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clinical review Application of Psychological Strategies for Pain Management in Primary Care Kathryn A. Sanders, PhD, Rebecca G. Donahue, PhD, and Robert D. Kerns, PhD Abstract • Objective: To review behavioral and cognitive behavioral strategies for pain management and describe their application in the primary care setting. • Methods: The biomedical model, gate-control/ neuromatrix theories, and biopsychosocial model for understanding chronic pain are discussed followed by a review of behavioral, self-regulatory, and cognitive behavioral treatments and research supporting their use. • Results: Operant learning strategies, cognitive behavioral therapy, hypnosis, and biofeedback have been shown to improve patients' pain experience; however, many patients are not engaged in these treatments. Primary care providers may help prevent a cycle of pain and disability from occurring by organizing their treatment approach around the idea of pain management, not pain amelioration. They may help to promote patient motivation to engage in pain management therapies through the use of motivational interviewing strategies. Additionally, patientcentered education and counseling in primary care may facilitate the management of chronic pain. • Conclusion: Primary care providers can help patients to manage their pain without an overreliance on medications or medical procedures. They can help dispel common misconceptions of psychological approaches, help patients set realistic goals for pain management, provide referrals for more comprehensive pain management treatment, and collaborate with other providers managing their patients’ pain. A pproximately 50% of adults in the United States experience chronic pain [1]. Pain is one of the most common complaints made to primary care providers (PCPs) [2,3]. In addition, over $100 billion in lost productivity and disability per year is attributable to chronic pain conditions [4]. Unfortunately, despite advancements in our understanding of physical mechanisms that play a role in chronic pain as well as the development of sophisticated assessment and treatment procedures, there is no medical www.turner-white.com treatment that consistently alleviates pain for all patients [5]. The lack of consistent and permanent alleviation of pain with current medical interventions points to the importance of considering psychological and social factors in an attempt to understand and treat chronic pain and disability [5]. In this review, we explore psychological approaches to the management of chronic pain and discuss strategies that primary care providers can use to promote patient acceptance and participation in these treatments. We begin by providing a historical context for the involvement of psychology in the treatment of chronic pain and review the models of chronic pain that have shaped our thinking over the past several decades. Next, we review research supporting the use of behavioral, self-regulatory, and cognitive behavioral approaches to pain management. Finally, we focus on self-management approaches that can be used in the primary care setting and discuss how PCPs can use this information when working with patients with chronic pain. Models for Understanding Chronic Pain Biomedical Model A comprehensive review on this topic has been published [5]. The field of pain management has been slowly transitioning from a biomedical model of pain to a more comprehensive biopsychosocial understanding of the chronic pain experience. The biomedical model assumes that a patient’s amount of pain is proportional to the amount of tissue damage or disease and that treatments to reduce disease activity or tissue damage will also reduce pain [6]. The major problem with this model is that it ignores the wide variability in patient reports of pain in response to similar physical disturbance and treatment. In fact, associations between physical impairments on the one hand and pain report and disability on the other are modest at best [5]. Treatment focuses on correcting the source of pathology or physical damage. Additional symptoms reported by patients, such as sleep difficulty, mood symptoms, and impairments in social or work functioning, are seen as ancillary to the primary physical complaint and will resolve once the primary issue From the VA Connecticut Healthcare System, West Haven VA, West Haven, CT. Vol. 14, No. 11 November 2007 JCOM 603 pain management has been resolved. Only after treatment of the underlying physical pathology has failed to provide pain relief are these additional factors considered in a causative role. Therefore, according to this model, symptoms are either biologically or psychologically caused. Gate-Control Theory and Neuromatrix Model In response to criticisms of the biomedical model’s lack of consideration of the interaction between physical, social, and psychological factors in pain, Melzack and colleagues [7,8] developed the gate-control theory of pain. According to this model, there are 3 systems involved in nociceptive processing (sensory-discriminative, motivational-affective, cognitive-evaluative), which interact to produce the patient’s overall subjective experience of pain through activation of a gating mechanism in the spinal cord. After debate regarding the physiological evidence for such a model, Melzack [9] later extended the gate-control theory to a diathesis-stress model, which he termed the neuromatrix theory. This theory posits that the brain has a neural network that integrates sensory information, inputs from brain areas responsible for cognition and emotion, and inputs from our