There are various techniques for controlling pain
Pain relieving chemicals
Severe Phantom limb pain was treated, over a two-year period, with methadone and antidepressants. The patients who had had the pain syndrome for an average of five years reported that their pain had been reduced by about two thirds. This was maintained over the following two years using very low daily doses of each drug (Urban et al., 1986). The good news here is that the patients did not become addicted to the drugs.
Patients suffering from headaches under the double blind procedures given painkillers and placebos sometimes reported that the placebo relieved their headache (Andrasik, Blake, and McCarran, 1986). This would suggest that other psychological techniques might be equally as effective.
Some patients may not like being referred to a psychologist. They may not see the relevance, or they may think the doctor does not believe the pain is real, or the patient may believe the doctor considers them psychologically maladjusted. To overcome this problem the doctor should make it clear that they believed the patient is in a great deal of pain, that working with other professionals would be a good idea and that the doctor would be an active part of the team.
Behavioural and cognitive methods for treating pain
The operant approach
An example of the operant approach for a child with burns.
The child cries and complains of pain when ever she puts on her splints. The hospital staff has been giving attention to the crying behaviour. The remedy is as follows:
A technique for reducing medication is as follows:
Use a fixed schedule, such as every four hours, rather than when ever the patient requests it. The drug therefore does not become a reward for the patient. In addition, the medication is mixed with flavoured syrup to mask its taste. Over a period of several weeks the dosage is gradually reduced, but the patient because of the syrup does not detect this.
Problems with these studies
Relaxation and biofeedback
Patients using the technique of progressive muscle relaxation focus their attention on specific muscle groups while alternately tightening and relaxing these muscles. Patients who received training in relaxation to control pain are urged to use this technique to reduce feelings of stress, particularly if they feel pain episodes coming on.
In biofeedback procedures, patients learned to exert voluntary control over a bodily function, such as heart rate, by monitoring its status with information, usually from electronic devices. Muscle contraction headaches can be treated by biofeedback procedures. Patients learned to control the tension of specific muscle groups -such as those in the scalp and neck- by receiving biofeedback from an electro-myograph (EMG.) device. Another method used for migraine headaches, focuses on the constriction and dilation of arteries -such as those in the head- which can be measured indirectly on the basis of the temperature of the skin in the region of the target blood vessels. Biofeedback techniques, such as these, can be used at home whenever a patient feels a pain episode is about to begin.
Biofeedback techniques have been shown to be successful in controlling headaches, but there has been little evidence of biofeedback procedures being effective in relieving other types of pain. Treatment with relaxation and biofeedback is about twice as effective in relieving pain as placebo conditions. A combination of relaxation and biofeedback has been shown to be more successful than biofeedback on its own. Biofeedback has been shown to be more successful than relaxation techniques. (Holroyd & Penzien, 1985). There is much variability in the success of these techniques. Middle-aged and elderly patients seem to gain relatively little relief with these treatments (Blanchard & Andrasik, 1985). Biofeedback treatment is relatively expensive to conduct, and the likelihood of improvement beyond just using relaxation for many pain conditions may not justify its expense (Turk, Meichenbaum & Berman, 1979). There is some evidence that most children and people who show certain psychophysiological patterns, such as a high correlation between their pain and EMG. Levels, may be better candidates for biofeedback treatment than other people (Attanasio et al., 1985).
Cognitive techniques
Researchers asked children and adolescents what they think about when getting an injection at their dentists (Brown, O'Keeffe, Sanders, & Baker, 1986). Over 80% of these subjects reported thoughts that focused on negative emotions and pain, such as, "this hurts, I hate injections," "I'm scared," and "my heart is pounding and I feel shaky." One fourth of the subjects had thoughts of escaping or avoiding the situation, as in, "I want to run away." These types of thoughts focus the persons attention on the unpleasant aspects of the experience and make the pain worse (Turk, Meichenbaum, & Genest, 1983). Many people use cognitive strategies to modify their experience of pain. For instance, by 10 years of age, many children reports that they tried to cope with pain in a dental situation by thinking about something else or by saying to themselves such things as, "it's not so bad," or, "be brave" (Brown, O'Keeffe, Sanders, & Baker, 1986).
People cope with chronic pain by using one of two strategies:
The problem with passive coping is that this leads to feelings of helplessness and depression, which leads to more passive coping, and so on (Smith & Wallston, 1992). Patients who feel that their pain will last a very long time and their doctors don't know what causes their pain tend to cope poorly. On the other hand, patients who believe that they understand the nature of their pain and that their conditions will improve tend to use active coping strategies.
