Friday, September 01, 2006

Managing and Controlling Pain

Reinforcement.

One important approach to pain management is the operant view. This is best represented in the writings of Fordyce (1976). According to this view of pain, there is an initial response to pain stimulation that produces certain behaviors. These pain behaviors might include avoidance of work, staying in bed, and verbal descriptions of pain. In addition, pain behaviors might include taking medications. Initially, these pain behaviors are a response to pain stimulation. However, according to the principles of learning, behaviors can be strengthened through reinforcement. If pain behavior is reinforced or followed by positive consequences, its probability will increase in the future.

Flor, Kerns and Turk (1987) used questionnaire reports by pain patients and their spouses to assess how the patients' behaviors were related to their spouses' being solicitous, that is, reacting to pain behaviors by giving attention and care. Higher levels of solicitousness by the spouse were associated with patients showing more pain behavior and less activity, such as in visiting friends or going shopping.

Therefore the operant approach to pain requires that 'well behaviour' activities be reinforced and that pain behaviors be extinguished. Thus, families might be taught to ignore pain behaviors, but to provide reinforcement for functional activity/'well behaviours'.

Cognitive Behavioural Approaches

A cognitive-behavioural approach to pain regards pain as a perception that involves an integration of four sources of pain-related information:

  1. Cognitive, e.g. the meaning of the pain ('it will prevent me from working').
  2. Emotional, e.g. the emotions associated with the pain (T am anxious that it will never go away').
  3. Physiological, e.g. the impulses sent from the site of physical damage.
  4. Behavioural, e.g. pain behaviour that may increase the pain (such as not doing any exercise) and pain behaviour which may decrease the pain (such as doing sufficient exercise).

Cognitive-Behavioural approaches are popular because they integrate techniques that deal with the experience of pain on a number of levels, rather than viewing pain as a simple experience. This can be seen in a study by Basler and Rehfisch (1990) in which sixty chronic pain sufferers, who had experienced chronic pain in the head, shoulder, arm or spine for at least 6 months, were recruited. Ps were allocated to either (1) the immediate treatment group or (2) the waiting list control group.

All Ps completed measures at baseline (time 1), after the 12-week treatment intervention (time 2) and at 6-month followup (time 3). Ps in the control group completed the same measures at comparable time intervals. At times 1, 2 and 3, all Ps completed a 14-day pain diary, which included measures of: Intensity of pain, mood, functional limitation and pain medication.

The treatment programme consisted of weekly 90-minute sessions, which were carried out in a group 1 up to 12 patients. All Ps in the treatment group received a treatment manual. The following components were included in the sessions:

  • Education. This component aimed to educate the subjects about the itionale of cognitive behaviour treatment. The subjects were eniraged to take an active part in the programme, they received formation about the vicious circle of pain, muscular tension, demoralization and about how the programme would improve their sense of self-control over their thoughts, feelings and behaviour.
  • Relaxation. The subjects were taught how to control their responses pain using progressive muscle relaxation. They were given a home relaxation tape, and were also taught to use imagery techniques and visualization to distract themselves from pain and to further improve their relaxation skills.
  • Modifying thoughts and feelings. The subjects were asked to complete coping cards to describe their maladaptive thoughts and adaptive coping thoughts. The groups were used to explain the role of fear, depression, anger and irrational thoughts in pain.
  • Pleasant activity scheduling. The subjects were encouraged to use distraction techniques to reduce depression and pain perception. They were encouraged to shift their focus from those activities they could no longer perform to those that they could enjoy. Activity goals were scheduled and pleasant activities were reinforced at subsequent groups.

The results showed significantly different changes between the two groups in all their ratings. Compared with the control group, the subjects who had received cognitive behavioural treatment reported lower pain intensity, lower functional impairment, better daily mood, fewer bodily symptoms, less anxiety, less depression, fewer pain-related bodily symptoms and fewer pain-related sleep disorders.

(Reported in Ogden, 2000)

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