Psychological techniques, including cognitive ther-apy, behavioral therapy, biofeedback, relaxation techniques, and hypnosis, are most effective when employed by psychologists or psychiatrists. Cogni-tive interventions are based on the assumption that a patient’s attitude toward pain can influence the per-ception of pain. Maladaptive attitudes contribute to suffering and disability. The patient is taught skills for coping with pain either individually or in group therapy. The most common techniques include attention diversion and imagery. Behavioral (oper-ant) therapy is based on the premise that behavior in patients with chronic pain is determined by conse-quences of the behavior. Positive reinforcers (such as attention from a spouse) tend to enable or intensify the pain, whereas negative reinforcers reduce pain. The therapist’s role is to guide behavior modification with the aid of family members and medical pro-viders in order to nurture negative reinforcers and minimize positive reinforcers.
Relaxation techniques teach the patient to alter the arousal response and the increase in sympa-thetic tone associated with pain. The most com-monly employed technique is a progressive muscle relaxation exercise. Biofeedback and hypnosis are closely related interventions. All forms of biofeed-back are based on the principle that patients can be taught to control involuntary physiological parameters. Once proficient in the technique, the patient may be able induce a relaxation response and more effectively apply coping skills to con-trol physiological factors (eg, muscle tension) that worsen pain. The most commonly utilized physi-ological parameters in biofeedback are muscle tension (electromyographic biofeedback) and tem-perature (thermal biofeedback). The effectiveness of hypnosis varies considerably among individuals. Hypnotic techniques teach patients to alter pain perception by having them focus on other sensa-tions, localize the pain to another site, and dissoci-ate themselves from a painful experience through imagery. Patients with chronic headaches and musculoskeletal disorders benefit most from these relaxation techniques.
Heat and cold can provide pain relief by alleviat-ing muscle spasm. In addition, heat decreases joint stiffness and increases blood flow, and cold vaso-constricts and can reduce tissue edema. The analge-sic action of heat and cold may at least partially be explained by the gate theory of pain processing.
Superficial heating modalities include con-ductive (hot packs, paraffin baths, fluidotherapy), convective (hydrotherapy), and radiant (infrared) techniques. Techniques for application of deep heat include ultrasound as well as shortwave and micro-wave diathermy. These modalities are more effective for pain involving deep joints and muscles. Cold is most effective for pain associated with acute injuries and edema. When applied selectively, cold can also relieve muscle spasm. Application may take the form of cold packs, ice massage, or vapocoolant sprays (ethyl chloride or fluoromethane). Exercise should be part of any rehabilitation program for chronic pain. A graded exercise pro-gram prevents joint stiffness, muscle atrophy, and contractures, all of which can contribute to the patient’s pain and functional disabilities. McKenzie exercises are particularly helpful for patients with lumbar disc displacement. Patients may state that physical therapy has not helped in the past. The effi-cacy of previous physical therapy techniques should be assessed, and the appropriateness of current physical therapy sessions and of the home exercise program should also be evaluated. By facilitating increased range of motion and providing constant resistance, aquatherapy may be particularly helpful for patients who may not be able to tolerate other forms of therapy.
Acupuncture can be a useful adjunct for patients with chronic pain, particularly thatassociated with chronic musculoskeletal disorders and headaches. The technique involves insertion of needles into discrete anatomically defined points, called meridians. Stimulation of the needle after insertion takes the form of twirling or of application of a mild electrical current. Insertion points appear to be unrelated to the conventional anatomy of the nervous system. Although the scientific literature concerning the mechanism of action and role of acupuncture in pain management is controversial, some studies suggest that acupuncture stimulates the release of endogenous opioids, as its effects can be antagonized by naloxone.
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