Kontantji et al (2000) has demonstrated the different ways in which high-pain frequency students compared with low-pain frequency students process sensory or affective words that are associated with pain. The high-pain students, being those who experienced pain quite often, recalled more sensory and affective words when they were incidentally learnt by self-referencing them (thought of in relation to themselves) compared to when they were other referenced (thought of in relation to a friend). Affective words included: unbearable, discomforting, mild, horrible, fearful, and cruel. Sensory words included: scolding, stabbing, pressing, boring, pounding, tugging, tender. This demonstrates how cognitive processes are affected by pain. Here we consider the reverse, how cognitive processes can affect pain sensation!
Coping techniques can be classified into three basic types:
Distraction
Distraction is the technique of focusing on a non-painful stimulus in the immediate environment in order to divert our attention from discomfort. Research has shown that distraction is more effective if the pain is mild or moderate than if it is strong (McCaul & Malott, 1984).
A laboratory experiment involving college students rated the subjects pain distress for holding their hand in cold water. Subjects given a distraction task involving numbers did not give lower pain ratings than controls, who just watched numbers being displayed (McCaul, Monson, & Maki, 1992). This result might be because subjects needed to believe that these distraction techniques would relieve pain. Subjects believing that loud sound would relieve pain, listened to the sound and did not feel as much pain (using the cold-presser procedure, hand in cold water) as did controls who were listening for a non-existent hum (Melzack, Weisz, & Sprague, 1963).
Its importance that patients understand that distraction can work. One therapist used the analogy of a TV set. For example whilst watching channel 11, channel nine is still being received. The metaphor means whilst the patient is attending to a non-painful stimulus the pain is still there but is not tuned in.
Distraction works best for acute pain, such as the pain experienced in a dental surgery. Chronic sufferers might find it useful to engage in an extended activity, such as watching a film or reading a book.
Imagery
Non-pain imagery-sometimes called guided imagery-is a strategy whereby the person tries to alleviate discomfort by conjuring up a mental scene that is unrelated to or incompatible with the pain (Fernandez, 1986). Therapists encourage the patient to include aspects of a variety of senses: vision, hearing, taste, smell, and touch. Imagery is like distraction except that imagery is based on the person's imagination rather than on real objects. The advantage here is that the patients can develop one or more scenes that work reliably and carry them around in their heads. Imagery works best for people with mild or moderate pain than with strong pain. A disadvantage is that some patients are less adept in imagining scenes than others.
Redefinition
Pain redefinition is when the person substitutes constructive or realistic thoughts about the pain experience for ones that arouse feelings of threat or harm. Therapists can help by providing information about the sensations to expect in medical procedures. There are basically two kinds of self-statements for controlling pain:
Coping statements emphasise the person's ability to tolerate the pain by saying to themselves, "it hurts, but you're in control," or, "be brave-you can take it."
Reinterpretative statements are designed to negate unpleasant aspects of the pain, as when people think, "it is not so bad," "it's not the worst thing that could happen," or, "it hurts, but think of the benefits of this experience."
Evaluation of cognitive strategies in controlling pain
Cognitive strategies are effective in reducing acute pain. Distraction and imagery seem to be particularly useful with mild or moderate pain, and redefinition appears to be more effective with strong pain. A combination of behavioural and cognitive methods is at least as effective as chemical methods in reducing chronic muscle-contraction headaches (Holroyd et al., 1991). Patients with a variety of medical problems including arthritis, amputation, and spinal cord injury reported that redefinition helped in reducing the experience of pain more than distraction did (Rybstein-Blinchik, 1979). Arthritis sufferers received a five-week pain control programme that included training in distraction, imagery, and redefinition. The programme gave special emphasis to having the patients use these techniques in specific painful activities, such as carrying groceries, climbing stairs, and mopping floors. A control group simply received a self-help book for arthritis sufferers. The control group showed little improvement but the treated group reported having less pain, greater self-efficacy, less depression, and improved Sleep patterns.
A programme combined imagery, redefinition, and progressive muscle relaxation training to treat chronic low back pain patients. This programme was compared with one that consisted of only relaxation training, and a control group. Patients in the two treatment programmes reported much less pain, depression, and disability. The patients were benefiting from these two programmes more than a year and a half later. The patients who had been trained in cognitive strategies and relaxation showed an improvement in their employment, working 60 per cent more hours per week than those who had the programme of relaxation only.
