Author(s): Derick Davis, MD, Chiamaka Sonubi, MD, Travis Coats, MD, MPH
Originally published: September 20, 2014 Last updated: June 22, 2023
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Disease/ Disorder

See Part 1.

Essentials of Assessment

See Part 1.

Rehabilitation Management and Treatments

Introduction

Physical or biological disorders that culminate in chronic pain, illness, and disability from loss of mobility, function, and/or independence are commonly encountered in virtually all subspecialties of physical medicine and rehabilitation practice.  Many individuals afflicted with a devastating illness or injury endure an adjustment period as a reaction to the stressful life event; some may go through a grieving process from loss of the “old self”.  Most recover over time and ultimately adjust positively to their disability and impairment(s) and lead meaningful and fulfilling lives. A significant number, however, remain chronically burdened by persistent psychological distress or psychiatric illness, amplified by their inability to cope with pain and/or disability.

In the rehabilitation patient population, chronic pain is a major source of suffering and a potential barrier to rehabilitation and adaptation. In chronic pain syndromes, when pain becomes more disabling than the underlying biologic injury, or when pain is the sole or primary complaint in the absence of significant biologic injury, chronic pain may be conceived as a disease in its own right.

As defined by the IASP (The International Association for the Study of Pain), pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. Chronic pain is further classified by IASP as, “pain that persists or recurs for more than 3 months.” While biologically serving an aversive and adaptive purpose that is vital to individual (and species) survival, pain can also develop and endure in the absence of apparent biologic injury or can exceed the degree of biologic injury (as in complex regional pain syndrome). Moreover, pain from biologic injury can persist beyond the period of expected tissue healing and, in such cases, may no longer serve a useful purpose. 

Pain is a complex perceptual phenomenon in addition to a sensory experience that can be influenced by neurobiological, psychological, socio-cultural factors, and learned cognitive and behavioral responses. Viewing pain from a perceptual, and not exclusively a biologic, narrative allows for a greater recognition of the cognitive, affective, behavioral, and social components of the pain experience. Once concrete negative beliefs and expectations about pain are formed, they tend to drive maladaptive behaviors and thoughts which can become challenging to extinguish.  Individuals who have little or no control over their pain are more likely to catastrophize about their pain and suffering and develop aversive behaviors to minimize or avoid exposure to activities and situations that trigger or amplify their pain. Studies have demonstrated that a patient’s control beliefs can have an impact in pain intensity following a multidisciplinary treatment program. Meaning, patients who see themselves as having control over their health, have been shown to have greater reduction in pain intensity, reduction in depressive symptoms, increased resilience and improved physical functioning compared with patients who believe medical experts or fate are in control of their health.1

In order to effectively manage complex syndromes as chronic pain, it is imperative to not become fixated on finding biomedical causes of pain, but to also take into account the contributions of psychological and social elements. The biopsychosocial model serves as a guide to better understand how disease and illness is affected from the molecular to the societal level. With this philosophy, all three dimensions (bio, psycho, and social) are viewed to contribute equally to the patient’s pain and disease experience. 

Psychological therapeutic strategies are geared towards helping patients achieve a greater sense of control over their pain or disabilities by eliminating maladaptive physical and psychological responses and replacing them with positive coping mechanisms and constructive strategies. Early intervention can help individuals learn to adapt and cope, and potentially prevents maladaptation that can become pervasive over time.

Concurrent treatment of pain and underlying psychiatric condition(s) can be achieved in individuals with untreated or under-treated psychiatric comorbidities including active substance abuse.  Antidepressants can be selected to alleviate underlying depression and treat the underlying pain complaints as well. Similarly, cognitive behavioral approaches shown to be helpful in pain may also be effective for anxiety, depression, PTSD and substance use disorders. Aggressively addressing both the psychiatric illness and chronic pain is necessary for optimal recovery.  Otherwise a vicious cycle can ensue wherein poorly treated pain may exacerbate the underlying psychiatric condition and, conversely, the untreated or under-treated psychiatric condition may exacerbate pain, disability and maladaptation.2

Similar to other forms of therapies, psychological therapies are most successful when patients demonstrate interest, motivation, and compliance, and when a strong therapeutic alliance is developed between the patient and the provider.

