difficult for the patient to "flesh out" the beliefs or automatic negative thoughts about a situation. Automatic negative thoughts often contain such words as should, ought, must, never, and always. As can be seen in the previous examples, phrases with these words are common in negative thinking. It is best to have the patient practice just the three-column technique for a week. In the follow up session, the chart should be reviewed to ensure that the patient understands the concepts and is being compliant with the charting. Any problems can then be resolved early on.
Negative thinking often takes on certain styles or patterns; these are important to identify and discuss with the patient. Briefly, these styles can be summarized as follows:
This type of negative thinking is characterized by imagining the worst possible scenario and then acting as if that will actually happen. It will often include a series of “What if’s” such as:
In catastrophic thinking, the dire predictions are not based on facts but rather on pessimistic beliefs.
This negative thinking style involves focusing on only the negative aspects of a situation to the exclusion of any positive elements or options. This style will commonly include searching for evidence of "how bad things really are" and discounting any positive or coping focus. Examples include:
This style of thinking is often characterized by discounting and "yes, but-ing." No matter what positive option or coping method is suggested, the chronic pain sufferer will discount it with a "yes, but." For instance, a person with back pain has been able to stop the pain medicines and start on a mild exercise program. When this is discussed as being a very positive change, the person retorts, "Yes, but I still have pain, I haven't returned to work, and I'll bet this pain doesn't go away." This type of thinking continues to foster helplessness, hopelessness, and depression.
This type of thinking is seeing things either one way or the other. There is no middle ground or shade of gray. This type of thinking is typified by:
This thinking undermines any small steps toward improvement, severely limits one's options, and filters out any positive aspects of the back-pain situation.
This is the process of taking one aspect of a situation and applying it to all other situations. It involves generalizing reactions to situations in which such reactions are not appropriate. For instance:
As can be seen, this style of irrational thinking will take one incident and make it apply to many other situations.
This negative thinking trap involves making assumptions about what other people are thinking without actually knowing. The person will then act on these assumptions, which are usually erroneous. Examples of this include:
If a person accepts these assumptions as facts, then the behavior will follow accordingly, and a possible self-fulfilling prophecy will be created. For example, a patient’s spouse might ask, "How does your back feel today?" Instead of taking his comment at face value, the patient believes he really means, "Are you still letting that little back pain bother you?" Therefore, the patient responds, "How do think it feels today?! The same as always –– that's how!" One can easily guess how this scenario would be completed.
Should statements are key elements in negative automatic thinking. Examples of such thinking include:
Should thinking also includes words such as ought, must, always, and never. Should thinking is very judgmental and often involves measuring your performance against some irrational perfect standard. It has the effect of making you feel worthless, useless, and inadequate. When directed at others, it will have the effect of making the patient feel angry and resentful in those relationships.
In blaming, the person makes something or someone else responsible for the chronic pain. This kind of negative thinking is often seen in trauma cases such as industrial injury or automobile accidents. Examples include:
Blaming as a form of negative automatic thoughts can be focused either externally or internally. Blaming can be very destructive in keeping the patient from focusing on what he needs to do to get better.
To help the patient become proficient at the three-column technique, exploring some possible antecedent events can be helpful (e.g., pain flare-up, negative relationship interactions, other stressors). Once several antecedent situations are identified as examples, the patient’s beliefs and emotional responses can then be discussed. In some cases, it is easier for patients to identify emotional reactions first and then work backwards to identify the negative automatic thoughts or beliefs.
When the patient has become skilled at identifying the ABC components of stress and pain, the three-column technique can be expanded to a five-column technique. This expansion is done by adding the columns for Disputing Thoughts and Evaluation. The disputing thoughts are constructed to directly "attack" and counter the negative automatic thoughts that are generated in column B. Challenging the negative automatic thoughts can be done using the six questions that follow; these will help the patient develop the “coping” thoughts to be recorded in column D:
Having the patient subject her self-talk to these questions will help identify negative versus positive (or coping) messages. After helping the pain patient to identify and challenge any negative self-talk, it is important to facilitate the process of substituting positive, realistic, or coping self-talk. The patient writes these coping thoughts in the thoughts and feelings diary, and then practices them through rehearsal. Bourne (1995) has developed the following rules to help patients write positive coping self-talk statements.
When having patients write positive coping statements, teach them to avoid using negatives. For instance, instead of saying, “I can’t be nervous about the pain increasing,” a patient can say, “I will be confident and calm about completing this activity.” The first type of statement can be anxiety producing in and of itself, defeating the purpose of the coping thought.
Since most negative self-talk occurs in the here and now, it should be countered by coping thoughts that are in the present tense. Instead of a patient saying, “I will be happy when this pain is gone,” he or she might say, “I am happy about ____ right now.” Teaching pain patients to begin self-statements with, “I am learning to ____” and “I can ____” is very beneficial for cognitive restructuring.
Whenever possible, have patients keep their thoughts in the first person. This can be done by having patients begin coping thoughts with “I” or by being sure that “I” occurs somewhere in the sentence.
Coping thoughts should be based in reality. This will insure that the patient will have confidence in his own coping self-talk. As a patient practices the positive self-talk, it becomes more and more believable. A person’s coping thoughts should not be broadly positive, Pollyannaish, and unrealistic; otherwise, the patient will completely discount them as untrue. For instance, the coping thought of “I can’t wait to have the surgery. I’m sure it will completely take away my pain” is unrealistic and not believable. Rather, the thought, “I will do my best to make sure the surgery is as successful as possible, and I look forward to beginning the recovery process,” is much more tenable.
Coping self-talk can challenge each of the negative styles. The clinician can review the following examples with the patients to help them understand how the disputing or challenging thoughts are generated
For catastrophizing, the patient should be reminded that no one can predict the future. Tell the patient that it is probably in her best interest to predict a realistic or positive outcome rather than a catastrophic and “what if....” outcome. Explain to the patient that acting “as if” things will turn out OK is usually the best course of action.
If a patient is filtering out everything except the most negative aspects of a situation, he needs to learn to shift focus. First, teach the patient to redirect his attention onto active strategies that can be used to make the situation more manageable. Help the patient look at the situation realistically rather than magnifying the negative aspects. Then, have the patient focus on the positive aspects of the situation. Patients should be encouraged to avoid the negative thought, “I can’t stand it.”
Thinking in black and white will always set the patient up for disappointment because there will be no allowance for gradual improvement. The first step in changing this thinking is to help the patient identify when she is using absolute words like all, every, always, never, and none. The second step is to have the patient focus on how the situation may be changing in gradual steps. Lastly, remind the patient there are always different options, not just the two extremes of black and white.
Overgeneralizing
In overgeneralizing, the patient is taking one element of a situation and applying it to everything else. A patient can stop overgeneralizing by being reminded to evaluate each aspect of a situation realistically and independently.
Nobody can read another person’s mind although individuals often have the tendency to act as if it is possible. This causes a person to act and feel toward others based upon inaccurate conclusions. For instance, a patient might think, “I know my doctor doesn’t like me,” based simply on mind reading. Remind patients that nobody can read another person’s mind, and it is important to “check it out.”
If a patient has a propensity towards using the words should, ought, and must, then he is either self-discounting or is judging others by standards that are unrealistic. These types of statements seek to lower a patient’s self-confidence and self-esteem. To help patients evaluate when this is happening, teach them to ask themselves, “Is this standard realistic?” “Is this standard flexible?” and “Does this standard make my life and situation better?”
If patients are tending towards self-blame, they should be reminded that they tried to make the best choice at the time, and can continue to make healthy choices from now on. If they are blaming others, have them assess realistically how they went about making their choices and remind them of what aspects of the situation are in their control and realm of responsibility.
The result of these exercises is the five-column technique as illustrated in the following table. Give the patient several blank five-column tables
The Five-Column Technique
|
Activating Event |
Beliefs |
Consequent Emotions |
Disputing Thoughts |
Evaluation |
|
Sitting at work. Supervisor gave me too much to do. I’m noticing worse pain in my back and neck. |
“There is something seriously wrong with my back.” |
Fear |
“Hurt does not equal harm! This pain does mean injury.” |
Much less fear |
|
“I’ll never lead a normal life.” |
Helplessness |
“No one can predict the future.” |
More feeling of control |
|
|
“There is nothing I can do about this pain.” |
Hopelessness |
“There are things I can do. They are _____.” |
Somewhat better |
|
|
“My back pain is all their fault.” |
Anger and Entitlement |
“Blaming does not help me get better.” |
Decreased anger |
|
|
“I should be better by now.” |
Guilt |
“I am trying to get better and am working hard at it.” |
Guilt improved |
Excess anxiety and tension can cause such reactions as heightened emotional upset (anxiety, depression, anger), increased pain, slower healing times, and increased side effects to medications. A sustained stress response causes multiple negative problems such as increasing muscle tension and pain while decreasing the activity of the immune system and blood flow to the extremities.
It is important for the patient to have a good understanding of what stress is, what it can do to the body and mind, and its impact on chronic pain. A detailed discussion with this patient regarding these issues will provide a solid rationale for the benefits of relaxation training.
