Psychological Approaches to Pain Management

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Pain Management

What is Pain Management?

Pain management is an area of modern medicine which utilises the multi-disciplinary team to help ease the pain and suffering of patients living with long-term pain to improve their quality of life. Medicine is usually the first port of call to manage pain, however, when pain in not responsive to medication, or resistant to treatment, or persists after healing has occurred and an exact cause of the pain has not been found alternative treatment or a combined approach can be used. 

The alternative to medicine or combined approaches to pain management are broad and each of which can be based upon different paradigms of understanding pain. The different approaches come from the wide range of healthcare professionals unique treatments towards pain management, not only limited to Mental-Health or Psychiatrists but can include Physiotherapists, Occupational Therapists, Nurse Practitioners, Medics, Nuse Specialists and Massage Therapists.

Different Types of Management/Treatment

The techniques these professionals use can be and not limited to: (This list is not exhaustive and please add more!)

• Patient Education
• Operant Conditioning Approaches
• Cognitive Behavioural Therapy
• Distraction
• Classical Conditioning Approaches
• Social Support Methods
• Relaxation Methods
• Acceptance and Commitment Therapy
• Hypnosis
• Biofeedback
  

What is the Psychological Approach to Pain Management

As well as the neural interactions and links the brain goes through when a person is in pain, there are multiple layers of complex abstract thoughts and feelings a person goes through which culminates how much pain a person feels and how they deal with pain. Their cognitive constructs, behavioural constructs and environmental influences are all intertwined in a complex web of individuality which need to be considered and incorporated into any treatments for them to be effective and are found out during an initial assessment. It is these personal, individual and holistic areas which make it a pscyhological approach sitting within the biopsychosocial model of patient treatment.

The Difference Between Acute and Chronic Pain

Previously pain used to fit into the biomedical model with a reductionist view (i.e Pain was derived from a specific physical pathology) and catagorically dismissed social, psychological and behavioural mechanisms as irrelevent and of no importance to understanding pain. This is grossly oversimplified and now we understand that pain is more than a simple response to a physical stimulus and in recent years several models of pain models have been created to explain and develop our understanding of pain. 

Acute pain can be defined as:

the normal, predicted physiological response to an adverse chemical, thermal or mechanical stimulus… associated with surgery, trauma and acute illness.

As the definition states, acute pain is a predicted response to a stimulus. If you have had surgery to repair and fractured hip, there will be a usual pattern of pain and rate of recovery based upon the patients demographics. However to take this definition further one could say that pain is:

a complex perceptual phenomenon that involves a number of dimensions, including, but not limiting to, intensity, quality, time course and personal meaning. 

This definition incorporates the modern thinking of pain, not just acute pain but pain as a whole. The first definition is still true in the fact that acute pain is predictable and does follow a pattern but the second quote reflects the more complex nature of pain and is a reminder that pain should not be thought of as the same for all patients. It becomes even more complex when pain changes from the predictable pattern of duration and nature to an unpredictable and unexplained phenomenon that exceeds the usual duration of healing and becomes chronic.

Chronic pain can be defined as when:

pain persists for 3 months or longer, it is considered chronic and, while not necessarily maladaptive, often leads to physical decline, limited functional ability and emotional distress.

Although this quote only gives the time duration there are many others which consider chronic pain to be unexplained, irregular, unique and incredibly dependent upon the individuals personal beliefs and coping strategies and it is this chronic pain which is subject to a large amount of study and psychological management strategies. This is in part due to the impact it has on healthcare systems worldwide, for example common chronic pain problems cost the U.S.A US$60 billion per year and in the UK somewhere in the region of £5 billion per year and there are millions of lost work days throughout the world subsequently it is a crucial area in which treatment and management is continually being developed.

Key Models to Understand Pain

Pain Gate Theory

The pain gate theory (PGT) was first proposed in 1965 by Melzack and Wall, and is a commonly used explanation of pain transmission, it was one of the first models to incorporate biological and psychological mechanisms within the same model. Thinking of pain theory in this way is very simplified and may not be suitable in some contexts, however when discussing pain with patients this description can be very useful.

In order to understand the PGT, the sensory nerves need to be explained. At its most simple explanation there are 3 types of sensory nerves involved of transmission of noxious stimuli.