Psychotherapy for chronic pain primarily targets improvements in physical, emotional, social, and occupational functioning (improvements in pain-interference) rather than focusing on resolution of pain. However, psychological therapies vary in their scope, duration, and goals, and thus show distinct patterns of treatment efficacy.3 Individuals respond variably to specific psychological interventions and do not conform to a “one size fits all” treatment paradigm. It has yet to be determined which specific interaction is best suited for which individual.4 Psychotherapeutic treatments are ideally combined with anti-nociceptive therapies and physical rehabilitation as part of an integrated, interdisciplinary, multidimensional paradigm. 

Available or current treatment guidelines

Most psychological interventions, including structured therapies, can be successfully conducted in individual or group settings. Telehealth and other internet-based patient-therapist interventions have also been employed with success.

Cognitive behavioral therapy (CBT)

CBT is the most widely employed and thoroughly researched psychotherapeutic approach that has evidence-based efficacy for a number of mental and behavioral disorders, including many chronic pain conditions, depression, anxiety, and PTSD. CBT involves a structured, time-limited approach that focuses on the inextricable link between cognition (thoughts), emotions (feelings), and behaviors (actions) which interact to create maladaptation, catastrophizing, and global dysfunction.5

CBT employs a “problem-focused” and “action-oriented” approach. The aim of cognitive behavioral therapy is to extinguish maladaptive thoughts, beliefs, and behaviors that lead to increased pain, emotional distress, withdrawal from activities, and social isolation. CBT aims to replace them with positive and rewarding alternatives, as well as foster acquisition of new coping skills and techniques.  The individual is first taught to identify and record maladaptive thoughts, beliefs and behaviors that induce stress, anxiety, sadness, anger, and increased pain, which are then systematically replaced with balanced and productive ones.

Other essential components of CBT include

  • Stress and anger management
  • Relaxation strategies
  • Identification and modification of adverse emotional and thought responses to perceived or real antagonistic behaviors of family, friends and other contacts that perpetuate maladaptive behaviors.

Treatment includes assertiveness training and improvement in communication skills. Distraction techniques are also employed as they can be an effective tool for exerting control over pain. CBT may also involve maintaining a pain diary.

CBT is generally conducted in a 3-step skill-building progression with each phase representing attainment of a higher level of skill development, understanding, application, functioning, motivation, and resiliency.

  • Psychoeducational phase: During this patient education phase, concepts like the mind-body connection and pain-stress cycle, and their relationship to perpetuation of pain and suffering, are introduced to the individual. The patient is then encouraged and assisted in identifying and understanding the thoughts, beliefs, behaviors, and attitudes that amplify pain, stress, anger, disability, and feelings of hopelessness, helplessness, and despair, as well as those that mitigate or extinguish these aberrant thoughts and emotions, and, consequently, the behaviors that accompany them.
  • Skills-building phase: During this phase, individuals develop cognitive and behavioral strategies to identify aberrant thoughts, emotions, and behaviors to counteract them with positive and rewarding coping alternatives that will help them regain self-control and self-adaptation.  Coping strategies, such as stress management, anger management, assertiveness training, relaxation training, and pacing may be utilized. Other psychotherapeutic tools such as meditation, relaxation techniques, self-hypnosis, biofeedback, as well as Yoga and Tai-Chi have also been introduced during this phase of CBT with favorable outcomes.
  • Application Phase: The final step in CBT involves the individual applying the techniques and skills developed during the first two phases to create an enduring maintenance program that is easily integrated into daily life. 

Cognitive functional therapy (CFT)

This method differs from CBT in that instead of focusing on improving coping mechanisms of pain control from a mental approach, CFT directly highlights maladaptive behavioral patterns and challenges the patient to change them in a stepwise functional manner. This allows for CFT to be customized to each individual’s needs to help them overcome the barriers that are preventing their overall functional status improvement. 

With the CFT method, an individual undergoes a detailed interview process to identify thought patterns and behavioral responses to pain. This allows clinicians to provide tools to effectively self-manage their pain with a program that is personalized to their clinical presentation and context. Subsequently, three fundamental components of the intervention are implemented. 