Stress can be generally defined as a “demand” – either physical or mental -- that is made upon the body. Certainly, chronic pain and associated “losses” (both physical and mental) fall within the boundaries of a significant demand on the body and mind. The body’s stress responses include:
Having the chronic pain patient learn the “relaxation response” is the key to overcoming these symptoms. It should be explained to the patient that the stress response and the relaxation response are completely incompatible. If the patient can learn to elicit the relaxation response, the stress response can be effectively blocked and the pain (or suffering) can be diminished. The relaxation response also provides many benefits beyond simply blocking the stress response and helping with pain.
It is important to distinguish from the "relaxation response" versus simply "relaxing." When discussing relaxation training as part of chronic pain management, patients often ask if they can simply do something they enjoy such as listening to music or sitting out in the backyard. It should be explained that although these types of activities are certainly “relaxing,” they do not elicit the “relaxation response.”
The type of relaxation that is important in chronic pain management is some form of deep relaxation. Deep relaxation, or the relaxation response, refers to a specific physiological state that is the exact opposite of the way the body reacts when it is under stress. The relaxation response was first described by Dr. Herbert Benson and his colleagues at Harvard Medical School in the early 1970's. The relaxation response involves a number of physical changes, including:
This type of deep relaxation or relaxation response can only be achieved with regular practice of a relaxation technique. Once the patient learns to elicit the relaxation response, he will notice feeling more relaxed even when not directly practicing the relaxation technique. A direct comparison of the physiologic effects of the stress response versus the relaxation response is as follows.
|
Physiologic State |
Stress Response |
Relaxation Response |
|
Metabolism |
Increases |
Decreases |
|
Blood Pressure |
Increases |
Decreases |
|
Heart Rate |
Increases |
Decreases |
|
Blood Flowing to the Muscles of the Arms and Legs |
Increases |
Stable |
|
Muscle Tension |
Increases |
Decreases |
|
Slow Brain Waves |
Decreases |
Increases |
Learning how to achieve a relaxation response produces many benefits, both directly associated with managing the symptoms of chronic pain and in other aspects of the patient’s life. These have been summarized as follows:
The deep relaxation response also directly affects the physical stressors associated with chronic pain. These include:
There are many techniques and exercises for bringing about deep relaxation or the relaxation response. These include breathing techniques, progressive muscle relaxation, visualizing a peaceful image, meditation, and imagery. In general, the breathing exercises seem to be the easiest way to learn to elicit the relaxation response and are probably the most appropriate initial technique to be used with chronic pain patients. The exercises are straightforward and require a minimal amount of body movement. This makes them easily applied to most chronic pain conditions, even those in which restriction on movement or position may be part of the functional problem. Generally, there is no problem with using any of the breathing techniques that will be presented here.
At first, the patient may think it strange to discuss learning how to breathe properly. Breathing is essential for life, and it is often taken for granted that we all know how to do it properly. In reality, very few people actually breathe in the healthiest fashion. The following explanation works well for patients:
Breathing allows us to take in oxygen, which is transported through the blood to the lungs. When your blood leaves your lungs through arteries, it has a high oxygen content. It is pumped by your heart to all parts of the body, delivering the essential oxygen. The oxygen in the blood cells is exchanged for waste products. The blood is then pumped back through the heart and is returned to the lungs where the waste products are expelled in the form of carbon dioxide. Once the waste products are released by the blood cells, they take in the fresh oxygen and the cycle repeats itself.
Breathing improperly can cause an insufficient amount of oxygen to reach the blood cells, causing waste products that should have been removed to be kept in circulation. Poorly oxygenated blood is one aspect of a stress response.
There are generally two types of breathing -- one is called chest breathing and the other is termed abdominal, or diaphragmatic, breathing.
Chest breathing, which is also termed, “shallow breathing,” leads to poorly oxygenated blood. Chest breathing occurs when you expand your chest with each in-breath and tuck in your abdomen. The breaths tend to be shallow and short. They can also be quite irregular and rapid. When the air is inhaled, the chest expands and the shoulders rise.
Chest breathing can be associated with high anxiety states in which a person may experience holding her breath, hyperventilation, shortness of breath, constricted breathing, or feeling as if she going to pass out. People are more prone to chest breathe when they are under stress (such as with increased pain), which in turn decreases their ability to cope with the stress.
In extreme cases of chest breathing, a hyperventilation syndrome can occur. This is due to exhaling excess carbon dioxide in relation to the amount of oxygen the person is taking in. This can result in a syndrome of symptoms that include a rapid heartbeat, dizziness, tingling sensations at the fingertips and around the mouth, feeling nervous and jittery, and disorientation. Learning how to breathe abdominally will help alleviate any symptoms of stress or hyperventilation syndrome.
Abdominal, or diaphragmatic, breathing is how we breathe naturally. Newborn infants are abdominal breathers, as evidenced by their stomach moving with each breath. In addition, adults breathe abdominally when they sleep. Unfortunately, most of us learn to be chest breathers over the years. Learning to breathe diaphragmatically can produce the positive benefits discussed previously. Although it may seem unnatural at first, abdominal breathing is, indeed, the most natural and healthy way to breathe.
The diaphragm is a sheet-like muscle that stretches across the chest and separates the chest cavity from the abdominal cavity. The diaphragm muscle generally expands and contracts automatically, although it can be done voluntarily. When inhaling, the diaphragm contracts, causing air to be pulled into the lungs. As this is occurring, the abdominal wall moves out. When the diaphragm and the chest relax, the lungs contract and the air is forced out, which is "exhaling." As this process occurs, the abdomen once again flattens out and the cycle starts over. Breathing diaphragmatically, or abdominally, allows a person to take a deeper breath, as well as permitting a more complete exhale.
Learning how to breathe diaphragmatically is a key component to learning how to elicit the relaxation response.
Patient should be told that they will be taught an easy-to-learn technique for eliciting the relaxation response, and that this will involve a 3-step process:
This section outlines a variety of breathing/relaxation exercises because people have different likes and dislikes in terms of techniques. It is important that the patient chooses the technique that is enjoyable and works. This will increase the likelihood of regular practice.
By regularly practicing proper breathing techniques, the patient can learn to elicit the relaxation response. In this section, several types of breathing exercises will be reviewed. Prior to teaching the relaxation exercises, have the patient assess how he breathes currently.
The following is a four-step exercise to help the patient become aware of how he normally breathes. Have the patient complete the breathing awareness by giving the following directions:
If the patient’s abdomen moves up and down with each breath, then he is breathing diaphragmatically. If the chest moves up and down with each breath, chest breathing is taking place.
The following exercise will help the patient develop the skill of abdominal breathing. Have the patient practice it until he is able to breathe abdominally during a relaxation session of 5 to 10 minutes.
After the patient has mastered abdominal breathing, a deep breathing exercise can be helpful to begin to learn to elicit the deep relaxation response. The deep breathing exercise is accomplished as follows (this exercise can be practiced in a variety of positions, but the following one is recommended):
Successfully teaching the chronic pain patient how to elicit the deep relaxation response is only half the battle. The next critical component to this type of intervention is generalization of the skill. This is where the cue-controlled relaxation can be very effective.
Cue-controlled relaxation is a powerful technique that can be used either in conjunction with relaxed breathing or alone. In cued relaxation, the patient learns to use a cue to signal the relaxation response. The cue can be anything, and is best developed based on discussions with the patient. One example is to have the patient place small colored dots around her environment. The colored labeling dots available at most stationary stores work quite well. Have the patient get the dots in a color that is “relaxing” for her. Tell the patient to place the dots where they will be seen at least every 15 minutes throughout the day. Some excellent places are on the back of the phone, on the computer monitor, and on the dashboard of the car. Each time the patient sees a dot, she is reminded to “check your muscle tension level, take a relaxation breath, and go about your business.”
Other examples of cues might be a verbal signal such as a word or a muscular signal. When a word or phrase is used, it is most commonly something that the patient can say quietly to herself, such as “relax.” This is usually done while taking a relaxation-breath. Instead of a verbal signal, a muscular signal such as gently touching the thumb and index finger together can also be used.
To use cue-controlled relaxation with a muscular signal, the patient would simply touch the thumb and forefinger together in order to elicit the deep relaxation response. This is especially useful when the patient is in a situation where actually engaging in the relaxed breathing is difficult. For example, when the patient is talking to doctors or undergoing an uncomfortable procedure.
It is very helpful for patients to understand how a cue, such as a word or touching fingers together, can cause relaxation. To do this, explain the process of classical conditioning as follows:
In the early 1900s, Ivan Pavlov, a Russian physiologist, did a series of experiments that demonstrated the ability of basic physiological responses to come under the control of cues that are totally unrelated to them. In his now famous experiments, which you may have heard of, he showed that the salivation response in dogs could be caused or elicited by the sound of a bell. Since bells having nothing to do with the salivation response in animals, how did they cause salivation? Pavlov found that by repeatedly associating the bell with food (which does cause salivation), the bell would begin to cause salivation even when no food was present. He did this by first ringing the bell and quickly following with the food. Dogs quickly learned to salivate to the sound of the bell.
This form of learning is called Pavlovian or Classical Conditioning, and occurs daily in all avenues of our lives. For example, like the bell, even thoughts can be conditioned to elicit a physiological response. Simply think about biting into a juicy slice of lemon, and you will likely experience some salivation. The thought, or visual image, of biting into a lemon has been associated with past experiences of tasting an actual lemon and has thus become conditioned to elicit salivation. Another example of classical conditioning can be seen in patients who have become nauseated following the injection of a drug. After this experience, they find themselves becoming nauseated at the smell of the alcohol that was used to clean the skin prior to the injection. This occurs even though the alcohol smell itself originally had nothing to do with them becoming nauseated.
