Interview: The 'Menu' Approach

Studying Optimists' Brains

Francis Keefe, PhD, has researched behavioral/psychosocial treatment of chronic pain for more than two decades, as director of the pain management program at Duke Medical Center, Durham, NC, and now with the health psychology program at Ohio University, Athens, Ohio. We talked with Dr. Keefe about the growing interest in non-drug approaches to pain control.

Q. Why is interest increasing in non-drug approaches to pain control?

A. There's growing recognition that the pharmacologic approaches often are helpful in the short run, but for many people with persistent pain, they don't provide the total answer. Many times medications have side effects and people use them inconsistently, or don't use them at all.

Q. What evidence do we have that non-drug approaches are effective?

A. One area where the research really stands out is the headache literature. Studies of both migraine and muscle contraction headaches show that behavioral methods such as relaxation and biofeedback can be quite effective in helping people control their pain and reducing their pain medication intake. Another area is low back pain. More recently, there's been work on arthritis, sickle cell disease, cancer, and other pain conditions.

Q. What kinds of non-drug approaches work?

A. They fall into three broad categories: relaxation training, cognitive/behavioral techniques, and biofeedback.

One of the more widely used techniques is progressive muscle relaxation. People are taught to slowly tense and relax major muscle groups, typically starting with their feet and progressing up through their trunk, arms, and head. Gradually you can learn to pinpoint signs of tension and get very skilled at just letting it go. It's probably one of the most effective pain control methods we have.

Q. And the cognitive/behavioral techniques?

A. Most cognitive techniques help people divert attention from the pain. Using guided imagery, for example, a therapist will have people imagine themselves in a pleasant scene, telling them: "You can hear the gulls, you can taste the salt on your lips, you can feel the warmth of the sand." You try to get them very involved in the entire experience. Other cognitive strategies challenge how people think about pain. If you are saying things like "I'm worthless," or "There's no hope for me," or "No one really cares," it probably is contributing to your distress and pain.

Behavioral techniques are used to alter people's routines. "Activity-rest cycling," for example, teaches people to pace their activity. So, rather than attempting to do all their housework in one day, people set up a daily schedule, with periods of activity alternating with rest breaks. They gradually increase the overall amount they are able to do each day, yet don't experience the peaks of painfulness they did before.

Q. How does biofeedback work?

A. Biofeedback techniques use monitoring devices to give patients physiological information about their bodies. An electromyograph, for example, can help you recognize and control a muscle spasm that causes recurrent neck pain. If you look at the research, however, it appears that part of the effect is related to the cognitive changes that occur. As you start to control that muscle tension, you begin to believe you can control your body. That sense of mastery explains outcomes better in many cases than the actual physiological changes.

Q. What else is important to pain control?

A. Self-efficacy is very important. It's the belief that you have the capability to engage in behavior that will change your response to pain. You can have self-efficacy by telling yourself you can control severe pain. Or you might have self-efficacy by insisting, "Even in the face of pain, I can put on my clothes and work a couple of hours." Research suggests that among people having similar degrees of physical damage, those with higher levels of self-efficacy will have a lot less pain.

Q. Does one technique work better for a certain kind of pain than another?

A. The results are not that consistent, so it is hard to say. What seems to work best is a program that combines a "menu" of skills. If you come to me with a persistent back problem, I will train you in six to 12 different coping strategies. People come with a limited menu: "I rest in bed, I take pain medication, I try to distract myself." We try to give them many more options, give them control.

Q. What other questions do you hope to answer in future pain research?

A. Two areas are very important. One is the benefit of early intervention. Is it true that the longer you have pain, the more entrenched you are going to be in your ways of dealing with it? The other is the question of matching treatment to the unique profile of the patient. I think when we can do that, we can streamline the treatments.

Interview: 'Pain Is Always Real'

Dennis C. Turk, PhD, is John and Emma Bonica Professor of Anesthesiology and Pain Research at the University of Washington in Seattle. Dr. Turk's research has explored chronic pain related to migraine, fibromyalgia, and pain in facial muscle and joint (temporomandibular joint- TMJ) disorders.

Q. Everyone believes they know what pain is, but how does science define it?

A. The International Association for the Study of Pain defines it as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage." The key thing is that pain is both sensory and emotional. It's not just a physical phenomenon.

You can have pain in the absence of physical pathology, which is true in the case of 85 percent of people with back pain and 95 percent of people who have headaches. As a clinician, I know that pain is subjective, that each individual interprets it for himself or herself. Pain is always real to the individual, so there's no way you can say it's "psychological" or not real. It's basically what the patient tells you.

We have to make a distinction between simple sensory information, such as the prick of a pin, and the more complex perception of pain that results when sensory information is filtered through an individual's experience, mood, or expectations. Two individuals who experience the same amount of noxious stimulation may interpret it very differently depending on a host of psychological factors.

