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For pain specialists, most of the psychological/mind-body approaches to chronic pain are considered mainstream medicine; for many others in the health professions, and for the public at large, the same therapies might be considered complementary or even alternative. The fact is that the evidence in support of these psychological approaches is very strong and how they are labeled is less important than their acceptance as necessary treatments. These approaches include psychoeducational interventions, cognitive-behavioral therapies, and a variety of other types of psychotherapy.
- Education. Education is an important element of a comprehensive treatment program. Back school programs, for example, especially those conducted in occupational settings, have been found to be effective as part of conservative treatment for chronic low back pain. These group programs provide patients with information about helpful ways of dealing with pain so they can manage it more effectively. (van Tulder, 2000).
- Cognitive-Behavioral Therapy (CBT). CBT seeks to modify the thoughts, attitudes, feelings and behaviors that can contribute to the distress caused by pain. It can include the teaching of coping skills and relaxation techniques. The main assumption of this approach is that pain and disability are not only influenced by physical illness but also by psychological and social factors. CBT has been found to be most useful for non-specific chronic low back pain (van Tulder, 2000).
Many studies have been conducted in order to assess the effectiveness of cognitive-behavioral therapy in the treatment of chronic back pain. According to the 1996 National Institutes of Health report on the integration of cognitive-behavioral therapy into the treatment for low back pain, there is moderate evidence for the usefulness of CBT in chronic pain (NIH, 1996).
- Biofeedback. Biofeedback for chronic low back pain has undergone much research over the years. There is considerable support for the position that biofeedback training can be useful for chronic back pain, although the reasons why it works are still unclear. The underlying assumption is that pain is related to sustained muscle contraction, increased muscle activity or muscle irritability (the slow and incomplete relaxation of muscles after use) as mediated through the nervous system. EMG biofeedback treatment procedures have been used to teach voluntary muscle relaxation as well as to decrease muscle hyperactivity and irritability. This can help the patient learn to reduce muscle contraction and supports the efficient and posturally correct use of muscles in order to decrease pain (Middaugh, 1987).
One interesting study attempted to understand the underlying mechanisms that account for its success in chronic low back pain patients. The average improvement rate in pain intensity was 63% in this study. While researchers initially thought that its effectiveness would be related to the amount of voluntary control over muscle activity that patients had gained, this did not prove to be the case. Instead researchers speculated that biofeedback may be effective for this condition because it leads to a decrease in pain sensitivity and an increase in tolerance to previously painful experiences. It was felt that this reduction in the experienced strength of painful stimuli might decrease both fear and pain in chronic low back pain patients (Biedermann, 1996).
- Hypnosis. According to current research, hypnosis is most effective for the treatment of chronic musculoskeletal pain when used by highly suggestible people to increase their pain tolerance and decrease pain sensation.
In several small studies, hypnosis was found to be effective as part of the overall treatment for chronic low back pain. In one study patients reported chronic pain reduction, increased psychological well being and increased sleep quality. It was recommended that hypnosis and other psychological interventions be introduced as early as possible as adjuncts to medical treatment (Crawford, 1998).
In another study comparing hypnosis to relaxation in the management of chronic low back pain, both groups showed significant reductions in the average level of pain, the level of depression, and the length of pain. Hypnosis was more effective than a standard relaxation technique in reducing the time to sleep onset and in physicians' rating of patients' medication use as less problematic after treatment (McCauley, 1983).
- Imagery. Imagery involves the use of the imagination for healing. Images involving all or part of the sensory mechanisms (sight, sound, taste, smell and kinesthetic bodily sensations) can be directed to specific healing, life goals or for managing overall stress and anxiety. Imagery can enhance the effectiveness of other treatments and may be used to help people cope with a health condition, regain a sense of control, and as motivation in helping people initiate positive changes in their life-style and health practices.
In scientific research, imagery has been shown to increase skin temperature, relax muscles at trigger point sites and decrease pressure pain sensitivity (Albright, 1990). In a review of 46 studies of guided imagery interventions for the management of psychological and physical symptoms, preliminary evidence was found for its effectiveness in the management of stress, anxiety, depression, and pain, among other factors (Eller, 1999).
More controlled scientific research is recommended in order to further evaluate its effectiveness and to understand more clearly how it works, which individuals might benefit the most, and how it is best administered for maximal effect, including for low back pain.
- Relaxation/meditation. Relaxation is often a part of combined medical and behavioral programs for chronic low back pain. In studies it has shown effectiveness for decreasing pain, muscular tension, medication use and depression, and increasing activity and relaxation, especially when combined with other cognitive-behavioral strategies (Linton, 1984) (Stuckey, 1988
Meditation is known to bring about a healthy state of relaxation by decreasing the response of the sympathetic nervous system and thus reducing heart rate, respiration rate, plasma cortisol levels and increasing EEG alpha brain waves (Luskin, 2000). There are two basic approaches to meditation, both of which serve to calm the mind: focusing the attention on a specific object or concept or keeping moment to moment awareness of the flow of experience by observing rather than reacting to it.
Several studies have investigated the effect of meditation on chronic pain from a variety of causes. Positive results include a higher pain tolerance, decreased anxiety and depression, increased activity levels, decreased use of pain-related medications, and increased levels of self-esteem (Mills, 1981, Kabat-Zinn, 1985).
More controlled scientific studies are needed on the specific use of meditation for chronic back pain. However, existing data and results from programs that use meditation as part of an integrated health program have shown promising results. There is a reason it has been integral to most all spiritual systems' approaches to health and healing for millennia.
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