  • “Making sense of pain” encourages the individual to self-reflect and frame their pain into a story. Clinicians are then able to assist in identifying contextual factors and unhelpful behaviors that may be barriers to progress. 
  • “Exposure with control” involves a behavioral assessment targeted to the functional tasks mentioned during the interview as being painful, feared or avoided which forms the basis of a series of guided behavioral experiments that seek to target the sympathetic responses to pain, safety behaviors, and functional tasks while gradually exposing individuals to their feared, avoided, or painful tasks. Ultimately, this stage is targeted to remove fear-avoidance beliefs and behaviors. 
  • “Lifestyle change” is the ultimate goal of CFT therapy. Exercise, normalization of movement, and avoidance of sedentary behaviors are integrated into daily life as pain is better understood and managed.6,7

Studies have shown superior long-term efficacy compared to manual therapy, physical therapist-led exercises, and pharmacological interventions. These studies typically focus on outcomes such as functional and lifestyle improvement as opposed to the “pain scores” methodology of rating pain. Qualitative data has shown that people benefiting from CFT report that they have a changed mindset regarding the multidimensional understanding of their pain and enhanced self-awareness about achieving functional and lifestyle goals.7

Relaxation techniques

Relaxation techniques aim to target the activation of the parasympathetic nervous system. In doing so, these strategies down-regulate the stress response and sympathetic nervous system. Relaxation is effective in treating chronic pain because psychological stress and physical tension both perpetuate and exacerbate chronic pain. Although most studies suggest that relaxation techniques play a valuable role in the management of pain, it is still unclear if they are more beneficial than other non-pharmacological therapies. Nonetheless, it is the frequent application of relaxation practices over a period of time that makes them most effective.8  These techniques are relatively easy to implement, not expensive, and not associated with adverse effects and can be a part of clinician-directed psychotherapy (CBT) or used as a stand-alone self-guided therapy. 

Progressive Muscle Relaxation:  Patients are instructed to simultaneously tense, then relax individual muscle groups to gain the ability to selectively relax stressed muscles.

Focused Breathing: Patients are taught to focus on breathing with actively controlled inspiration and expiration, which may help reduce stress, anxiety, sympathetic overactivity and pain and stress-related hyperventilation. Focused breathing is also an integral part of other mind-body therapies such as Tai Chi, Qi Gong, and Yoga

Autogenic Relaxation: This is a technique that involves 6 standard exercises that teach the body to respond to verbal commands telling the body to relax, control breathing, heart rate and body temperature. 

Guided Imagery: This technique can provide additional benefits after the individual has learned to achieve a relaxed state, by enhancing an overall sense of well-being. Enhancement of coping skills can be achieved by employing imagery for desensitization by conjuring stressful situations while attempting to maintain a state of relaxation. Guided imagery is based on the idea that the mind and body are intertwined and capable of bidirectional interactions. 

Biofeedback: Biofeedback is a tool, not a specific treatment, employed to measure the progress and efficacy of other self-regulating mind-body therapies.  It involves the gathering of real-time feedback of one or more physiological responses. Feedback modalities include skin temperature, muscle tension (surface electromyography), heart rate variability, electroencephalography, breathing, skin temperature and sudomotor responses.

Mindfulness based cognitive therapy (Mbct) and Mindfulness based stress reduction (Mbsr)

Variations of self-regulated meditative techniques have been adapted as psychological approaches to treating pain as well as stress, anxiety, and depression. Meditation approaches may be concentration-focused or mindfulness-focused. Concentrative meditation may be challenging in the presence of nagging pain which is constantly demanding the individual’s undivided attention.

Probably the best-known and most widely employed mindfulness meditative treatment for chronic pain is Mindfulness Based Stress Reduction (MBSR). Professor Jon Kabat-Zinn, who developed the practice in the 1970s, defined mindfulness as “moment-to-moment non-judgmental awareness” of thoughts, emotions, and sensations.  Mindfulness-based cognitive therapy is a modified form of cognitive therapy that uses mindfulness strategies to extinguish negative thought patterns. It may also be helpful for treating generalized anxiety, substance use disorders, and improving symptoms of mood disorders.

