January 1, 2007

Dealing with Chronic Pain: The Mind Body Solution

Hilary Tindle, M.D., M.P.H.
Dr. Hilary Tindle is Assistant Professor of Medicine, University of Pittsburgh School of Medicine.

When medical professionals talk about "persistent" or "chronic pain," they are referring to debilitating, day-in-and-day-out pain that is difficult or impossible to cure. Persistent and chronic pain affects approximately 30% of the United States population; for a significant portion of them, the pain is centered on the back, joints or other part of the musculoskeletal system. While this kind of pain remains a frustrating and difficult-to-treat condition, our understanding of what pain is and how it works has advanced greatly in recent years, leading to innovative and effective treatments. Many of these are so-called "mind body" therapies that aim to help people to control their own pain response.

The bottom line is that the brain controls the perception of pain quite directly, and has a proven ability to moderate or even turn on and off certain forms of pain.

The groundbreaking gate control theory of pain helped explain how psychological factors influence pain perception. Put forward in 1962, gate control theory says that physical pain is not a direct result of an assault from the outside on the pain producing neurons, (as is the case when you bang your elbow or break a leg), but rather the result of interaction between different parts of the brain and nervous system. The bottom line is that the brain controls the perception of pain quite directly, and has a proven ability to moderate or even turn on and off certain forms of pain. In earlier theories of neurochemistry, the role of the brain had not been taken into account; pain was thought to be a sort of one-way "alarm system" that always responded in the same way to the same stimuli.

Also, in accordance with the biopsychosocial model of disease, a late 20th-century alternative to the traditional ("biomedical") model of disease, in which medical conditions are seen as having biological, psychological and sociological aspects, there is now increasing attention on pain as not only a physiologic, but also a psychological phenomenon. This broader understanding of the complex interaction of mind and body has resulted in new approaches to pain treatment.

The Advantages of Mind Body Medicine in Treating Pain
In 1996, the NIH Consensus Panel on the Integration of Behavioral and Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia recommended the use of mind body therapies for chronic pain. Since that time, increasing evidence has supported the use of mind body therapies. In addition, many mind body therapies are relatively inexpensive When used appropriately, mind body therapies are generally safe.19 Finally, to the extent that mind body therapies emphasize self-care, they are economical and result in decreased utilization of the health care system.


Mind Body Medicine
Mind body medicine, as defined by the National Center for Complementary and Alternative Medicine (NCCAM) "focuses on the interactions among the brain, mind, body, and behavior, and the powerful ways in which emotional, mental, social, spiritual, and behavioral factors can directly affect health." Mind body medicine is one of the five major domains of complementary and alternative medicine, and mind body therapies are some of the most commonly used CAM therapies among US adults.

Mind Body Therapies
Mind body therapies are characterized by NCCAM as "techniques designed to enhance the mind's capacity to affect bodily function and symptoms." ) Common examples include (see also Table 1):
  • relaxation techniques such as deep breathing, progressive muscle relaxation and the relaxation response,
  • guided imagery
  • biofeedback
  • hypnosis
  • cognitive behavioral therapy
  • mediation
Meditation is further divided into several sub-types, the two most commonly studied being transcendental meditation, and mindfulness meditation, (mindfulness meditation is also referred to as attentional training or metacognitive awareness). There is substantial overlap between different mind body therapies. For example, many guided imagery exercises begin with progressive muscle relaxation and involve deep breathing and meditation, while various forms of meditation incorporate breathing exercises and imagery. Table 1 does not provide an exhaustive list but rather provides basic information on common mind body therapies.

Table 1.
Description of Common Mind Body Therapies.
Relaxation techniques
Relaxation techniques include a variety of practices intended to effect a state of relaxation or reduced sympathetic arousal. The goal of these therapies is to allow patients to perform self-relaxation at will.

Guided Imagery
Guided imagery involves the process of image generation for the purpose of improving health. There are active styles of guided imagery, where the patient mentally creates the image(s), as well as more passive styles in which the guide describes the images using a script, while the patient listens intently.

Biofeedback utilizes a device to amplify normal physiological processes (e.g., muscle tension) to make them more easily perceptible. Patients then receive feedback regarding their physiologic state (e.g., tension in a given muscle group) and learn to manipulate their own physiology (e.g., decreasing muscle tension), guided by cues.

Similar to passive style guided imagery, described by expert David Spiegel as "a natural state of aroused, attentive focal concentration coupled with a relative suspension of peripheral awareness."66,67 The hypnotic state includes three main components:
  1. absorption (in an object of concentration),
  2. dissociation (from aordinary conscious perception) and
  3. suggestibility.
Cognitive Behavioral Therapy
Cognitive behavioral therapy is composed of cognitive and behavioral techniques that address the role of maladaptive cognitions and behaviors in disease. Cognitive therapy emphasizes correcting negative thinking patterns through a process called cognitive restructuring, while behavioral therapy rewards behaviors that are beneficial.

When used in clinical settings, meditation is the practice of consciously focusing one's attention on inner experience. It may also be described as the self-regulation of attention. Two main forms of meditation interventions that have been extensively studied for health conditions are transcendental meditation, in which practitioners silently repeat a word or phrase (mantra), and mindfulness meditation, which involves non-judgmental attention to internal events such as thoughts, emotions and physical sensations on a moment-to-moment basis. Like other mind body therapies, meditation often brings about a hypometabolic state, or overall slowing down of bodily systems.

While most mind body therapies are considered to be part of complementary and alternative medicine, cognitive behavioral therapy is an example of a mind body therapy that has gone main stream. Like other mind body therapies, cognitive behavioral therapy addresses the associated cognitive and emotional issues that accompany or enhance pain symptoms, such as a person's feelings of helplessness or associated depression.