In cue-controlled relaxation, the cue is conditioned to elicit the relaxation response using classical conditioning. The cue (the word relax, a phrase, seeing a colored dot, or touching your fingers together), is analogous to the bell in Pavlov’s experiments. The cue is associated with the relaxed breathing, which elicits or causes the physiological changes associated with relaxation. Eventually, with practice, the cue becomes conditioned to elicit the relaxation response the same way the bell caused salivation. It should be noted that the cue will not typically result in the same degree of relaxation as actually doing the breathing, but in many situations, you do not need to be too deeply relaxed. In these situations, you may need to just stop stress, anxiety, and pain from escalating further. This use of cue-controlled relaxation for damage control can be very effective.
The following paragraphs will step the patient through the procedures involved in learning cue-controlled relaxation. However, before the patient tries to learn cue-controlled relaxation, it is important to have a basic mastery of relaxed breathing and eliciting the deep relaxation response. Have the patient practice relaxed breathing for at least a week or two prior to learning the cue-controlled relaxation. After the deep relaxation response is established, use the following script to help the patient develop cue controlled relaxation:
The cue you choose can be verbal or muscular. Verbal cues include a word like relax, breathe, or the number one; a phrase, such as I am Calm; or, a phrase from a prayer. An example of an easy muscular cue is to gently touch your thumb and index finger of your non-dominant hand together. You can even combine several cues, though we tend to favor the simplicity of using only one. While many patients prefer a verbal cue, the use of the finger cue is easy to use and frequently you must use the cue in situations where you have to be interacting with others or engaging in thought processes, which would make the use of verbal cues very difficult.
Whenever you practice the relaxed breathing exercise, use the last 20 breaths at the end of your practice sessions to learn cue-controlled relaxation. For example:
Word or Phrase Cue: If you choose to use a word cue, such as relax, stretch out the sound of the word while you are exhaling by saying reeelaax. With practice, simply saying relax to yourself will result in relaxation.
Finger Cue: If you choose the finger cue, gently squeeze your thumb and forefinger together on the inhalation, or in-breath, but not too tight, and then relax the squeeze on the out-breath. You do not need to part the thumb and forefinger when you relax the squeeze; the action should be effortless. Remember, squeeze and release very gently. The cue, then, is to simply squeeze your thumb and forefinger together and then release the squeeze when you need to signal the relaxation response. The finger cue is discrete, can be used anywhere, and does not interfere with social interactions or thought processes.
Cue-controlled relaxation can be used in many situations where it is either difficult or impossible to actually engage in relaxed breathing, or when the patient needs to slow things down and redirect his attention to relaxation. Examples of the uses for cue-controlled relaxation are:
The cue-controlled relaxation can be used in any situation, especially if the pain patient is having difficulty actually being able to do relaxed breathing. For example, if the patient is in a stressful meeting with his doctor, is discussing medical matters, and wants to reduce his distress, doing the breathing would be conspicuous and disruptive but the cue relaxation works just fine.
To refocus one’s concentration on breathing, relaxing and coping
For example, the patient is in a situation where she is being distracted from relaxing and is beginning to feel distress. The cue can be used as a signal to relax.
Cue-controlled relaxation is a powerful technique for stopping or disrupting negative automatic thinking. For example, the cue-controlled relaxation can be used if the patient finds that he tends to get carried away with negative thoughts that are causing anxiety or distress. The cue can be used to disrupt or stop these thoughts, and redirect thinking towards coping self-statements. This can be very useful as part of the cognitive-behavioral intervention presented previously.
The cue-controlled relaxation is an excellent way to prepare for an uncomfortable medical procedure, particularly when doing the breathing is difficult or not possible. Employing a cue to prepare for, or to cope with, a painful medical procedure is one of the most effective uses of cue-controlled relaxation. For example, the pain patient can use the cue to signal relaxation to reduce the discomfort associated with such procedures as a nerve block, an injection, the placement of an IV catheter, or when working through a difficult exercise.
Cue-controlled relaxation can be used to manage pain flare-ups. Virtually all chronic pain patients complain of periodic episodes of pain flare-up. The cue can be used to get the patient through these episodes by using it as soon as the increased pain is experienced. This can also help reduce the overall amount of pain medication consumption since the patient has other “tools” available to help manage the pain.
In summary, cue-controlled relaxation is a very powerful skill, which can be used in a variety of situations related to pain management as well as in every day life. As with all skills, one must TAKE TIME TO PRACTICE! The cue will work for the patient, but only if it is practiced and given a chance to become conditioned to the deep relaxation response.
Just like learning any new skill, the deep relaxation exercises must be practiced to be effective. The following guidelines will help the patient establish a regular practice regimen. These guidelines will also help insure that the patient gets the most out of each breathing session. The learning process will require more time initially, but after the patient masters the skill of deep relaxation, less practice time overall will be required. The following guidelines should be reviewed with the patient:
It is important to have patients practice the breathing exercises once or twice per day. Practicing at least once per day is mandatory in order to learn to elicit the deep relaxation response. As patients practice regularly, they may find that the amount of time required to elicit the relaxation response decreases.
It is important for patients to practice the breathing exercises in a quiet location where they will not be disturbed or distracted. For instance, patients should be told turn the ringer on the telephone off and the volume down on the answering machine. Also, they should not be able to hear outside distracting noises. It can often be useful for patients to use something like a fan or air conditioner to block out outside noise if that is a problem.
It can be useful to have the patient give other family members a five-minute warning when he begins breathing exercises. This can help a patient take care of "loose ends" prior to practicing the deep breathing. For instance, if a patient tends to be worried about a number of things "to do," it can be helpful to have him make a short list prior to doing the relaxation exercise. This will help the patient be able to focus on the deep relaxation exercise rather than "trying to remember" what "needs" to be done after relaxing.
It is important to have patients set up regular practice times, as this will increase the likelihood or follow-through on deep relaxation exercises. These times should be when a patient is most likely to complete the exercises. The regular practice times should not be when the patient is so tired (for instance, right after a big meal or just prior to bed) that he is likely to fall asleep.
As discussed above, practicing deep relaxation after a big meal increases the likelihood that a patient will fall asleep in the middle of trying to relax. In addition, the process of digestion after meals can disrupt deep relaxation. Therefore, it is recommended that patients try to practice on an empty stomach, if possible.
A patient should be in a comfortable position when practicing deep relaxation exercises. A common position is lying flat on one’s back with the legs extended out, and arms comfortably at the sides. Depending upon the patient’s pain condition, this posture may not be possible. In that case, some other position can be used (e.g., knees up with a pillow underneath, sitting, or even standing). If a patient is tired or sleepy, relaxation exercises can be practiced sitting up, as opposed to lying down, to prevent falling asleep
It is useful to have patients loosen any tight clothing, and take off such things as shoes, watch, glasses, jewelry, and other constrictive apparel when practicing relaxation. Again, the object is to have the patient be as comfortable as possible while practicing.
It is important for patients to complete the deep relaxation exercise while adopting an attitude of "allowing" the relaxation response to happen. The patient should not "try" to relax or "control" her body.
Almost everyone who practices the deep relaxation exercises finds the relaxed state quite enjoyable and beneficial. Certainly, the research has demonstrated how useful learning to elicit the deep relaxation response can be in helping to manage chronic pain and associated symptoms. Even so, nearly everyone comes up against common obstacles to practicing the deep relaxation exercises on a regular basis. Regular practice is essential to learn to elicit the deep relaxation response so that it can be used when needed. The following are some of the most common obstacles to practicing the deep relaxation on a regular basis.
This is one of the most common obstacles to practicing the deep relaxation procedures. What this statement really means is that the patient has not made practicing the deep relaxation exercises a priority. It may be useful to review with the patient why he has not found the time to practice on a regular basis. Most often, people will have made everything else a priority except for taking care of themselves by practicing the exercises. Explain that the patient must choose to practice on a regular basis, knowing that the outcome will be improved pain management skills as a whole.
Some people have trouble with the deep relaxation exercises because they feel they are "boring." Often, these are the types of people that must be busy all of the time, and who feel particularly anxious when they try to relax or close their eyes. If the patient experiences this situation, it can be important to explore why the patient may have trouble just "being still.” The more common reasons include negative thoughts such as:
When people have trouble practicing the relaxation exercises on a regular basis, a common excuse is that they don't have a place to relax. They will often state that the house is too "noisy" or their attention to the needs of others is in constant demand (such as job responsibilities or caring for the children). Even in these situations, it is very possible to structure one’s environment to get 20 minutes per day to practice the exercises. The following suggestions for the patient might be helpful:
A small group of people will experience peculiar sensations when they practice deep relaxation or they may feel more anxious when they relax. This can occur when a person is especially not accustomed to the feelings of deep relaxation due to being "speeded up" most of the time. In these cases, it can be useful for the patient to start out slowly and keep the practice sessions short at first. As the patient practices more, she can gradually work up to longer periods of practice, until a target of about 15-20 minutes is reached. Although some people try to practice longer, it is generally not recommend that pain patients practice for more than 30 minutes at a time.