Mindfulness-based interventions endeavor to decouple the sensory aspects of pain from the evaluative and emotional components and enable intrusion of somatic and cognitive sensations without becoming entangled by them.9 Through mindful awareness and meditation, distressful thoughts can be viewed as discrete events rather than sequelae of an underlying problem that demands immediate attention and cultivates aberrant responses. The individual is taught to recognize these thoughts as something familiar, which may help to ameliorate emotional or maladaptive behavioral responses.3

Typically, MBSR interventions are structured as 2-hour sessions occurring weekly over 10 weeks. These sessions serve to develop awareness of the body, breathing, physical and intrapsychic sensations, and development of mindful counter-responses.9 MBSR promotes mindfulness primarily through daily meditation, which is a requisite component of the treatment.  MBSR primarily serves to increase tolerance for negative emotions, thereby fostering more constructive and adaptive responses to pain.10 MBSR reduces rumination11 and interoception of distressing physical signals,12 and increases mindful awareness11 and pain acceptance.  The mechanisms underlying effective MBSR intervention, similar to in vivo exposure therapy for pain, may induce desensitization to pain. Meditations involve motionless sitting practices that expose participants to painful sensations, in the absence of deleterious consequences.9,10

Adherence rates of MBSR have been found to compare favorably to behavioral pain management techniques.13 Unlike CBT, which identifies thoughts as distorted and in need of change, mindfulness is geared towards a nonjudgmental approach to thoughts as “discrete events” that encourage emotional distance from thoughts.14,10   Since chronic pain signals are challenging to extinguish or ignore, this detachment may extinguish negative individual responses to chronic pain and foster positive alternatives.9

MBSR has efficacy in reducing the severity of medical and psychological symptoms9 and pain intensity.13,15 Additionally, MBSR addresses co-occurring symptoms of depression in individuals with some chronic pain conditions like fibromyalgia16 and enhances the effects of multidisciplinary treatment on disability, anxiety, depression, and catastrophizing.17 More studies are needed to understand the effects of MBSR on functioning, disability, and quality of life as a primary outcome.18

Hypnosis and self-hypnosis

Hypnosis is an attention-focusing procedure in which changes in thoughts, emotions, behavior or perception are suggested directly or indirectly to the patient. Although it has historically been employed as a component of a multimodal treatment program, usually as an adjunct to CBT, there is growing empirically supported evidence for its effectiveness as mainstream structured therapy for chronic pain, anxiety, depression and cognitive and behavioral disorders. Hypnotic analgesia has been shown to be effective in reducing pain and anxiety symptoms in patients with advanced chronic diseases as an adjuvant to analgesic medications and combined with strategies such as CBT.19  However, the magnitude of these effects is variable by condition and across individuals. 

The induction of hypnosis usually begins with suggestions for some form of relaxation, leading to sustained focus, followed by a specific suggestion to alter the individual’s view of the pain or stress experience, which, in turn, helps reduce acquired aberrant protective psychological defense mechanisms (self-judging, monitoring and avoidance).

Post-hypnotic suggestions are often added to extend the duration of benefits experienced during the treatment session to well beyond the hypnotic phase and/or provide post-hypnotic pain tolerance while subsequently engaging in specific pain or stress enhancing activities.

The enduring cost-effective goal of hypnosis is to train the individual in self-hypnosis techniques for long-term management of pain, discomfort, stress, and avoidance behaviors beyond the structured hypnotic treatment sessions with the therapist.

Acceptance and commitment therapy (ACT)

ACT is a psychological intervention that attempts to provide patients with psychological flexibility, that is, increasing one’s ability to be present in the moment and to react in line with personal values. This treatment modality uses 6 processes: acceptance, cognitive defusion, being present, self as context, values, and committed action.20 ACT emphasizes the acceptance, as opposed to avoidance, of negative thoughts or feelings and helps to refocus individuals on their personal goals or values.