Q. How do those psychological factors affect our perceptions of pain?

A. The most convincing explanation is the "gate control" theory that dates back to the 1960s. Ronald Melzack (PhD) and Patrick Wall (MD) proposed that sensory information coming from the body's periphery may be transmitted through the spinal cord to the brain directly. As the result of certain emotions or other cognitive factors, however, the brain may send a signal down the spinal cord that "closes a gate" and prevents that information from ever getting into sensory awareness. People have modified the original theory, but the general conceptual model holds to this day. The anatomy, the physiology, the neurochemistry of pain - those we're still wrestling with.

Q. If emotions and other cognitive factors can mask pain, can they also heighten it?

A. Sure. My favorite example is a study of patients who went to the doctor with a variety of symptoms - but not pain - and were later diagnosed with cancer. Almost immediately, the patients reported pain, even though the sensory input couldn't have been different. They went from being sick to having a potentially terminal disease. Their arousal level went up and it changed their interpretation of that same sensory information.

Q. What else influences our experience of pain?

A. Prior learning experience is a common one. Go out to a playground and watch what happens when a child falls down. I guarantee that the closer he gets to mom, the louder the crying, and the more tears you're going to see. And how mom responds is going to have an impact the next time the child has pain.

Q. Are there any gender differences?

A. Some studies show women have a lower threshold for pain, and some suggest men have a lower threshold. So the field is somewhat split. Most chronic pain conditions, however, are three to seven times more common in women than in men. This includes arthritis, headaches, TMJ disorders, and fibromyalgia. Only cluster headaches and back pain are more common in men.

Q. In your research, you are trying to match different patients to particular treatments. What have you found?

A. We've found that chronic pain patients generally fall into three categories: "Dysfunctional" patients are in severe pain, have a high level of emotional distress, and feel they have little control over their lives. "Interpersonally distressed" patients also have severe pain, but say they get very negative responses from significant people around them. "Adaptive copers" deal much better with their severe pain. They have much less emotional distress and tend to be more active.

In fibromyalgia patients, an aggressive rehabilitation program is most effective for dysfunctional patients but has no impact on the interpersonally distressed. In patients with TMJ disorders, we found that biofeedback and stress management were most effective for the dysfunctional patients, but again not for the interpersonally distressed.

So we have been able to show that an individual who is dysfunctional might need a treatment that's quite different from someone who has interpersonal problems, which might in turn be very different from the treatment you offer someone who is coping pretty well.

Cutting the Cost of Pain

Evidence suggests that cognitive-behavioral techniques can reduce pain patients' use of other medical services and lower their costs.(4)

After participating in a 10-week behavioral medicine program at the Hitchcock Clinic in Nashua, New Hampshire, 109 patients who had head, neck, limb, or chest pain that had lasted more than six months reduced their average visits for medical care from 12 a year to seven during the first year. At a cost of $45 per visit, their first-year savings totaled $24,525. After the $11,000 cost of the program itself, net savings came to $13,525 during the first year, according to Margaret Caudill-Slosberg, MD, PhD, now co-director of the Department of Pain Medicine at Dartmouth Hitchcock Clinic in Manchester, NH, and her colleagues.

Participants in the program learned the physiological causes of pain and practiced relaxation techniques, then learned to pace themselves by alternating rest with activity. During the final sessions, they addressed the way they thought about pain and learned more productive ways to cope with it. Throughout the program they were encouraged to practice relaxation techniques and to keep a daily diary of their pain.

'Unlearning' Pain

One of the first to explore using behavioral techniques on chronic pain patients, Wilbert E. Fordyce, PhD, believes pain frequently results from a series of learned behaviors.(5)

He and his colleagues drew a distinction between "pain" and "pain behavior" - the actions of someone in pain. A person who feels pain, they said, may take medication, receive help from a spouse, or reduce activity with each occurrence. Each positive response tends to reinforce the pain behavior, so that over time the patient may continue to feel pain even after the injury heals.

In the 1960s Fordyce designed an in-patient program that sought to break the connection between pain and the reinforcing responses. Instead of receiving medication whenever they said they were in pain, patients received it at fixed intervals each day, whether they asked for it or not. Physicians, nurses, and spouses were told to praise positive accomplishments and to ignore moans and complaints. Rest was scheduled at the completion of activity, not in response to pain.

After completing the four-week program, patients significantly reduced their reports of pain and use of medication. They also showed significantly greater tolerance for physical exercise and overall activity. Many of the program's principles can be found in outpatient pain programs today.

Pain the World Over

Persistent pain is common among primary care patients worldwide, according to Michael Von Korff, ScD, a senior investigator with the Center for Health Studies, Group Health Cooperative of Puget Sound.