Chronic pain may lead people to seek out mind body therapies.

Complementary and alternative therapies such as Qi Gong, Tai Chi and yoga share many of the features of mind body therapies (e.g., the use of imagery and breathing techniques) but are not always classified as such. For the purposes of this article, we will focus on the more classical mind body therapies in Table 1. Similarly, prayer also meets the criteria for a mind body therapy and is widely used by U.S. adults for health reasons. However, in research studies of mind body therapies and health, prayer is often considered separately because the characteristics of respondents who pray and the reasons for use of prayer may differ from those of other mind body therapies.

How do People Receive Mind Body Therapies?
Mind body therapies may involve group or one-on-one therapy, but they also lend themselves well to self-care. For example, many forms of relaxation techniques combine practitioner-based instruction, often on video or CD, with a home-study program. There are no hard and fast rules for types of mind body therapies to avoid, because they are generally safe. Therapies such as guided imagery or meditation may not be appropriate for those with untreated psychiatric conditions, (such as uncontrolled depression or active hallucinations), although one recent study safely used a mindfulness-based therapy for people with active depression and anxiety.

Mind Body Therapies Are in Widespread Use
According to three large, nationwide surveys, the use of mind body medicine by U.S. adults is surprisingly common. In 1997, one study surveyed 2,055 individuals and found that 16.3% used relaxation techniques such as meditation or the relaxation response. Chronic pain was the third-most common reason (19.5%) to use mind body therapies and was reported to be "very useful" for that condition by 55% of users.

Chronic pain may lead people to seek out mind body therapies. The 1999 and 2002 National Health Interview Surveys (NHIS) were conducted by the Census Bureau for the National Center for Health Statistics. In 1999, 30,801 U.S. adults were asked if they had persistent joint pain during the past year and if they had used a mind body therapy (including relaxation techniques, guided imagery, hypnosis and biofeedback) during the past year. People with musculoskeletal pain were almost twice as likely as those without pain to use mind body medicine and prayer. The 9% who used mind body medicine represents about 3.5 million U.S. adults.

The Effectiveness of Mind Body Therapies for Musculoskeletal Pain

Back Pain
Back pain is an area where we are beginning to have some data on the effectiveness of alternative therapies for pain. One study of behavioral therapy (such as cognitive behavioral therapy) for chronic low back pain in people ages 18 - 65 was conducted to determine if behavioral therapies were effective, and which therapies were most effective.

The results suggested that there was strong evidence to support respondent therapy (e.g., relaxation techniques or guided imagery) for a medium effect on pain. There was moderate evidence suggesting that progressive relaxation had a large effect on both pain and behavioral outcomes, but only in the short term. Interestingly, there was no evidence that one behavioral therapy was more effective than another for pain-related outcomes.

Breath therapy (a mind body therapy integrating body awareness, breathing, meditation and movement) for treatment of chronic low back pain was about as effective as physical therapy both in the short and in the long term in one study. Mindfulness meditation resulted in significant improvements in pain acceptance and physical function in a study of 37 older adults with chronic low back pain.

Headaches, Arthritis and Other Musculoskeletal Pain
Mind body therapies appear to be effective for some types of headache. Relaxation training, electromyography (EMG) biofeedback (the recoding of muscle activity at rest and while contracting) and a combination of the two therapies reduced the severity of tension headaches by half. Relaxation and biofeedback were as effective as the drug propranolol for the treatment of migraine.

Fibromyalgia is one area where mind body therapies have not been yet shown to be effective, or to have very limited effectiveness.

Several mind body therapies have also been studied for arthritis (both rheumatoid and osteoarthritis). The Arthritis Self Management Program uses cognitive therapy and relaxation techniques. People who used this self-management program had reduced pain and disability, though a study reviewing the overall results of over 20 trials of mind body therapies for rheumatoid arthritis found significant effects in the short-term on pain, functional disability, psychological status and coping with pain, but on follow up only moderate effectiveness for psychological status and coping with pain.

How Mind Body Therapies Treat Pain
The mechanism by which mind body therapies alleviate pain is not well understood, but it may result from their effect of increasing sufferers' sense of self control, which is known to influence how pain is experienced. Similarly, there is emerging evidence that mind body therapies facilitate a sense of empowerment. Mind body therapies may also modify the cognitive and emotional components of pain perception known as pain unpleasantness and pain affect; these are distinct from pain sensation and contribute significantly to suffering. The emotional components of pain often have the effect of magnifying pain severity.

Pain as a Complex Sensory Experience
Pain is not only sensory; it has a very powerful and unpleasant emotional effect. Pain researcher Troels Statehelin Jensen underscores the complexity of pain when he asks, "What is pain: a sensation, an experience, a symptom, or even a disease?"

Where We Are At the Moment
Mind body therapies are generally safe, inexpensive and already used widely by the U.S. public. Despite this, the effectiveness of most mind body therapies for pain has not been well tested and studied. While their effectiveness for musculoskeletal pain appears to be limited to moderate when used alone, when applied in combination with standard therapies, they may be considerably more useful.

Further study is needed to understand more fully how hypnosis and other mind body therapies for pain work in general and in particular. Some experts in the field have argued that the demonstrated effectiveness of many mind body therapies is more or less a "placebo effect." More studies need to be done to determine if this is the case, and to find the brain areas that are more or less active when mind body therapies are applied.

Finally, mind body therapies may be particularly suitable to certain populations, such as the elderly, where there is a higher risk of medication interactions, or in populations who prefer to use alternative therapies. This latter population is substantial, considering that in 2002 about 29 million people used relaxation techniques.

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