ACT shares conceptual similarity with MBSR.  Both promote mindfulness and acceptance of pain but, unlike MBSR, ACT does not utilize daily mindful meditation and instead focuses on identification of the values and goals of the individual, which serve to redirect behavior.21  ACT-based interventions have been shown to improve various aspects of mental health in chronic pain populations, including mental health, quality of life, self-efficacy, and mood.22 

Significant research has been done with this intervention in treating anxiety and depression with effects producing similar outcomes to cognitive behavioral therapy.23  In treating chronic pain, a 2021 meta-analytic review of 12 RCTs suggests ACT is more effective than control settings in improving pain acceptance and functioning.24,25  Evidence, however, is insufficient to say these effects improve quality of life. ACT does not appear to provide an advantage over CBT regarding chronic pain outcomes.24

ACT is most effective for mitigating pain-related anxiety and pain acceptance. It is less effective for mitigating pain intensity and pain interference.

Operant-behavioral therapy (OBT)

Operant-Behavioral therapy is based on the premise that a learned behavioral drive to elude or minimize pain leads individuals to avoid situations that are painful, which only serves to amplify their physical and emotional ailments; this avoidance behavior contributes to the development and maintenance of pain chronicity, deconditioning, depression, and social withdrawal. Operant therapy for chronic pain utilizes reinforcement and punishment contingencies to reduce pain-related behaviors and foster more adaptive behaviors.26 Positive reinforcement increases the probability of the behavior being repeated while punishment aims to extinguish it. Negative reinforcement strengthens a response or behavior by preventing, removing, or avoiding a negative outcome or aversive stimulus. Behavioral therapy for pain has shown positive effects on pain experience, mood, negative cognitive appraisals, and functioning.26

Learning theory postulates that aversive pain signals, which contribute to avoidant behavior, can be passed to neutral stimuli (like physical movement behaviors).4

In vivo exposure therapy aims to extinguish perceived threats, fear, and behavioral avoidance through progressively encouraging engagement in painful behaviors in the absence of catastrophic outcomes; when these behaviors are performed without serious negative consequences, patients may realize that their expectations about the consequences of physical movement and pain are unrealistic.5,27,28 Similar to exposure treatments for phobias and other anxiety disorders, in vivo exposure treatment for fear of pain involves identification and development of a personalized, graduated hierarchy of activities that typically elicit a fearful response, psychoeducation related to pain and fear-avoidance behaviors, and ultimately, slow and systematic exposure to activities related to the individual’s fear hierarchy.27

In vivo exposure treatment for pain-avoidant behavior has demonstrated efficacy in improving pain, pain catastrophizing, and functional disability,29 and in decreasing pain-related fear as well as anxiety and depression.30 Based on a systematic review of literature from 2015-2016, the American College of Physicians (ACP) developed guidelines with a three-tier recommendation system for the noninvasive treatment of low back pain.31  Despite low-quality evidence ACP gave the use of operant therapy a strong recommendation (recommendation 2) for use in patients with chronic low back pain. 

OBT is not generally implemented as stand-alone psychotherapy for chronic pain conditions. Understanding operant-behavioral theory, however, is important for providers, patients, and family members in order to avoid unconsciously reinforcing negative pain behaviors.

Behavioral activation (BA)

Behavioral Activation is an evidence-based and an effective treatment psychotherapy modality for depression.32  Originally considered a principle of cognitive therapy,33 Behavioral Activation engages patients in pleasurable activities with the aim of increasing both the frequency and duration of participation in these events over time.32  The underpinning of Behavioral Activation is that one’s daily mood positively correlates with pleasant activities.34  Though lacking randomized controlled trials, its theoretical ease of application to individuals who suffer from chronic pain make it an appealing intervention that needs further investigation in the future.35,36

Group psychotherapy

The primary benefit of group therapy is to use the dynamics of the group to benefit each participant. To ensure that the group dynamics are optimized, participants must be willing and compliant, possess at least basic skills of social interaction, and not have personality traits that can adversely impact the group dynamics. Group therapy can also increase the efficiency of the therapist by treating multiple patients in one time slot. Other advantages of group therapy include affordability for patients and health-care payers.

