Friday, August 19, 2011

IASP e-Newsletter - Chronic Pain: An Integrated Biobehavioral Approach By Herta Flor and Dennis C. Turk

This month, IASP Press releases its latest book, Chronic Pain: An Integrated Biobehavioral Approach, written by Herta Flor, PhD, of the Central Institute of Mental Health, University of Heidelberg, Germany, and Dennis C. Turk, PhD, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA. We asked the authors to give us a glimpse inside the book:

Q: The book describes how cognitive and behavioral factors play a major role in chronic pain. Can you give an example (from your own clinical experience, perhaps) that shows how powerful memories or expectations of pain can be?

One of our patients, a 48-year-old woman, came to an assessment interview with her husband. As she slowly walked into the room, her husband was carrying her purse. He helped her to sit down, which was accomplished with some difficulty and posturing. The husband was extremely solicitous, encouraging her to move carefully and not "overdo it." He explained that he was carrying her purse because the weight added to her pain. The husband's behavior demonstrated the role of reinforcement contingencies on the patient's behaviors and became an important target of treatment because we did not want him to undermine his wife's plan to increase her activity, which would most likely be accompanied by some behaviors that conveyed distress.

Q: Is this book intended to be a handbook for clinical psychologists? Will other clinicians—physicians or nurses, for example—be able to use the assessment and treatment protocols you provide?

The biobehavioral perspective and many of the assessment methods and treatment principles that we describe can be used by the entire range of health care providers, not just clinical psychologists. Some of the treatment techniques can be used by most clinicians. Specific treatments such as biofeedback or cognitive restructuring, however, do require specialized knowledge and training and would best be provided by clinicians with appropriate behavioral health care training.

Q: Why is it that patients with low back pain, for example, are coming to psychological treatment only after a series of medical treatments have failed?

Several factors contribute to such excessive delays. Health care providers as well as patients tend to believe in what we call an acute illness model, in which the presence of symptoms is an indication of underlying physical pathology. The assumption is that once the cause of the symptoms is identified, it should be removed, or if that is not possible, then treatments should be provided—whether pharmacological or surgical—that cut or block the "pain signals." If pain persists, then a quest begins to find THE treatment that will resolve the problem. Unfortunately, there may not be any treatment that can eliminate all of the pain, yet the futile search drags on and may contribute to even greater disability.

Q: According to the evidence base, would it be better to apply treatments such as relaxation training or operant group therapy earlier on, rather than as a last resort?

Absolutely! The longer the patient continues to seek treatment, going from provider to provider and from treatment to treatment, the greater the chance for excessive disability and depressed mood. In an early study, the pioneer of behavioral pain treatment, Bill Fordyce, and his colleagues once showed that a simple limitation of bedrest, along with taking medication not "as needed" but on a fixed schedule, greatly reduces the chronicity of acute back pain.

Q: What's your philosophy on tailoring a treatment to the individual patient? How can you tell whether behavioral (operant) therapy, cognitive-behavioral therapy, biofeedback, or relaxation training will be most effective?

We strongly advocate customizing treatments to individual patient needs and characteristics. Having said that, we are only just beginning to learn about how to match treatments to individual patients. This is an important area of future research. It is also important to monitor progress and modify treatments depending on how well the patient is accomplishing the goals of pain reduction, functional improvement, and improvement in overall health-related quality of life.

Q: What are the most promising new treatment methods based on new insights about learning-related maladaptive plastic reorganization of the brain?

Recent treatment methods that focus on the reversal of brain changes related to chronic pain attempt to eliminate pain memory traces from the brain. This can be accomplished by a number of methods, including pain extinction training, which focuses on reducing pain-related behaviors and increasing positive pain-incompatible behaviors. Other promising methods include cognitive interventions that divert attention from the pain and treatments such as mirror therapy or virtual reality training that provide feedback of an intact body to the brain. Various types of biofeedback may achieve similar results. They all have the goal of altering maladaptive brain changes by providing "normal feedback" to the brain, which helps to target maladaptive changes and replace them with non-pain-related positive associations.

Q: Are psychological therapies appropriate or feasible in the low-resource setting? What about in war-torn parts of the world?

Not only are they feasible, psychological methods may be the best alternatives for use when sophisticated and expensive interventions are not available. We do need to develop more efficient ways to deliver these treatments, or at least components of these treatments, more efficiently and effectively. Developing technologies from the Internet and smart phones with lower costs are making these approaches more reasonable. A number of studies are beginning to demonstrate potential creative and innovative uses of these technological advances. We expect to see them used much more in the next few years.

Q: This book promises to be very accessible and useful for psychologists as well as pain clinicians. Any final comments?

We have provided a detailed and comprehensive rationale for the biobehavioral approach to the management of patients with chronic pain. We show how assessment should follow this model and guide treatment. We believe this integrated approach will lead to the best outcomes for the majority of patients. We provide detailed clinical protocols for assessment and treatment, and we also include our clinical insights from over 60 (combined) years of experience working in the field of pain management. We present the empirical and evidence-based background for this approach. Of course, we also acknowledge the limitations in our current knowledge. We realize that additional research will surely lead to refinements in assessment methods and treatment methods; however, we believe the perspective on patients that we have presented will continue to guide the evolution of successful outcomes in the future.