At times, the patient may find it difficult to keep her mind focused on the breathing exercises. The patient may complain of her mind wandering to other issues of the day or being distracted by outside noises or negative thoughts. Explain to the patient that this is a common occurrence and is nothing about which to worry. Discuss with the patient that the following can be helpful to manage mind chatter:
Using the deep breathing exercises to elicit the relaxation response is both safe and natural. Even so, there are some instances when precautions might need to be taken; these are generally related to the body needing to adjust to being relaxed. These would include such things as seizure disorders, insulin-dependent diabetes, and hypertension.
In seizure disorders, some seizures are brought on by a change in the level of arousal such as going to sleep or waking up. Since the brain waves that occur during deep relaxation are similar to those of some stages of sleep, people with sleep-onset seizure disorders may experience seizures when they first start practicing the exercises. Have the patient discuss this issue with his doctor. Research indicates that the triggering of these types of seizures generally subsides with continued practice or choosing another type of relaxation technique.
In rare cases, patients who are on insulin may find that their insulin requirement is decreased after starting regular practice of the deep relaxation exercises. Again, this issue should be discussed with the patient’s doctor as hypoglycemic reactions need to be taken seriously.
Lastly, certain medications such as antihypertensives and antidepressants can interfere with normal blood pressure adjustments when making postural (or position) changes. For instance, the patient may feel lightheaded or dizzy when rapidly going from a lying down to a standing position. Therefore, warn the patient to slowly change her posture after practicing the deep relaxation exercises. For instance, the patient should go slowly from lying down to a sitting position, giving the body time to adjust. Then, she should move slowly to a standing upright position. This will prevent any drop in blood pressure due to rapid postural changes.
The previous section reviewed treatments that are directly applied by the pain management clinician in treating chronic pain. However, the expertise of the pain management clinician (especially in the use of behavioral principles) also allows for other “indirect” interventions that can be very powerful in treating chronic pain. In this role, the pain management clinician acts as a consultant to other healthcare providers and the patient. Two of the most commons areas of “consulting” are medications and physical re-activation. Of course, these types of indirect interventions require a close and collegial working relationship with the other healthcare providers; however, this should be the case in providing effective treatment of chronic pain patients anyway. Of course, these other providers must be respectful of what psychology has to offer in terms of applying behavioral principles to medical care and treatment.
This section is an overview of medicines that are commonly used in the treatment of pain. It is important for the pain management clinician working with chronic pain patients to be familiar with the various medications that are commonly used in the treatment of chronic pain.
You may be asking why the pain management clinician working with chronic pain patient needs to know information about medications. Since the pain management clinician will generally spend more time with the patient than the treating physician, he is in a unique position to monitor:
In addition to providing psychological treatment in the form of chronic pain management, the pain management clinician is also a patient advocate. For instance, it is not unusual for the astute pain management clinician to discover that a chronic pain patient has been on an extensive medication regimen for years, and has not had regular liver and kidney function tests. Or, the pain management clinician may be the first to hear about significant (and serious) side effects to medications that have been occurring for quite some time that the patient has not described to her physician (e.g., bleeding, bruising). I make it a rule to ask patients the following questions on a regular basis:
If problems are discovered, encourage the patient to schedule an appointment with her physician. At the next visit, verify that the patient followed through and was actually reevaluated by his doctor. If you have the appropriate release of information, contacting the physician about such issues is important.
Traditional medicine will often look to medicating chronic pain suffering without providing other treatments (e.g., physical conditioning, relaxation training, and mind-body approaches) that are more likely to be of long-term benefit. In the vast majority of cases of chronic pain, if a decision is made to use medication, it should be done in conjunction with a treatment plan including other approaches. Medications used for chronic pain can be divided into six general categories:
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen have been placed together since they are commonly used in the treatment of chronic pain. NSAIDs have been around for over 100 years. They are a class of medications that, as their name implies, have the purpose of reducing inflammation. Inflammation can also be thought of as a "swelling," and includes a process whereby local chemical irritants are released from the involved tissue. These chemicals have several effects on the surrounding tissue, including altering the normal patterns of blood flow and irritating the nerve endings that carry the pain signal (nociception). As an example, when you suffer from a bruise, you will see a black-and-blue mark or bump on the skin as well as swelling. This happens because of a local inflammatory reaction in which various chemicals are released, causing leakage of fluid into the local area, irritation of nerve endings, and changes in blood flow. The chemicals released during the inflammatory process include prostaglandins, which have an ability to stimulate various cells associated with the inflammatory process. If not brought under control, this inflammatory process can persist and impede healing, as well as be painful. NSAIDs are directed at stopping the inflammatory process by inhibiting the production of prostaglandins.
One of the original anti-inflammatory drugs commonly used is aspirin. Besides reducing inflammation, aspirin also has the properties of being an analgesic and antipyretic (antifever) medication. In many studies, aspirin has been found to be as effective as other prescription medications for chronic pain. Although aspirin remains the first and most widely used of the NSAIDs, it can be associated with several side effects including gastrointestinal upset, ulcers, and increased bleeding tendencies. Using enteric-coated forms of aspirin to protect the GI tract can help with some of these side effects.
There has been a rapid proliferation in the development of various classes of anti-inflammatory agents. All of these have certain pharmacologic similarities in that they inhibit the synthesis of prostaglandins. The most commonly known NSAIDs presently used in the United States, aside from aspirin, include ibuprofen (Motrin and Advil) and naproxen (Naprosyn and Aleve). People use these NSAIDs for everything from sports injuries to menstrual cramps to headaches. One of the newest categories of NSAIDs is the COX-2 inhibitors including Vioxx, Celebrex, and Bextra. The COX-2 inhibitors are purported to provide the anti-inflammatory action without the GI problems. Vioxx was recently completely removed from the market due to a pattern of serious cardiac side effects. Other medications in the COX-2 category are now under scrutiny to determine the safety of long-term use. It should be noted that cardiovascular risk extends to all non-aspirin NSAIDs with the highest risk found in the COX-2 agents.
Because NSAIDs can cause nausea and GI upset, the medication should only be taken with meals. NSAIDs can also increase bleeding time, which slows down blood clot formation and increases the possibility of bruising. Less common side effects include tinnitus (ringing in the ears), lightheadedness, and gastritis. Many of the NSAIDs are metabolized primarily by the kidneys and some by the liver, so these organs need to be checked regularly if there is chronic use. The main reasons not to use NSAIDs include ulcer disease and bleeding problems. NSAIDs should be prescribed on a regular dosing schedule for most conditions, and usually continued for at least two weeks. This allows for establishment and maintenance of a therapeutic blood level.
It should be noted that patients will often have a tendency to discontinue the use of their NSAIDs within the first couple of days of treatment when they start to feel better. One often sees a recurrence of symptoms from this discontinuation of the NSAID. As the physician often has a goal of obtaining a certain blood level of medication when prescribing it, the patient should be cautioned to discuss with him any desire to stop the medication prematurely or to change the dosage, even if the symptoms seem to have disappeared. In addition, NSAIDs should usually be used on a time-limited basis due to the side effects listed above.
Acetaminophen (Tylenol) is a very commonly used analgesic both alone and compounded with other medicines. It has pain-relieving properties but no anti-inflammatory effect. Similar to the NSAIDs, acetaminophen should be taken for at least several days to have an effect on chronic pain. In chronic pain patients, the acetaminophen is most often taken combined with some other analgesic. This is usually codeine (e.g., Tylenol #3), hydrocodone (e.g., Vicodin, Lorcet, and NORCO), or oxycodone (Percocet). It is generally recommended that patients not exceed a total of 4,000 mgs per day of acetaminophen from all sources due to possible negative effects on liver function. It is important for the pain management clinician to be aware of these issues, since she may be the first to uncover a problem. A common example is the patient who is taking 5 Vicodin per day as prescribed by the physician (500 mg of acetaminophen per pill yielding 2,500 total), and then decides to add an over-the-counter Extra Strength Tylenol with each dose to try and get better relief (5 per day at 500 mgs each yields 2,500 total). The total dose is 5,000 mg per day, which is well over the recommended amount. Add to this a patient who has an alcohol drink or two each evening, and problems can develop. Often, the patient will not mention adding the OTC medications to his doctor and, as discussed previously, blood tests may not be regularly scheduled. When this is discovered, the issue must be discussed with the patient and a follow-up visit with the physician scheduled.
Muscle relaxants are usually prescribed with the goal of reducing muscle spasm, and generally should be used on a limited or short-term basis. In the case of chronic pain, this might include short-term use for pain exacerbations. How muscle relaxants work remains somewhat controversial. Many of these medications are known to work through the central nervous system, and thereby secondarily ease the muscles by “relaxing” the brain. There are several muscle relaxants that appear to work directly on the cells of the muscle itself by decreasing the "hypercontractual state" (overcontracted or in spasm). However, these also have known effects on the central nervous system. The more commonly prescribed muscle relaxants in use today for musculoskeletal disorders include Valium, Soma, Robaxin, and Flexeril. All of these are known to have effects on the brain, including a slowing of overall mental functioning and sedation. In addition, they may have an anxiolytic effect. In fact, Soma is metabolized to meprobamate, an anxiolytic. Finally, efficacy of the muscle relaxants appears to diminish over time, and there is the risk of dependence. Although it is recommended that their use be short term, one will often see chronic pain patients taking these medications at fairly high doses over the long term. In many cases, a careful assessment indicates the patient is using the medication more for its sedative, and possibly anti-anxiety, effects than for muscle relaxation. One of the muscle relaxants purported to be non-sedating is Skelaxin.