stress-regulation systems [6]. Predispositional factors such as physiological (neural networks, genetics) and behavioral response patterns interact with an inciting pain event to produce stress. Over time, cognitive processes (eg, worry about the future, the meaning of pain) contribute to this stress until the pain becomes a stressor in and of itself. This repetitive and ongoing input leads to structural and functional changes that may cause altered perceptual processing and contribute to pain chronicity. At this point, patients may continue to report pain without any evidence of physical pathology. The implication of this model is that targeting just one of these systems will be inadequate due to the multidimensional nature of pain. This model replaces the biomedical model with a more comprehensive model that includes psychological and social variables. Biopsychosocial Model The biopsychosocial model explains the variety of illness expression (severity, duration, and effects on the person) by accounting for the interrelationships among biology, psychological status, and social and cultural contexts [5]. These factors interact to create each individual’s perception of and response to pain (ie, their pain experience). In contrast to the biomedical model, the biopsychosocial model views psychological and social factors not as reactions to disease but as factors that influence disease severity, maintenance, and exacerbation. This multifactorial approach to pain management highlights the need to assess which factors play a role in a patient’s pain and match treatment to address those variables [5]. Psychological and social factors, such as depression, 604 JCOM November 2007 Vol. 14, No. 11 anxiety, beliefs about pain, feelings of controllability, selfefficacy, coping, and social learning, influence pain and disability and are important areas to consider in the assessment and treatment of chronic pain [5,10]. It is in this area that behavioral and cognitive behavioral approaches to pain management have the most to offer patients with chronic pain. Behavioral, Cognitive Behavioral, and SelfRegulatory Treatments for Chronic Pain Operant Learning Model Fordyce’s [11] operant behavioral treatment was one of the first psychological interventions for chronic pain. This approach emphasizes social and environmental reinforcing factors and utilizes principles of reinforcement, punishment, and extinction to influence patients’ pain-related behaviors. An operant conditioning model predicts that if others reinforce a patient in pain with attention, sympathy, and other solicitous responses, the patient will continue to display pain-related behaviors (eg, reports of pain, moaning, limping, grimacing, guarding, rubbing, use of a cane, increasing amounts of time spent lying or sitting down, consumption of medications), even in the absence of continued nociception. In order to decrease the occurrence of these behaviors, contingent reinforcement needs to be removed and more adaptive behaviors (eg, exercise and activity) should be reinforced in their place. Most treatments include use of time-contingent (rather than pain-contingent) medication delivery to reduce medication-taking behavior. There have been several recent reviews and metaanalyses examining the efficacy of operant behavioral treatment for chronic pain associated with a variety of medical conditions (rheumatoid and osteoarthritis, back pain, limb pain, and fibromyalgia). In 1 meta-analysis, adequate effect sizes (0.32–1.41) were obtained for operant therapy on improvements in pain experience, mood/affect, cognitive coping and appraisal, behavior, and social role functioning when compared with wait list controls [12]. Effect sizes were somewhat smaller when compared with active treatment controls (0.06–0.62). Compas and colleagues [13] reviewed several studies of patients with rheumatoid disease, headache, irritable bowel syndrome (IBS), and back pain and concluded that operant behavioral treatment for chronic pain is an efficacious treatment. In a more recent review, there were no significant differences in outcome between operant behavioral and cognitive behavioral treatments for chronic low back pain, but both treatment approaches produced better results than wait list controls or no treatment [14]. Cognitive Behavioral Therapy The cognitive behavioral perspective on pain and pain management is informed by the operant model, gate-control theory, and biopsychosocial model [15]. Central to the www.turner-white.com clinical review cognitive behavioral model is an acceptance of the experience of pain as subjective, covert, and private. According to this model, individuals’ appraisals, attitudes, beliefs, coping processes, and problem-solving competence are viewed as key determinants to the development and perpetuation of the pain experience, functional disability, and distress [16]. The principle aim of cognitive behavioral therapy (CBT) for chronic pain is to promote the adoption of a self-management approach to the experience of pain and its associated problems. Individuals’ commonly experienced sense of helplessness and hopelessness is challenged systematically, and the development of a more constructive and optimistic problemsolving perspective is encouraged. This reconceptualization is fostered through a psychoeducational approach to therapy that encourages the development of an understanding for the perpetuation of pain, disability, and distress, while challenging erroneous beliefs, fears, and maladaptive avoidance behavior. The development of an effective self-management approach is reinforced by a collaborative process that involves