1. α-Beta fibres - Large diameter and myelinated - Sharp pain - Faster
2. α-Delta fibres - Small diameter and myelinated - Vibration and light touch - Fast
3. C fibres - Small diameter and un-myelinated - Throbbing or burning - Slow

The size of the fibres is an important consideration as the bigger a nerve is the quicker the conduction, additionally conduction speed is also increased by the presence of a myelin sheath, subsequently large myelinated nerves are very efficient at conduction. This means that α-Beta fibres are the quickest of the 3 types followed by α-Delta fibres and finally C fibres. 

The interplay between these nerves is important but it is not the whole story, as you can see only two of these nerves are pain receptors α-Delta fibres are purely sensory in terms of touch. All of these nerves synapse onto projection cells which travel up the spinothalamic tract of the CNS to the brain where they go via the thalamus to the somatosensory cortex, the limbic system and other areas. In the spinal cord there are also inhibitory interneurons which act as the 'gate keeper'. When there is no sensation from the nerves the inhibitory interneurons stop signals travelling up the spinal cord as there is no important information needing to reach the brain so the gate is 'closed'. When the smaller fibres are stimulated the inhibitory interneurons do not act, so the gate is 'open' and pain is sensed. When the larger α-Delta fibres are stimulated they reach the inhibitory interneurons faster and, as larger fibres inhibit the interneuron from working, 'close' the gate. This is why after you have stubbed your toe, or bumped your head, rubbing it helps as you are stimulating the α-Delta fibres which close the gate. 

In addition to the idea of the different nerve types influencing whether or not the gate is open or not, mood and cognition also influence the status of the gate in a "Top Down" fashion influencing the perception of the pain further.  

For an alternate explanation: Pain Gate Theory Article Science Daily Physiotherapy Journal Article: Pain Theory & Physiotherapy

This model was the first to challenge the long held assumptions of a biomedical approach to managing pain, and advancements in understanding of anatomy, neurology and cognition have led to models fully incorporating the biopsychosocial model contemplating the reciprocal nature of mood and cognition on pain and vice versa. 

Biopsychosocial Models of Pain

There are a large number of different models to contemplate and only a few will be discussed here, links and references to others will be provided here. 

The biopsychosocial approach holds that the experience of pain is determined by the interaction between biological, psychological (e.g. cognition, behaviour, mood) and social (e.g. cultural) factors.

This approach incorporates the view that perception of pain is influenced by the combination and interaction of biological, psychological and social factors (all of which can be broken down into different sub-categories). Not all models incorporate all three aspects, some focus mainly on behaviour such as Fordyce et al. It is important to consider that not one model is correct but that different models have strengths and weaknesses and suit patients on an individual basis.

As with all models there is some difference on opinion with certain respects, such as which aspect has the greatest influence on pain perception, however biopsychosocial models all agree on the central focus; the focus is not on a disease but on the behaviour around the disease, feeding and fueling beliefs and attitude which perpetuates a problem. The central argument, as stated, is illness behaviour which implies that individuals may differ in perception of an response to bodily sensations and changes (e.g. pain, nausea, heart palpitations), and that these differences can be understood in the context of psychological and social processes.

Assessment Considerations

According to Asmundson et al an in-depth and thorough assessment is required to discover the root cause of psychological aspects of pain and person specific influence which will be integral to know when it comes to selection and direction of treatment. There are a number of areas which need to be covered in the assessment but arguably the most important is the consideration of the pain intensity, severity and irritability along with location, distribution and duration. This is a useful marker for measuring pain and as a tool for differential diagnosis but asking how the patient is affected functionally is an important consideration but also cruical to confirming the subjective reports of the patient. Tools such as the Visual Analogue Scale, 4-Item Pain Intensity Measure or the Short-form McGill Pain Questionnaire. Another area of consideration are the various "empirically supported and theoretically relevant cognitive, behavioural and environment influences" which are person specific and can aid in assessment and conclusions relevant for treatment.

The idea of looking out for cognitive, behavioural and environmental influences ties with the concept of the Flag System which includes Yellow, Blue, Orange, Black and Red flags as universal indicators of how different psychological, and clinical signs can influence treatment outcomes. Head over to the page to find out more about it.

Recent Related Research (from Pubmed)

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Additional Key Resources

Additional Biopsychosocial Models of Understanding Pain

The Behavioural Management of Chronic Pain by Fordyce

A New Clinical Model for the Treatment of Low Back Pain. by Waddell.

Pain and Behavioural Medicine: A Cognitive-Behavioural Perspective. By Turk

Other Physio-Pedia Pages

Pain Course Pain Assessment Cognitive Behavioural Therapy All Physio-Pedia pages with PAIN as their category.