Long-term use of muscle relaxants can cause significant problems. For instance, patients can become dependent on muscle relaxants especially when using them as a sleep medication. In addition, long-term use of these medications may potentially promote symptoms of depression. Many muscle relaxants (most notably Valium) also play a role in reducing anxiety and, although this might be helpful for a short period in patients with acute pain or a chronic pain flare-up, they are addictive. Muscle relaxants should generally not be prescribed if it becomes clear that they are being used for anxiety and agitation rather than spasm. Some physicians feel it can be appropriate to utilize muscle relaxants on an as-needed basis instead of NSAIDs in the treatment of chronic pain. If the spasm is severe and not responding to ice, heat, or stretching, then muscle relaxants can be used as an adjunct for short-term relief. They should never be used as a substitute for these other methods of reducing spasm. The most common side effects of muscle relaxants relate to their depressant effects on the central nervous system. Dependency on the medication is the other major concern in view of their role in reducing anxiety, helping with sleep, and causing a somewhat euphoric state in some individuals. Dosages of these medications vary significantly.
In summary, the role of muscle relaxants should be limited to cases where muscle spasm is a well-defined component that is not responding to physical interventions, such as ice, heat, and stretching. For chronic spasms, biofeedback and relaxation training would be more appropriate. Long-term use of muscle relaxants is generally not indicated for chronic pain. Some specialists will use muscle relaxants rarely for two reasons. First, there is controversy as to whether muscle spasm is even significant in many musculoskeletal chronic pain problems (e.g., back pain). Second, the muscle tension, if it is present, may actually serve a protective function. These reasons, as well as those listed above, underscore that muscle relaxants should only be used in clear cases of muscle spasm when other modalities have not been effective and only on a time-limited basis.
Opioids and related compounds (e.g., semisynthetics such as oxycodone and synthetics such as methadone) are perhaps the most commonly used medications for all types of pain. The evidence for their efficacy in acute pain problems (including cancer pain) is without question. The use of opioids for chronic non-cancer pain is widespread but controversial.
There are five important concepts in the long-term use of opioids with chronic pain patients: tolerance, pseudotolerance, physical dependence, addiction, and pseudoaddiction. Patients very often confuse these terms and concepts causing problems with medication compliance. In addition, patients often have a fear of addiction, which causes noncompliance to the medication regimen and, in turn, poorer pain control. Careful explanation of the following concepts can be helpful for patients who are skeptical of appropriate pain medication regimens.
Patients should understand that a large body of research has demonstrated that if pain medication is given for a legitimate reason (e.g., related to surgery), addiction to analgesics is very unlikely (Cleary & Backonja, 1996; Porter, 1980; Portney, 1994; Zenz, Strumpf & Tryba, 1992). The fear of addiction is prevalent among chronic pain patients, and may cause reluctance in taking appropriate doses of medication for adequate pain control. To help ease patient fears, it is important to help them (and healthcare professionals) understand the difference between important pain medication concepts -- tolerance, pseudotolerance, physical dependence, addiction, and pseudoaddiction (see American Academy of Pain Medicine, the American Pain Society & American Society of Addiction Medicine, 2001):
Tolerance is a well-known property of all narcotics. It is the need for an increased dosage of a drug to produce the same level of analgesia that previously existed. Tolerance also occurs when a reduced effect is observed with a constant dose. Tolerance occurs at a chemical level in the body primarily through the liver producing more enzymes to neutralize the effects of the medicine. Some physicians believe that a certain level of opioid use can be reached for pain control and stabilized over the long term without the need for increasing the dose due to tolerance, but this is controversial.
Pseudotolerance is the need to increase dosage that is not due to tolerance but due to other factors such as changes in the disease, inadequate pain relief, change in medication, increased physical activity, drug interactions, lack of compliance. Patient behavior indicative of pseudotolerance may include drug seeking, “clock watching” for dosing, and even illicit drug use in an effort to obtain relief. Pseudotolerance can be distinguished from addiction in that the behaviors resolve once the pain is effectively treated.
Physical Dependence is also a well-known and understood physical process. It is a state of adaptation that is manifested by a specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. The withdrawal syndrome might include tremors, cramps, agitation, sleep disruption, and diarrhea. The patient might also notice an increase in the pain over the short term. Physical dependence is not a problem if patients are warned to avoid abrupt discontinuation of the drug, a tapering regimen is used, and opioid antagonist (including agonist-antagonist) drugs are avoided.
Addiction is a psychological dependence on the medication for its psychic effects; it is characterized by compulsive use. The medication is sought after and used even when it is not needed for pain relief. Addiction includes aspects of tolerance and dependency due to chemical events associated with long-term use. It should be noted that although addiction includes tolerance and dependence, the reverse is not necessarily true. One can show tolerance and dependence without showing addiction. In fact, addiction is a well-known, although relatively rare, occurrence in patients using narcotics for pain relief.
Pseudoaddiction is drug-seeking behavior that seems similar to addiction, but is due to unrelieved pain. The behavior stops once the pain is relieved, often through an increase in pain medication. If the patient complains of unrelieved pain and shows drug-seeking behavior, careful assessment is required to distinguish between addiction and pseudoaddiction.
Patients (and healthcare professionals) often confuse these concepts. Both tolerance and dependence commonly occur in pain medication use and can be readily managed by a physician specializing in this area. Tolerance can be managed by adding other non-addictive medicines that help the narcotics work better, and/or emphasizing non-medication pain control techniques. Dependence is addressed by slowly tapering the pain medication and, possibly, adding other medication to control withdrawal symptoms, as appropriate. The pain management clinician is often called upon to help the physician differentiate among symptoms of possible addiction, pseudoaddiction, and pseudotolerance.
Dr. Richard Sternbach has identified how tolerance and dependence on pain medicine can actually lead to higher levels of pain. Patients who have attained higher levels of pain medicine use will occasionally attempt to decrease their use. When they do attempt this decrease, withdrawal symptoms occur, the most prominent of which is usually an increase in pain. The patient will state that he does not have a "craving" for the medication except to relieve the pain. This increase in pain, in addition to the lack of craving, is then used as a rationale for the patient (and the patient's doctor) to once again increase the analgesic use, stopping the withdrawal symptoms, and decreasing the pain. This pattern will only lead to higher levels of pain, dependence, and tolerance.
Dr. Sternbach has identified this phenomenon as a "conditioned pain response." In this process, at the early stages of pain medication use, the patient waits until the pain is very severe before taking the medicine. The pain medicine results in a decrease in pain, which is a positive reinforcer. Anything that results in positive reinforcement is likely to be done again or to occur again. Therefore, the next time the patient has pain, he is more likely to take a pain pill. This process continues until tolerance and dependence develop. When this occurs, the withdrawal symptom of increased pain is more likely to occur as the medication wears off. As Dr. Sternbach says, "The pain becomes more severe as a signal to replenish the supply of narcotics which the body has now come to need." This, then, becomes a conditioned pain response in which higher pain levels are reinforced by the pain medicine. It should be noted that this process is not related to imaginary pain or addictive behavior.
In addition to the possibility of a conditioned pain response, the opioids are not without significant side effects. Long-term opioid use includes risk for constipation, itchiness, hypogonadism (shrunken testicles), interaction with other medication, respirator depression, and accidental overdose. In addition, recent studies have identified the potential for another side effect from long-term opioid use -- opioid-induced hyperalgesia (increased pain perception (Mercadante, Ferrera, et al., 2003). In this condition, the pain perception is made worse by the long-term opioids.
A significant controversy exists among medical professionals in determining the appropriate long-term use for narcotic analgesics in chronic non-cancer pain. There is widespread acceptance that it is reasonable to use narcotic analgesics for pain relief in the short term when the patient has severe pain and is unable to obtain relief by any other means. However, there is controversy when it comes to using these medications for chronic non-cancer pain; most physicians prefer other pain-control approaches. If one sees a chronic pain patient on long-term opioids, he is most likely being managed by a physician that specializes in pain management (usually an anesthesiologist or physiatrist).
Any analgesic taken as a long-term medication should be used on a "time-contingent" basis rather than ''as-needed.'' On a time-contingent schedule, the medication is taken on a fixed schedule rather than according to symptoms, regardless of the pain level. For instance, the schedule might be one tablet every four hours. The idea behind this approach is to keep the pain relieving effect constant, avoid the ups and downs of the as-needed approach, and prevent the conditioned pain response from occurring. It can also prevent severe pain episodes by catching the pain early.
Some of the newer time-release opioids have taken care of this time-contingent dosing problem since the dosing is either once or twice per day (e.g., Oxycontin, Kadian). It is always important for the patient to utilize the lowest level of pain medicine necessary. This will help avoid tolerance and keep dependence from occurring, in addition to ameliorating the side effects of the medicine. One should encourage the use of other non-medication approaches to pain control and increasing function (e.g., psychological and behavioral pain management interventions).
There are some physicians and researchers who feel that long-term use of opiates in very select patients with chronic pain can be an appropriate treatment; this does have some support in the clinical research. In this subset of patients who are deemed appropriate for this treatment, the goal is to achieve sustained analgesia and increased function without the occurrence of significant side effects or aberrant behavior (e.g., addiction, abuse). However, this approach continues to be highly controversial due to fears of addiction, side effects, physical dependence, and tolerance.