acquisition and practice of a range of cognitive and behavioral skills [16]. Common components of CBT include (1) patient/ family education regarding models of chronic pain and pain management, negative effects of health risk behaviors on pain, sleep hygiene, pain medication effects and intended use; (2) contingency management/training patients in appropriate goal setting and reinforcement; (3) relaxation training and/or biofeedback; (4) problem-solving skills training; (5) training in effective communication; (6) training in the use of distraction; (7) behavioral activation incorporating principles of activityrest cycling and pacing; and (8) cognitive restructuring [16,17]. CBT has been reported as an efficacious treatment for a variety of chronic pain conditions, including chronic pain syndromes; chronic low back pain; rheumatic diseases such as osteoarthritis, systemic lupus erythematosus, ankylosing spondylitis; and IBS [12]. Cognitive behavioral treatments, in comparison to alternative active treatments, produced greater changes in pain experiences and cognitive coping and appraisal and reduced behavioral expression of pain [12]. With regard to chronic low back pain, CBT was superior to wait list controls at reducing posttreatment pain intensity and interference in a meta-analysis of treatments for chronic low back pain [18]. Hypnosis Hypnosis is generally thought of as a state of highly focused attention at which time one is susceptible to direct or indirect suggestions to alter awareness, sensations, and affective response to perceptions. Suggestions may be offered in the form of imagery, relaxation, or meditation strategies and typically include images of comfort, well-being, and numbness. These suggestions have been thought of as the central component of clinical efficacy [19]. Global hypnotic www.turner-white.com responsivity and the ability to experience vivid images have been associated with treatment outcome in hypnosis, progressive muscle relaxation, and autogenic training [20]. However, if a patient is interested in hypnosis or imagery and has at least some attentional capacity, he or she will likely benefit from individualized treatment [19]. In a review of 19 controlled trials of hypnosis for several chronic pain conditions (headache, low back pain, temporomandibular pain disorder, cancer-related pain, sickle cell disease, fibromyalgia, osteoarthritis, disability-related pain, and mixed pain disorders), it was found that hypnotic analgesia produced significantly greater decreases in pain relative to no treatment, medication management, physical therapy, and education/advice [20]. These results supported the conclusions of a previous review of hypnosis as an empirically supported treatment for chronic pain associated with a variety of conditions [21]. However, the review reported that the effects of hypnosis were similar, on average, to progressive muscle relaxation and autogenic training [20]. In another review of empirically supported treatments [12], hypnotherapy was also found to be a potentially efficacious treatment for IBS pain compared with a psychotherapy plus placebo medicine control group. A more recent review of treatments for IBS confirmed these findings, stating that the evidence points to effectiveness of hypnotherapy as a treatment for IBS [22]. Biofeedback Biofeedback is a technique in which a patient is trained to control their body by using feedback from a variety of monitoring procedures and equipment. During a biofeedback session, a therapist will apply electrical sensors to different parts of the body to monitor the body’s responses and feedback auditory or visual cues to alert the patient to these responses. Once alerted, the patient may begin to engage in alternative responses (eg, relaxation) to decrease pain. Patients are typically asked to practice these strategies at home. It is suggested that biofeedback sessions occur initially twice per week followed by once-weekly sessions for up to 24 sessions [23]. In treatment of pain disorders, electromyographic (EMG) and thermal biofeedback have been most utilized. During EMG biofeedback, disposable sensors are placed on targeted major muscle groups (forehead, trapezius) to measure muscle tension. A list of biofeedback strategies are then given to the patient to choose from when attempting to relax (eg, relaxing imagery, autogenic phrases, deep breathing, awareness of sensations, mental games, concentrating on auditory feedback, clearing the mind). During thermal biofeedback, sensors are attached to fingers to measure skin temperature, and patients are trained to warm their hands using mental images of warm sun, watching the meter while directly trying to control it, and/ Vol. 14, No. 11 November 2007 JCOM 605 pain management or attending to the feeling of blood pulsations in the fingertips to successfully increase hand temperature [23]. Along with relaxation training, thermal biofeedback has been called the “standard treatment” for migraine and combined headaches (migraine and tension-type) [23]. EMG biofeedback has also been shown to be successful in reducing headache activity [23]. In addition to treatment of chronic headaches, relaxation training and biofeedback have been reported to maximize treatment effects of multidisciplinary programs in patients with chronic back pain [24,25]. Furthermore, in a meta-analysis of randomized controlled trials of chronic pain treatments excluding headache, relaxation and biofeedback were found to improve pain experience, mood/affect, cognitive coping, and social role functioning more than a wait list control in patients with arthritis, back pain, limb