He and colleagues recently surveyed more than 5,400 patients in 14 nations.(6) Over 20 percent had persistent pain, and those who did were more than three times as likely to have depressive or anxiety disorders.

Science isn't yet sure which comes first, the pain or the depression, but Von Korff points out, "If the patients' pain problems improve, their psychological symptoms also improve. If the pain continues, the psychological symptoms remain. That's consistent with the idea that pain is a stressful phenomenon. We have considerable evidence that treating depression in pain patients results in better alleviation of pain symptoms."

Better Than Pills

Extensive research clearly shows that biofeedback (along with relaxation and cognitive-behavioral approaches) is effective in treating tension-type headaches and that the outcomes rival those for drug treatments. Further, the good effects can last several years. The trouble is that no one knows exactly how it works.(1)

In biofeedback, people learn to relax their forehead muscles while using electromyography to monitor muscle tension. In an early study by Frank Andrasik, PhD, of the University of West Florida, and Kenneth Holroyd, PhD, of Ohio University, Athens, some tension headache patients were taught how to reduce forehead muscle tension, some how to increase it, and others how to maintain it. Everyone, however, was told they were learning to reduce tension.

Immediately after treatment, six weeks later, and again three years later, the researchers found no differences among the groups. All had achieved and maintained 50 percent improvement in the frequency and severity of headaches. This, they say, suggests that biofeedback works not entirely because of its tension-lowering abilities or even short-term as a placebo, but because it influences other cognitive and behavioral factors.

"We now know that many things happen during biofeedback," says Andrasik. "Yes, people learn muscle control, but they also become more aware of the headache process - its antecedents, exacerbators, and maintainers. Perhaps, as a result of learning to control their muscles, they become more confident and start to intervene in other ways suggested by the knowledge they've gained about their body and its response to stress and headache situations."

What is not known and is still being researched is exactly how biofeedback and related treatments work and for which patients they work best.

Relaxing Headaches Away

A group of 30 headache patients aged 60-78 who learned relaxation and cognitive/behavioral techniques had fewer headaches, used fewer medicines, and reported fewer symptoms of depression and stress up to four months after completing the program.

From: Mosley, TH, (1995), "Treatment of Tension Headache in the Elderly: A Controlled Evaluation of Relaxation Training and Relaxation Training Combined with Cognitive-Behavior Therapy," Journal of Clinical Geropsychology, 1:175-188.

The Research

1. Andrasik, F, and Holroyd, KA, (1983), "Specific and Nonspecific Effects in the Biofeedback Treatment of Tension Headache: 3-Year Follow-Up," Journal of Consulting and Clinical Psychology, 51: 634-636.
2. Atkinson, JH, (1991), "Prevalence, Onset and Risk of Psychiatric Disorders in Men with Chronic Low Back Pain: A Controlled Study," Pain, 45:111-121.
3. Basler, H-D, et al., (1997), "Incorporation of Cognitive-Behavioral Treatment into the Medical Care of Chronic Low Back Patients: A Controlled Randomized Study in German Pain Treatment Centers," Patient Education and Counseling, 31:113-124.
4. Caudill, M, (1991), "Decreased Clinic Use by Chronic Pain Patients: Response to Behavioral Medicine Intervention," The Clinical Journal of Pain, 7:305-310.
5. Fordyce, WE, (1973), "Operant Conditioning in the Treatment of Chronic Pain," Archives of Physical Medicine and Rehabilitation, 54:399-408.
6. Gureje, O, (July 8, 1998), "Persistent Pain and Well-being: A World Health Organization Study in Primary Care," JAMA, 280:147-151.
7. Holroyd, KA, (1991), "A Comparison of Pharmacological (Amitriptyline HCL) and Nonpharmacological (Cognitive-Behavioral) Therapies for Chronic Tension Headaches," Journal of Consulting and Clinical Psychology, 59:387-393.
8. Jamison, RN, and Virts, KL, (1990), "The Influence of Family Support on Chronic Pain," Behavioral Research and Therapy, 28:283-287.
9. NIH Technology Assessment Panel, (1996), "Integration of Behavioral and Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia," JAMA, 276:313-318.
10. Schappert, SM, (February 1998), "Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 1996," Vital and Health Statistics, Series 13(134): 1-80.

This report was prepared with assistance from:

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American Academy of Nursing
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychological Society
American Psychosomatic Society
American Sociological Association
American Society of Psychiatric Oncology
College on Problems of Drug Dependence
Institute for the Advancement of Social Work Research
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education

The Center for the Advancement of Health, a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

For more information contact:
Petrina Chong Director of Communications
Phone: 202.387.2829
E-mail Petrina Chong

© Copyright 1998, Center for the Advancement of Health