Dr. Russell Portenoy is probably best known for his research and interest in this area. He feels that there is a subpopulation of pain patients who are able to obtain at least partial pain relief from chronic opioid therapy without the development of toxicity or significant tolerance. He states that substance abuse behaviors may occur, but that these are uncommon if patients are carefully selected. Patients with a history of substance abuse tend to be at risk for developing problems in this regard. The most common physical side effects of long-term pain medicine use include persistent constipation, insomnia, and decreased sexual function. In addition, there may be cognitive difficulties (trouble thinking clearly or focusing) and sedation initially, but it appears that these effects tend to diminish over time, although some patients do report continued "mental clouding" sufficient to impair functioning.
In pursuing such a treatment approach with chronic non-cancer pain patients, Dr. Portenoy has proposed very specific guidelines for patient selection and evaluation of the treatment. As can be seen from the screening criteria, the assistance of an appropriately trained pain management clinician is indicated for both evaluation and ongoing treatment. The screening and management criteria are as follows:
As can be seen from the screening criteria, it appears that very few non-cancer chronic pain patients might be appropriate for this type of approach. Patient selection is critical, as is working with a physician who is knowledgeable of this type of treatment. Certainly, prior to utilizing this kind of approach, a behavioral/psychological approach to pain management including physical and mental reconditioning programs should be attempted. Even if these are not entirely successful, they should be continued in conjunction with the long-term pain medication program.
In actual clinical practice, I have seen many patients who are receiving long-term pain medication therapy that are either completely inappropriate for this approach or who are receiving it in an incorrect fashion. All aspects listed previously must be adhered to in an ongoing manner. Patients will often have unrealistic expectations about using opiates long-term, believing that "if my pain were gone, then I would resume my life." The chronic opioid therapy approach tends to reinforce this type of thinking, often to the exclusion of increasing functioning and improving other aspects of a person's life. In these types of cases, a multidisciplinary pain rehabilitation program that focuses on these issues rather than moving toward a chronic opioid approach might be much more beneficial.
As mentioned earlier, the pain management clinician is often called upon to help the physician determine if a patient who is on opioids is showing signs of addiction, pseudoaddiction, or pseudotolerance. Assessing opioid-induced disorders in a chronic pain population is extremely difficult especially when there is no abuse of illicit or recreational drugs. As discussed by Harden (2002), “to confuse the recreational/street abuse of drugs of any type with the private clinical decision between a doctor and patient to use these drugs for an appropriate medical indication is a serious error” (p. 8). However, psychological opioid dependency does occur in chronic pain patients within the context of being prescribed by one’s physician. As discussed in the review by Harden (2002), “psychological dependency, defined as an emotional state of craving for a drug for its euphorigenic effects or to avoid negative effects associated with withdrawal, occurs at variable rates dependent on specific characteristics of the clinical situation” (p. 8). Psychological dependency may be, in some cases, a consequence of fear of uncontrolled pain rather than pursuit of euphoria or avoidance of abstinence. Harden (2002) goes on to review the research literature that suggests the presence of certain other psychiatric diagnoses (particularly personality disorders) and certain sociologic milieu may make abuse and addiction much more likely.
Chronic pain patients often have significant disease conviction, somatic preoccupation, and an externalized locus of control. These factors often lead to increased opioid-seeking behaviors in the absence of increased nociceptive input. The non-analgesic operant reinforcing effects of taking opioids may also exacerbate opioid-seeking behavior. Thus, one might look for a cluster of psychosocial and psychological factors to determine possible addiction (e.g., a personality disorder, fear of withdrawal, external locus of control, extreme somatic focus, significant illness conviction). Behaviorally, one might see a patient who has tended to run out of medications early, take more medication than has been prescribed by the physician, been non-compliant in attending any treatments that require proactive rehabilitation behavior (e.g., psychological pain management or biofeedback), and pursued invasive procedures that have initially been beneficial but ultimately fail such that more narcotic medication is requested. These types of behaviors, together with the psychosocial factors identified, support the diagnosis of a psychological opioid dependence (or addiction).
The closest DSM-IV diagnosis representing psychological opioid dependence as discussed in the pain research is opioid dependence (304.00). DSM-IV states that opioid dependence includes signs and symptoms that reflect use of opioid substances that either serve no legitimate medical purpose or, if a general medical condition that requires opioid treatment is present, are used in doses that are greatly in excess of the amount needed for pain relief (p. 248).
Antidepressants are playing an increasing role as a medication adjunct in the treatment of chronic pain problems. All classes of antidepressant medications have been studied including the tricyclics, selective serotonin reuptake inhibitors (SSRI), and the selective serotonin and norepinephrine reuptake inhibitors (SSNRI). Extensive research is showing that certain antidepressant medications can provide pain relief in many chronic pain conditions, independent of their antidepressant effect. It should be underscored that the analgesic effect is seen even in patients who are not depressed. Extensive research is presently being done to better understand the exact roles of antidepressants for pain management. Some of the most widely used antidepressants for pain control in the area of chronic pain are the tricyclic antidepressants (TCAs) such as:
There is some indication that the Selective Serotonin Reuptake Inhibitors (SSRI) may have some use in certain chronic pain conditions (e.g., painful polyneuropathy, nerve injury pain) but their analgesic effect has not been firmly established. There is also ongoing research into the SSNRI medications (e.g. Cymbalta and Effexor). There is some support for the analgesic benefit from use of these medications in neuropathic pain syndromes. Of course, the SSRIs and SSNRIs may be appropriate to treat depressive symptoms in a patient with chronic pain.
Although the exact mechanism remains somewhat unclear as to how these medicines afford pain relief, they are considered to be helpful to varying degrees in different patients. The choice of antidepressant medication will depend on the symptoms the patient is experiencing. Some of the antidepressants have sedative properties, while others have an energizing effect. In addition, different antidepressants will affect different brain neurotransmitters (serotonin, norepinephrine, and dopamine). Some of the factors to be considered in choosing an antidepressant follow.
First, one might consider the role that antidepressants have in improving restful sleep in addition to decreasing pain. Many chronic pain patients, especially those with neuropathic (nerve) pain, have great difficulty obtaining restful sleep. The sedative properties of some of the antidepressants can be very helpful in normalizing sleep patterns while at the same time playing a role in the reduction of pain. The antidepressants seem to provide better restful sleep and other positive benefits (e.g., pain relief) than sleeping medications. In addition, unlike most sleeping medications, the antidepressants have no addictive properties and can be used over the long term.
|
Dosage Range for: |
Pain |
Depression |
|
Norpramine |
75 mg |
75-200 mg |
|
Pamelor |
50-100 mg |
75-150 mg |
|
Sinequan |
50-100 mg |
150-300 mg |
|
Tofranil |
50-75 mg |
150-300 mg |
|
Elavil |
25-150 mg |
150-300 mg |
|
Desyrel |
unknown |
150-400 mg |
These medicines are sometimes intended to have some role in combating depression, which is commonly seen in varying degrees associated with chronic pain suffering (as discussed previously). However, it should be reiterated that even if the patient is not clinically depressed, there appears to be a property in many of the antidepressants that decreases pain. This pain relief property occurs at dosage ranges much less than those used in the treatment of depression. For instance, a typical dose of Elavil for chronic pain would be approximately 50 to 75 milligrams, whereas the antidepressant dose might typically be 100 to 150 milligrams or more. There are also many patients who see a significant reduction of their pain and improvement in sleep with even lower doses of antidepressants.
Side effects will vary depending upon the medication used. Common side effects include dry mouth, blurred vision, constipation, urinary retention, sedation, and nausea. Side effects will usually be experienced when starting antidepressant medication and dissipate after two to three weeks or sooner. Be sure and discuss with the patient that mild side effects at the beginning of treatment are generally to be expected, but all side effects should be reported to his physician. In addition, it is helpful to warn the patient ahead of time that the dosages of these medications frequently have to be adjusted and tailored to the individual (which can take some time). It may take up to several months to find both the proper dose and the proper antidepressant medication for an individual patient. Patients should communicate regularly with their physician, and be well informed about changes in the doses and side effects. It is important to help patients not to get frustrated during this adjustment phase when trying antidepressant medications as an adjunct in controlling pain. Many patients are concerned about becoming chronically dependent on these medications, as well as of the possibilities of long-term side effects. It should be explained that antidepressant medicines are not addictive, and tolerance in the sense of narcotic analgesics does not develop. Many chronic pain patients are hesitant about trying these medications due to the stigma attached to taking psychotropics. This issue should be discussed fully with the patient.
It is important to stress having the patient also employ self-management techniques, such as relaxation procedures, cognitive behavioral techniques, meditation, and exercise. In certain cases, the pain management clinician may identify a clinical depression in the chronic pain patient. In these cases, appropriate use of antidepressant medications at therapeutic levels may be indicated and a referral for evaluation is certainly indicated.
Antianxiety agents (also termed anxiolytics or minor tranquilizers) are occasionally used on a short-term basis in chronic pain for their role in decreasing anxiety and helping with sleep. The most widely used anxiolytics are known as benzodiazepines, which include such medications as Valium (diazepam), Klonopin (clonazepam), Ativan (lorazepam) and Xanax (alprazolam). As discussed previously, Valium is also used as a muscle relaxant and most likely exerts the majority of its effect on the central nervous system. Long-term use of the anxiolytics in chronic pain patients is generally not recommended. Most physicians generally discourage the use of these agents for anything but very short periods and in very specific cases. If the chronic pain is associated with a high degree of anxiety and agitation, these medications can be useful. As with the other medications, they should be used as part of a comprehensive approach to the chronic pain problem including teaching the patient other non-medication techniques for managing anxiety, sleep disruption, and the like.