pain, and fibromyalgia [13]. What Can Be Done in Primary Care? Barriers to Adequate Chronic Pain Treatment Despite the availability of efficacious psychological treatments for chronic pain, many patients are not successfully engaged in these treatments, drop out or fail to adhere to therapist recommendations, or fail to maintain treatment gains following the completion of treatment [26]. Barriers to receipt of psychological treatment include patients’ unwillingness to acknowledge the role of stress and mood in their pain due to the fear that pain will be dismissed as psychological and not treated as real pain; patients’ belief that their pain is physical and nothing but medications or surgery will help; and negative attitudes and stereotypes regarding use of a psychological approach on the part of the patient, significant others, or caretakers [6]. Aspects of the patient-provider relationship can serve as additional barriers to appropriate pain management. According to 1 review [27], patients with chronic pain and their physicians often have opposing attitudes and goals, with patients seeking to be understood as individuals and struggling to have their pain complaints legitimized and physicians focused on treatment planning that obtains the best clinical outcome. The authors highlight the importance of the patient and physician having a shared conceptualization of the patient’s pain experience (ie, biopsychosocial approach) and the collaborative development of treatment recommendations based on this conceptualization. Using a biopsychosocial approach, physicians can help their patients with chronic pain by providing reassurance, encouraging self-management, and providing referrals when appropriate. Primary Care: A “Golden Opportunity” for Appropriate Pain Management As noted previously, patients’ cognitions, affect, and behaviors play a central role in the pain experience. PCPs may 606 JCOM November 2007 Vol. 14, No. 11 feel ill-equipped to manage these types of issues and subsequently feel they have little to offer patients in this regard [28]. This can lead to frustration and helplessness on the part of the physician and the patient. It is difficult for PCPs to adequately address patients' pain concerns during an office visit due to several factors [28,29]. Time pressures may not allow physicians to assess the multidimensional aspects of the patient’s pain complaint. Over-reliance on the medical model neglects psychosocial variables that have been shown to play a role in chronic pain. Extensive use of medical tests and treatments can lead to patients being more reliant on the provider and taking less personal responsibility for their pain management. Lack of clear and consistent guidelines for management of chronic pain and lack of provider education and clinical expertise in working with chronic pain patients may contribute to feelings of inadequacy and helplessness in PCPs. The first visit with a patient in pain is a golden opportunity to set the stage for the course of treatment [28]. A cycle of chronic pain and disability can be prevented by good management from the very beginning of treatment. Patients should be provided with reassurance, advice, and recommendations for self-management [28]. Reduction in medical testing, treatment, and attention during the early phase can prevent chronic problems. Physicians should organize their treatment approach around the idea of pain management, not pain amelioration, and ascribe to a stepped-care approach similar to that developed by Von Korff [30]. A Stepped-Care Approach According to Von Korff’s [30] stepped-care model, the level and intensity of pain treatment is guided by patient outcomes while matching interventions to the patient’s concerns, activity limitations, preferences, and readiness. In step 1, the least intensive level of care, the PCP provides patients with information and advice focused on returning to their usual activities as quickly as possible. Patients' fears about activity are addressed by explaining the “red flags” for serious disease and how history and diagnostic information can rule these out, providing information specific to each patient’s worries, advising patients on appropriate ways to return to physical activities and benefits of doing this, and finally, preparing patients for the likelihood of pain flare-ups in the future. Step 2 typically includes other practitioners (eg, psychologist, physical therapist) and often uses group formats to assist more moderately impaired patients in management of their activity limitations. This step usually includes a structured exercise program and cognitive behavioral strategies to reduce patients' fears. Patients are assisted in identifying goals and difficulties, planning to overcome difficulties and achieve goals, increasing motivation for exercise, and gaining support through follow-up. www.turner-white.com clinical review Finally, in step 3, patients who are disabled or are in danger of becoming disabled receive more intensive management including additional practitioners in a group or individual format. Providers work as a team to help patients identify work difficulties, prescribe an early return to work, engage the patient in graded exercise and strengthening, and identify and treat any psychiatric comorbidities. Use of Motivational Interviewing Strategies Individuals with chronic pain vary in their degree of readi ness to adopt a self-management approach. A patient’s readi ness is likely predictive of engagement in self-management therapies and outcome. Jensen [31] and Kerns and colleagues [32] suggest an adaptation of motivational interviewing strategies for