Hypnosis produces a high degree of analgesia in only a minority of individuals. Those people who can be hypnotised very easily and deeply seem to gain more pain relief from hypnosis than those who are less hypnotically susceptible. Hypnosis could be seen as a form of relaxation. Hypnosis often produces states of heightened attention to internal images and inattention to environmental stimuli.
Laboratory research on acute pain, induced by cold-presser or muscle-ischemia procedures, has found that:
Hypnosis can reduce pain.
The people who gained the most pain relief are highly responsive to other suggestions, such as that their arm is becoming light.
Whether under hypnosis or not, people tend to use distraction and redefinition techniques.
People usually show as much pain reduction using cognitive strategies as they do under hypnosis (Barber, 1986).
Hypnosis is mainly effective for relieving acute pain. There is little evidence to suggest that hypnosis would be effective for relieving chronic pain.
Insight-oriented psychotherapies for pain
This technique involves chronic pain patients gaining insights into the way that the pain is affecting their behaviour and the way their interpersonal relationships are being affected. Pain behaviour is seen as part of "pain games" they play with other people (Szasz, cited in Bakal, 1979). In these games, the patient takes on a role in which they continually seek to confirm their identity as suffering persons, maintain their dependent lifestyles, and receive various rewards, such as attention and sympathy. The patients are most likely unaware of the game they are playing; it is the purpose of this psychotherapeutic approach to make them aware.
Chemical - Aspirin -Acetylsalicylic acid - found in Willow trees, as discovered by a clergyman from Chipping Norton in 1763 - it relieved his rheumatism and bouts of fever.
Aspirin, Ibuprofen, Paracetamol (acetaminophen)
Against pain
Against inflammation
Against fever
Opium used before then, as early as 1550 BC
From Opium is produced morphine, heroin and codeine - all produce analgesia, drowsiness, change of mood, mental clouding.
Inhibit pain messages (close the gate).
Opiates work well because many nerves respond to opiates.
Keeri-Szanto (1979) - machine that dispenses tablets by the patient's bed, with lock to prevent patient from over-dosing - patient self-administering in this way reduces their drug intake, compared with when issued with tablets from the medical staff.
Cutting nerve pathways - gives temporary relief. Only recommended for people who are terminally ill.
Manual therapies e.g. massage
Mechanical therapies e.g. traction
Heat treatments e.g. microwave diathermy, ultrasound.
Cold treatments e.g. ice packs
Electrotherapy - electrical nerve stimulation.
Not known how heat works, but fits in with the gate theory (closes the gate)
Mild pulses of electricity in painful areas probably works in the same way.
Relaxation, Biofeedback, Hypnosis, cognitive coping skills, operant techniques, mental imaging, self-efficacy, counselling.
Operant - useful if patient has developed inappropriate response to the pain (e.g. too many tablets).
Basler and Rehfisch (1990) 12 week intervention
reinterpret pain experience
relaxation
avoiding negative and catastrophic thinking
use of distraction.
Six month follow up - significant improvement compared to untreated group. Fewer pain symptoms, lower level of anxiety and depression. Fewer visits to doctor.
Criticism of methodology - could be the result of attention received - placebo effect.
low self-efficacy - higher tolerance to pain
Bandura et al (1988)
Experiment - self-efficacy manipulated by demands of a mental arithmetic task.
Given Saline or Naloxone injection. Blocks the pain killing response of the body.
Measured the amount of time they could immerse their arm in ice-cold water.
Saline - low-efficacy could tolerate the pain longer than Saline high efficacy.
No difference between the two Naloxone groups.
This suggests low efficacy people produce more opiates in their system, to kill pain.
Sounds good, but probably wears down the immune system.
Many health professionals do not consider pain relief as part of their job. random use of drugs, did not take account of the pain.
Even though local anaesthetic used before surgery with general anaesthetic, means less post-operative pain, few medical staff carry out this procedure.
Biopsychosocial model important - Can't explain pain by biological factors alone.
Links
The American Chronic Pain Association (ACPA) is a non-profit, tax exempt organization with more than 800 chapters in the United States, Canada, Australia, New Zealand, Mexico, England, Ireland, Scotland and Russia. Our purpose is to provide a support system for those suffering with chronic pain through education and self-help group activities. We seek to get members out of the patient role and back to being a person.
Clinical Guidelines for the Management of Acute Low Back Pain