There are certain patients with more severe anxiety disorders who also suffer from a chronic pain problem. These patients may require more long-term use of anxiolytics when they do not respond to other interventions. The patient should be followed closely and regularly by a physician familiar with the use of these medicines in the chronic pain population (e.g., a psychopharmacologist or pain management physician). The pain management clinician can help in the management of these medications by assessing the patient use and response at the regular follow-up visits. Any problems can be reported to the physician managing the medications.
Common side effects of the benzodiazepines include drowsiness, sedation, and short-term memory loss. Many of these side effects are eliminated by adjusting the medication dose. Tolerance and dependence do develop when using these medications, just as in the case of pain medicines. Care should be taken to avoid alcohol while taking these medications. The patient should never abruptly stop taking benzodiazepines and they must be tapered appropriately as managed by the patient’s physician. As with the other medications, it is not uncommon for the treating pain management clinician to be the first practitioner to find out that the patient is not following the medication prescription properly (e.g., abruptly stopping the medication, increasing the dose, consuming alcohol or other medication that might have a synergistic effect).
Sedatives (also termed hypnotics) are used for sleep. There is a variety of medications classed in this group, but they generally include benzodiazepines (Dalmane, Restoril); non-benzodiazepine, benzodiazepine receptor agonists (Ambien, Sonata); barbiturates (Amytal, Nembutal, Seconal), chloral derivatives (chloral hydrate); and antihistamines (Benadryl). The barbiturates and chloral derivatives are rarely used now due to dangerous side effects, and therefore will not be discussed here.
In the past, the most commonly prescribed medications for sleeping problems included two classes of sedative-hypnotic drugs: the benzodiazepines and the “non-benzodiazepine, benzodiazepine receptor agonists.” In addition to these categories, a new medication has just been released (Rozerem) with a unique mechanism of action – melatonin receptor agonist.
Although all of the benzodiazepines are used for the treatment of insomnia, the first five in the list are used most commonly for sleep disorders.
Dalmane (Flurazepam)
Doral (Quazepam)
Halcion (Triazolam)
ProSom (Estazolam)
Restoril (Temazepam)
Klonopin (Clonazepam)
Ativan (Lorazepam)
Xanax (Alprazolam)
The benzodiazepines have been the most frequently used medications in the treatment of insomnia, and are certainly safer than some of the older sleeping medications such as the barbiturates (Amytal, Nembutal, Seconal). However, there have been concerns regarding inappropriate use and abuse of these medications. These medications are generally recommended only to be used on a short-term basis since physical tolerance and dependence can develop. In addition, these medications can often produce a “hangover” effect the following day.
In recent years, a newer class of medications has been developed; these are often termed the “non-benzodiazepine, benzodiazepine receptor agonists.” These newer medications appear to have better safety profiles and less adverse effects. These medications are associated with a lower risk of abuse and dependence than the benzodiazepines. Examples of medications in this class include:
Ambien (Zolpidem)
Sonata (Zaleplon)
Lunesta (Eszopiclone, formerly known as Estorra)
These medications are known to reduce the time it takes to fall asleep and, thus, their effects are quite similar to those in the benzodiazepine class. These medicines appear to have different characteristics and may be used in different ways. Again, although these medications are safer than the benzodiazepines, it is not recommended that they be used on a long-term basis (except Lunesta, which will be discussed below).
Ambien. This sleeping pill has effects that persist later into the night and may help the individual stay asleep longer. Thus, it must be taken at bedtime and may be used when the individual has trouble falling asleep and/or staying asleep.
Sonata. This sleep aid is generally used for those individuals having trouble falling asleep. Therefore, it is often taken at bedtime or later such as when awakening during the night as long as there are at least four or more hours left to sleep.
Lunesta. This sleep aid was approved by the FDA in December of 2004 as a new, longer-lasting sleeping pill. Clinical trials have demonstrated that Lunesta helps people get to sleep faster, similar to Ambien and Sonata. However, it appears that it also helps the individual stay asleep through the night. The FDA has approved Lunesta for patients who have difficulty falling asleep as well as those who are unable to sleep through the night. Lunesta has about a six-hour half-life, so it is more likely to maintain sleep. Due to its long half-life, Lunesta must be taken immediately before bedtime and the individual should make sure that she has a full eight hours devoted to sleeping before taking it. As with the other medications, side effects can occur, including daytime drowsiness, dry mouth, and dizziness. Unlike the other medications in this class that are recommended only for use on a temporary basis, Lunesta is approved for longer-term use.
In using these medications, one must first look at the reasons for sleep problems. If they are related to depression, then an antidepressant should be used. If they are related to anxiety, then an antianxiety agent should be used. If they are related to pain, then an analgesic or low-dose sedating antidepressant might be most appropriate. If none of these is the case, then consideration of a sedative for short-term use may be appropriate.
In choosing a sedative, the least addictive should be tried first. Using Benadryl (50 to 150 milligrams at bedtime) is a very good first choice. If that is ineffective, the benzodiazepines can provide a good sedative effect. These are relatively safe medicines and are the least disruptive to certain types of sleep patterns. The use of barbiturates has fallen into disfavor due to the potential for abuse and the availability of the much safer benzodiazepines. Using alcohol as a sedative is not indicated since it causes very disrupted, non-restful sleep as well as early morning awakening and depression. Any sedative should be used only as needed and on a limited basis, if possible. Teaching the patient other techniques for relaxation as well as good sleep hygiene is always indicated. This includes such things as going to bed and awakening on a consistent schedule, practicing relaxation exercises to fall asleep, and not doing anything stressful in bed (e.g., paying bills).
One of the newest classes of medications being used for certain chronic pain conditions are drugs originally developed for seizure disorders (called antiepileptics, anticonvulsants, or neurologics). The various categories of these medications will not be discussed here but four of the commonly used medicines are Lyrica (pregabalin), Neurontin (gabapentin), Depakote (divalproex sodium), and Tegretol (carbamazepine).
The anticonvulsants are generally used for specific types of chronic pain syndromes including the following:
These medications are often used in chronic pain that is of a neuropathic nature and is often associated with pain sensations described as burning, radiating, lancinating, or stabbing. Many patients have trouble with the side effects of these medications including sedation, dizziness, headache, nausea, vomiting, and cognitive changes.
Beyond direct treatment of the chronic pain condition, the pain management clinician also acts as a patient advocate or “coach.” In this role, the pain management clinician is teaching the patient to work effectively within the healthcare system to gain the maximum benefit from medical treatments and avoid being injured by the medical interventions. Unfortunately, iatrogenic problems in the treatment of chronic pain are not uncommon (e.g., medication problems, avoidable surgeries). One area in which the pain management clinician can provide very helpful “indirect” treatment is to teach the patient to be an active consumer relative to her medication regimen. I use the following handout for patients:
It is important to obtain accurate information about the medicines you are being prescribed for your chronic pain problem. You should know the answers to the following questions before taking medications:
Gatchel’s model of physical and mental de-conditioning explains a patient’s transition from acute to chronic pain. Consistent with this model, treatment approaches involve physical and mental reconditioning. When a chronic pain patient is involved in a multidisciplinary program, addressing both mental and physical elements are required for maximum success.
When the patient is involved in physical reactivation treatment, various cognitive factors must be successfully addressed. For instance, one key element will be helping the patient manage his fear of the pain, accepting the fact that hurt does not equal harm, and openly addressing issues that may be pressuring the patient into maintaining the sick role (and possibly sabotaging the physical therapy). This type of treatment will fall within the purview of the pain management clinician.
Aggressive conservative treatment should generally be preceded by a careful physical evaluation by the physician. This is done primarily to rule out any underlying serious condition that may need to be addressed, and to develop the physical reconditioning program. An aggressive conservative treatment program will generally be designed by the supervising physician and implemented by a qualified physical therapist or exercise physiologist; although in many cases patients can simply be given a program of exercises and complete them on their own, independent of a formal treatment setting.
Several important aspects must be attended to during the course of such a program. The following issues should be discussed with the chronic pain patient at the beginning of treatment:
To help the chronic pain patient understand the rationale behind the importance of physical reconditioning, it is useful to present the physical-deconditioning syndrome or "disuse syndrome.”
As far as I can determine, the deconditioning or disuse syndrome was first characterized in 1984. Since that time, it has received much attention in relation to back pain problems and other chronic pain disorders, as well as other illnesses. It has been generalized beyond chronic pain problems, and some feel it is related to "the base of much human ill-being."
The disuse syndrome is caused by physical inactivity and is fostered by our sedentary society. This disuse of our bodies leads to a deterioration of many body functions. This is basically an extension of the old adage, "Use it or lose it." There are several physical consequences from disuse and deconditioning. These occur in many body systems, most notably those of the muscles and skeleton, cardiovascular components, blood elements, the gastrointestinal system, the endocrine systems, and the nervous system. For instance, consider the following:
Many other detrimental physiological changes also occur that are beyond the scope of this discussion. Disuse has been summarized as follows, "Inactivity plays a pervasive role in our lack of wellness. Disuse is physically, mentally, and spiritually debilitating." Many experts believe that the deconditioning/disuse syndrome is a key variable in the perpetuation of many chronic pain problems.