promoting motivation to engage in pain management therapies. The stages of change model [33] conceptualizes patients’ readiness to change behaviors as moving through several stages: precontemplation, contemplation, preparation, action, and maintenance. Motivational interviewing [34] applies strategies for decreasing patients’ ambivalence and increasing their motivation for changing specific health behaviors. It is based on a collaborative, nonconfrontational approach that matches techniques with patients’ current stage of change with an eye towards moving them in a direction of maintaining a new healthy behavior, such as self-management of chronic pain (see Jensen [35] for a review of application of motivational interviewing with chronic pain patients). Patient-Centered Counseling in Primary Care Ockene and Zapka [36] also advocate a patient-centered education and counseling approach that could be adapted for use in primary care settings to facilitate management of chronic pain. This physician-delivered approach employs nondirective, open-ended questioning to elicit active patient participation in decisions about health behavior change. PCPs follow a stepby-step strategy in which they address a health risk behavior, assess the patient’s readiness to change their behavior, advise the patient about the importance of change, assist the patient in developing and implementing a plan for change, and arrange for follow-up (the 5 A’s). Personalized information and feedback about the patient’s behavior and health is incorporated. Motivational interviewing techniques [34] are also commonly used. Ockene and others have described specific protocols for effective training of practitioners to employ their patientcentered counseling approach with several health risk behaviors, including smoking, alcohol use, and diet [36–41]. This could easily be adapted for use in primary care settings with chronic pain patients. In fact, in 1 unpublished study [42], 89 primary care patients with chronic pain were randomly assigned to 3 treatment groups: treatment as usual/wait list; 10 sessions of CBT with a psychologist; and PRIME-CBT, which www.turner-white.com consisted of CBT with a psychologist that included 2 conjoint sessions with the psychologist and PCP using the 5 A’s approach. They found that both CBT and PRIME-CBT demonstrated significantly greater improvements on measures of pain, disability, and emotional distress than treatment as usual. In addition, PRIME-CBT resulted in significantly increased adherence to weekly homework and goals, greater goal accomplishment, and greater patient satisfaction relative to CBT. This study provides preliminary evidence that PCP integration into CBT treatments for pain can be an effective approach to enhancing compliance and satisfaction with treatment. In summary, it is clear that PCPs can do much to encourage self-management in their patients with chronic pain, despite the many barriers to adequate care. In addition, because of their long-term relationship with the patient, PCPs are in a unique position to make a referral for more comprehensive pain management treatment when necessary. Providers can help dispel common misconceptions regarding psychological approaches to pain management and help their patients set realistic goals for management of their pain. Finally, preliminary evidence shows increased compliance and satisfaction when PCPs work alongside psychologists in managing their patients’ problems with pain. Conclusion Research data demonstrate a high rate of chronic pain among primary care patients as well as a significant relationship between concerns about chronic pain and health care utilization [43,44]. The goals of primary care are to provide comprehensive services, improved coordination and continuity of care, and greater accountability. Encouragement of patients with chronic pain to participate in selfmanagement and reduce reliance on health care resources is consistent with the goals of primary care. Evidence from a huge body of research supports the use of behavioral and cognitive behavioral treatments based on a biopsychosocial approach to pain management. PCPs can contribute much to their patients by helping them to manage their pain without an overreliance on medications or medical procedures. They can also help during referral of a patient to a psychologist for CBT by enhancing patients’ motivation, easing patient concerns regarding seeing a mental health provider, and ensuring compliance and satisfaction with treatment by maintaining ongoing involvement in the patient’s care. Corresponding author: Kathryn A. Sanders, PhD, VA Connecticut Healthcare System, 950 Campbell Ave., 116B West Haven, CT 06516, [email protected]. Funding/support: Dr. Kerns is supported by Merit Review grants from the Department of Veterans Affairs Office of Research and Development Rehabilitation and Clinical Science Research Services Vol. 14, No. 11 November 2007 JCOM 607 pain management and by a grant (no. DF03-035) from the Donaghue Research Foundation. Financial disclosures: None. Author contributions: conception and design, KAS, RGD, RDK; drafting of the article, KAS, RGD; critical revision of the article, KAS, RGD, RDK; obtaining of funding, RDK. References 1. Novy DM. 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Benedetto MC, Kerns RD, Burg MM, et al. Health risk behaviors and their relationships to health care utilization among veterans receiving primary medical care. J Clin Psychol Med Settings. In press. Copyright 2007 by Turner White Communications Inc., Wayne, PA. All rights reserved. www.turner-white.com Vol. 14, No. 11 November 2007 JCOM 609