However, the evidence for psychotherapeutic interventions for persons with chronic pain (Guideline #9), including cognitive-behavioral therapy, relaxation training, functional restoration, and education, was judged to be in the moderate range, and received a strong recommendation by the review committee. The following is a brief description of these interventions.

The Importance of a Multidisciplinary Team

Chronic pain involves a complex interaction of physiological and psychosocial factors, and successful intervention requires the coordinated effort of a treatment team with expertise in a variety of therapeutic disciplines. Although some clinics offer a single treatment approach, most pain programs use a blend of medical, psychological, vocational, and educational techniques. Treatment modalities for chronic pain generally include medical assessment, medication management, pain-reduction treatments, didactic instruction, relaxation training, biofeedback, physical therapy, psychotherapy, and vocational counseling.

An interdisciplinary staff coordinates efforts to rehabilitate the pain patient and provides a comprehensive discharge and follow-up plan designed to meet the patient's short- and long-term needs. The patient's active participation in the treatment plan is strongly encouraged. Among the predictors of success in a multidisciplinary pain program are the patient's motivation to cope with pain and his or her external support systems.

Education

Most people with chronic pain have an inadequate understanding of the nature of their painful condition. It is important for them to be knowledgeable about their pain and the treatments designed for them. Information can be conveyed through patient manuals on chronic pain, video presentations, handouts, individual sessions, and interactive programs on the Internet. Topics for educational sessions may include:

1. Physiology of pain
2. Medication for chronic pain
3. Exercise and pain
4. Stress management
5. Sleep disturbance
6. Assertiveness training
7. Posture and body mechanics
8. Problem solving
9. Weight management and nutrition
10. Vocational rehabilitation
11. Sexual issues
12. Positive thinking
13. Relapse prevention.

In general, patients who understand their condition, and who have been exposed to relevant management techniques, maintain a perception of control over their pain and show higher rates of success in meeting their goals. Active learning techniques, including the completion of homework such as periodic surveys, checklists, diaries, or questionnaires are an important part of the educational approach.

The ultimate goal of any educational intervention is to increase the patient's perceived control over pain. Several important themes critical to pain management can be emphasized:

1. You will most likely not be "cured."
2. You need to expect ups and downs.
3. Rarely does pain intensity remain exactly the same over time.
4. You need to have a fall-back plan for those times when you have a flare-up of pain.
5. What you do about your pain may be as beneficial as anything that is done to you.
6. You need to work towards gaining control over your condition with the help of medical treatments and psychological pain management strategies.

Patients who can understand and embrace these important principles have a greater ability to cope with their condition.

Relaxation Training

Chronic pain patients tend to experience substantial residual muscle tension as a function of the bracing, posturing, and emotional arousal often associated with pain. Such responses, maintained over a long period, can exacerbate pain in injured areas of the body and can increase muscular discomfort. For example, it is common for patients with low back pain or limb injuries to develop neck stiffness and tension-type headaches. Relaxation training is recommended as a way to reduce pain through the relaxation of tense muscle groups, the reduction of symptoms of anxiety, the use of distraction, and the enhancement of self-efficacy. In addition, this training can increase the patient's sense of control over physiological responses. In a pain management intervention, patients can be taught and encouraged to practice a variety of relaxation strategies, including diaphragmatic breathing, progressive muscle relaxation, autogenic relaxation, self-hypnosis, guided imagery, and cue-controlled relaxation. Biofeedback training may also be employed. Live demonstrations of these techniques are preferable to verbal explanations. All patients should be encouraged to practice each technique at home. Relaxation recordings can be made available for practice purposes.

Cognitive/Behavioral Therapy

Pain patients frequently show signs of emotional distress, with evidence of depression, anxiety, and irritability. Therapy with a cognitive/behavioral orientation helps patients gain control of the emotional reactions associated with chronic pain. Specific problem-solving strategies can be offered during therapy sessions, including:

1. Identifying maladaptive and negative thoughts
2. Disputing irrational thinking
3. Constructing and repeating positive self-statements
4. Learning distraction techniques
5. Working to prevent future “catastrophizing
6. Examining ways to increase social support.

Personal relationship issues can also be explored. The patient's strengths and positive coping mechanisms should be emphasized.

Cognitive/behavioral therapy has a number of objectives. The first is to help patients change their view of their problem from overwhelming to manageable. Patients who are prone to catastrophize benefit from examining the way they view their situation. What might otherwise be perceived as a hopeless condition can be reframed as a difficult yet manageable condition, over which the patient can exercise some control.

A second objective is to help convince patients that treatment is relevant to their problem and that they need to be actively involved in their own treatment and rehabilitation. Patients need to understand how relaxation training, cognitive restructuring, adaptive coping skills, and pacing behaviors can help decrease their pain. They also need to reorient their view away from that of passive victim and toward that of proactive, competent problem-solver. When individuals are successful in managing difficult painful episodes, their views change. They eventually begin to believe themselves capable of overcoming any acute flare-up of pain.

A third objective is to teach patients to monitor maladaptive thoughts and substitute positive thoughts. Persons with chronic pain are plagued, either consciously or unconsciously, by negative thoughts related to their condition. These negative thoughts have a way of perpetuating pain behaviors and feelings of hopelessness. Demonstrating how and when to attack these negative thoughts, and when to substitute positive thoughts and adaptive management techniques for chronic pain, is an important component of cognitive restructuring. Patients are encouraged to attribute success to their own efforts; they need to know that they are responsible for the gains they make. Finally, future problems and lapses need to be discussed so that the patient will have a "game plan" to manage short-term setbacks.

Physical Activity and Exercise

Most patients are de-conditioned because of their reluctance to exercise and because of a perceived need to protect themselves. Some patients have been medically advised to restrict activity when pain increases. Patients with chronic pain need to know that exercise is important. Some stretching, cardiovascular activity, and weight training should be encouraged. Each patient should be asked to keep track of his/her activity in an exercise record. It is important to set an exercise quota so that the patient will work to meet a weekly goal. The exercise plan should initially be determined by the patient, and reviewed and supervised by a physical therapist or exercise physiologist. Patients should be instructed to stretch before and after each exercise session.

Any attempt by chronic pain patients to exercise is bound to entail some disappointment and perceived failure. Patients may make excellent gains, only to experience a flare-up of their condition. These setbacks should be anticipated, so that the patient does not become excessively disappointed. Behavioral research suggests that compliance with exercise is best when each person is monitored and given encouragement for his/her accomplishments. Unfortunately, many persons with chronic pain tend to discontinue a regular exercise regimen within 6 months after a treatment program is concluded. Ways to encourage perseverance, such as organizing an exercise period with others, joining a health club, or combining exercise with another everyday activity, should be explored.

Summary

Despite the strong support for the above co-interventions and for a multidisciplinary treatment approach, the Chou article points out that there are barriers to obtaining these therapies, including cost, lack of insurance coverage, and limited availability. Fortunately, information on appropriate pain management is increasingly readily available for patients over the Internet, and individuals are increasing coming to doctors visits armed with information on the best ways to manage their pain.

Within the current debate over healthcare coverage, there will hopefully emerge an acknowledgement that informed consumers with chronic medical conditions who are offered a multidisciplinary treatment approach, and who are encouraged to actively participate in their treatment will have a greater likelihood to improve the outcome of the chronic medical condition that significantly impacts their morbidity and quality of life. Let’s hope that the collective wisdom summarized in these guidelines will prevail.

References

1. Chou R, Fanciullo GJ, Fine PG et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal Of Pain: Official Journal Of The American Pain Society 2009;10(2):113-130.