In summary, the disuse or deconditioning syndrome can result in a myriad of significant medical problems and increase the likelihood of a chronic pain syndrome developing. Unfortunately, common attitudes and treatments in the medical community reinforce the fear patients have about their pain (and increasing movement), leading to passive treatment and deconditioning. The deconditioning syndrome can also result in a variety of emotional changes that are associated with an increased perception of pain.
The most ideal approach to managing the physical- and mental-deconditioning syndromes is to prevent their occurrence altogether. However, even if the disuse syndrome has developed, the reconditioning approach is very effective if done appropriately. Completing physical reconditioning should be guided by appropriate behavioral principles.
Fully participating in a reconditioning program, which includes strengthening, stretching, and aerobic exercise, is essential for maximum benefit. These programs may cause an initial increase in the patient’s pain; this is to be expected. In addition, passive modality-oriented therapies such as hot packs, massage, and ultrasound are generally not indicated as part of the program since this tends to place the patient back in the sick role. Use of ice or self-administered hot packs to help relieve symptomatic pain in conjunction with aggressive exercise may be appropriate.
In chronic pain problems, it is most appropriate to exercise and physically recondition oneself using what has been termed the “quota system.” The quota system was first developed by a pain psychologist, Wilbert Fordyce, at the University of Washington.
The quota method involves setting up an exercise regimen that progressively becomes more and more strenuous according to a fixed pattern rather than how the patient feels. For instance, a patient might start walking one-half block each day and then increase this by one block each week. With the quota system, the patient would complete these exercises according to the plan whether or not the pain was better or worse. In this approach, the pain is essentially taken out of the equation, since the exercises are designed to be safe for a given chronic pain condition. It can be helpful to remind the patient that, “hurt does not equal harm.” Each time the quotas increase, there may be a slight (and temporary) increase in pain due to the reconditioning (not injury). The quota-system approach has been shown to be very effective in university pain program settings. Unfortunately, it is used much less frequently in routine physical therapy practice.
The following sections discuss how to approach a conditioning program in the treatment of chronic pain. The general principles include using the quota system, having an aerobic component to the program, and making sure that family and friends support the patient in a proper manner. A multidisciplinary pain program with reconditioning also includes cognitive behavioral therapy and medication management (often with detoxification), as discussed previously.
As mentioned above, the quota system is a specialized approach to exercising (or to any activity, for that manner) that involves working to a specific quota rather than being guided by the pain. It is important that this be done initially under the supervision of a physician and a qualified physical therapist. The quota system can be applied to any type of exercise or activity that the patient wishes to increase. In setting up a quota system for an exercise program, the patient starts with what are called baseline measurements. In developing a baseline, the patient exercises until pain or fatigue stops him over three consecutive sessions. An example of this might be doing repetitions of a strengthening exercise. The patient may only be able to do four repetitions on the first session, six repetitions on the second session, and five repetitions on the third session. Once the three baseline measures are taken, an average is then determined. In the example above, the average would be five repetitions for the particular exercise (4 + 6 + 5 = 15, divided by 3 = 5).
The initial quota is then set at 70 percent of the baseline average. Therefore, the patient would begin the program for this particular exercise at an initial quota of four repetitions (70 percent of 5 = 3.5, and round off to the next highest number). Setting the initial quota at 70 percent of the baseline average ensures that the patient will be successful in meeting the quota. Once the initial quota is established, the patient is instructed to do that number of repetitions regardless of the pain. The same type of quota can be set for such diverse things as walking distance, swimming distance, amount of miles on a stationary bicycle, and any exercise that involves repetitions. A baseline measure is always taken over three or four sessions and then 70 percent of the average constitutes the initial quota.
It is helpful for patients to chart their progress for each exercise. The x-axis can be labeled “exercise session number” and the y-axis is the number of repetitions (or other exercise variable) required to meet the quota. This gives a visual record of progress as well as the quota that is required for the specific exercise session. It is also helpful to chart the "target" value (the quota) and the "actual" amount of repetitions for each exercise session. These are used to document the patient’s quota target for the exercise and the actual amount of the exercise done for that session.
The quota system forces a patient to exercise to a certain, safe level while removing pain from the treatment equation. In addition, the quota system forces the patient to use proper pacing techniques. If patients are allowed to exercise depending upon how they are feeling that particular day, one often sees very inconsistent progress values. On a “good” day when the patient is in less pain, she will “go for it” and do much more than is recommended. Of course, most of the time, this results in a severe flare-up in symptoms, causing the patient to miss subsequent exercise sessions and regress to a lower quota value upon returning. This pattern (overdoing exercises, exacerbation in symptoms, and “crashing”) is very frustrating for the patient and can lead to a treatment dropout.
A question that must always be dealt with is how rapidly to increase the quotas. This is usually determined by the supervising physician or physical therapist, and will depend on the type of exercise as well as the chronic pain problem. In addition, the therapist will take into account how physically deconditioned the patient has become.
The concept of pacing is built into the quota system of exercise. Pacing is a technique for approaching any activity such that the chronic pain is kept under reasonable control. Pacing involves a gradual increase in activity according to a systematic plan. This approach can be used for exercise as well as any other activity. For instance, it might also involve doing some activity and then taking regular breaks throughout the day to prevent acute exacerbations of the pain.
As discussed previously, a common pattern seen in people with chronic pain is the "overdo and crash" pattern, whereby the patient begins a day with minimal pain and subsequently engages in so many activities that she is literally in bed with pain for the two or three days following. This pattern may then continue such that the patient is continually overdoing activities when she begins to feel good and then "crashing" for several days thereafter. This is an unhealthy approach to pain rehabilitation and should be replaced with a "pacing" format. Pacing should not be confused with the concept of "being guided by the pain." Pacing encourages a reasonable amount of activity and exercise, not more and not less. The patient must attempt to do activities and exercise each day while pacing herself.
One component of a good exercise program for chronic pain should be aerobic conditioning. This should also initially be supervised by a physician or qualified physical therapist. Aerobic conditioning exercises are those that result in an increase in the uptake and utilization of oxygen. Actual aerobic conditioning occurs when the heart rate reaches a certain level and is maintained at that level for a specific period of time. A rough estimate of a person’s target heart rate for aerobic conditioning is to subtract your age from 220, and then take 70 percent of the resulting number. The following formula represents this equation for a forty-five-year-old person: 220 - 45 = 175, then 70 percent of 175 = 123 (the target heart rate rounded off to the nearest whole number).
The quota system can be used for aerobic conditioning as well. First, the patient must choose one or more aerobic conditioning exercises under the supervision of his physician. This might include such activities as brisk walking, swimming, or a stationary bike. The baseline is established by doing the exercise until the patient must stop due to increased pain or fatigue. The patient should be reminded that he should not attempt to "push it" when the baseline is being established. After doing three or four sessions of a baseline, take the average and multiply this by 70 percent. This will give you a beginning quota for the aerobic conditioning program.
For instance, if the patient can initially do an average of ten minutes on the stationary bicycle, then the initial quota would be seven minutes. A typical quota system for this type of exercise would be to start at seven minutes twice per day and increase the bicycle sessions by one minute every fourth session. This quota system will gradually increase the patient’s tolerance on the bicycle and increase the amount of aerobic conditioning that she is able to obtain. This could be done until the patient has reached a reasonable goal, which might be getting to a target heart rate for twenty minutes on the stationary bicycle three times per week. A similar system should be set up for other aerobic conditioning exercises, such as swimming and brisk walking.
Aerobic conditioning is an important part of a chronic pain rehabilitation program, not only for its conditioning component but also to help decrease stress, increase the fluidity of movements, and decrease the overall pain.
The last aspect of an exercise program is the patient’s psychosocial environment, which includes family, friends, and work associates. The psychosocial environment is an important element in any chronic pain rehabilitation program. Consider the following case example, which is not uncommon in patients with chronic back pain:
A forty-six-year-old woman had undergone three previous spine surgeries. She had developed chronic back-pain syndrome and was attempting to increase her functioning through many of the principles presented in this course. As she started to attempt more activities, she noticed that her husband would make comments such as "why don't you take it easy," "you shouldn't be doing that," and "you need to get more rest." She noticed that he was becoming overly protective, and would often express to her that attempting to increase activities would certainly lead to injury. She noticed a similar reaction from many of her friends who knew she had a long-standing back pain problem.
In this situation, the patient's family and friends misunderstood her back pain problem and the importance of the rehabilitation approach. The patient was instructed to educate them as to the importance of a quota-system-based increase in exercise and activity. She was also instructed to give them specific guidelines to not to respond to her pain behaviors and to encourage her for any increase in activity that was observed. This example underscores that guidelines are needed in terms of dealing with family and friends when embarking on an exercise program or increasing one's activities. Specific guidelines are:
The following books are excellent resources for any who works with chronic pain patients.
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Gatchel, R.J. (2004). Clinical Essentials of Pain Management. Washington, DC: APA Books.
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Gatchel, R.J. & Weisberg, J.N. (2000). Personality Characteristics of Patients with Pain. Washington, DC: APA Books.
Turk, D.C. & Gatchel, R.J. (2002). Psychological Approaches to Pain Management: A Practitioner’s Handbook 2nd edition. New York: Guilford Press.
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