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
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.