  • Support Groups: Support groups are the most popular approaches to group therapy. They are frequently led by patients or volunteer staff. They may be organized into physical groups or online virtual groups. In ideal circumstances, these groups can provide social and emotional support and improved self-esteem to poorly adapted chronic pain patients who often suffer from social isolation and pervasive negative thoughts and emotions, while also offering participants a forum for comparing experiences and sharing information.  Additionally, peer support groups are social interventions that may foster bonds between patients going through similar maladies such as chronic pain.37  Having such bonds may promote maintenance of recovery and decrease the use of healthcare resources. However, this forum does not offer an environment for structured learning of new coping skills and adaptive strategies, and may suffer from inadequate supervision and direction, or detrimental group dynamics.
  • Cognitive-Behavioral Medicine Groups: are structured, time-limited CBT groups directed toward specific patients with chronic pain who can learn and function well in a group setting. Interventions employed typically include those fostered in individual CBT and may include mind-body interventions including relaxation, meditation, hypnosis or self-hypnosis, guided imagery, pacing activities, Tai Chi, Yoga and maintaining a pain diary. These groups are generally led by professionals who are active practitioners of CBT.
  • Chronic Disease Self-Management Programs (CDSMP): CDSMP was developed by a team of researchers at Stanford University. It is based on the generic principles of the Arthritis Self-Management Program that is taught at community sites and designed to help patients with chronic disease develop self-management skills. It involves small groups of participants of mixed disease diagnoses and may include family members who choose to attend. Instruction and training are provided by a pair of certified community leaders who are often chronic disease patients themselves. Based on self-efficacy theory, it incorporates guided mastery of skills, through weekly sessions, with content that includes: addressing physical and psychological effects of chronic disease (including pain fatigue, fear, anger, depression, anxiety, and frustration); adoption of exercise programs; use of cognitive symptom management techniques, such as guided relaxation and distraction; dietary/nutritional change; sleep management;  judicious use of medications and community resources; communicating effectively with friends, family, care-givers and health-care professionals; health-related problem solving; and decision making.38 The program content has been published in “Living a Healthy Life with Chronic Conditions,” which serves as a guide for participants. The implementation of the program is documented in a detailed protocol, Chronic Disease Self-Management Leader’s Manual.39 CDSMP is an effective, low-cost self-management program that helps patients with chronic health conditions, including chronic pain, lead more fulfilling lives. There is strong evidence from peer-reviewed publications and program evaluations that participation in CDSMP workshops can improve physical and psychosocial outcomes and quality of life for people with chronic health conditions.40
  • Chronic Pain Self-Management Program (CPSMP): Initially developed by Sandra LeFort, PhD, MN, RN in 1996 at McGill University, Montreal, and later updated at Memorial University, St. John’s, Newfoundland, Canada, with Lisa Cardas, RN, the CPSMP was revised in 2008, in conjunction with Kate Lorig, DRPH and the staff of the Stanford Patient Education Research Center. It was revised again in 2015 when the book Living a Healthy Life with Chronic Pain was written to accompany the program. The group structure parallels CDSMP workshops, and outcomes are comparable to studies of CDSMP and other chronic pain programs reported in the literature.

Benefits include:

  • Decreased pain and health-related distress
  • Increased energy and less fatigue
  • Increased physical activity
  • Increased confidence and self-efficacy
  • Decreased depression and anxiety
  • Better communication with health-care providers
  • Decreased social role limitations
  • Increased confidence in managing chronic disease
  • Proactive mindset

The efficacy of group psychotherapy in reducing psychological and physical distress accompanying chronic medical illness is well documented.41,42 Patients with a broad range of medical illnesses demonstrate improved compliance, reductions in somatic symptoms, anxiety and depression, and increased self-esteem.43

Complementary and alternative medicine

Non-pharmacological alternative therapies have been around for hundreds of years. Currently, alternative medicine is most frequently used to treat a variety of painful musculoskeletal conditions and is often employed with CBT therapy. musculoskeletal pain. However, the efficacy of these therapies is heavily debated, and more research is necessary to determine their role on chronic pain management. 

Tai Chi, Qi Gong and Yoga: Other forms of mind-body interventions employed in pain management, include movement meditation adaptations of Tai Chi, Yoga and Qi Gong. These therapies combine meditation and movement to improve and maintain health. In a RCT of 320 athletes with chronic low back pain, they found that tai chi practice resulted in pain reduction compared with no exercise and jogging but had no significant difference when compared with swimming. In another RCT conducted over 10 weeks, tai chi led to a reduction of pain and improved self-reported disability. Tai chi has also demonstrated significant benefits for depression, quality of life, and motor control. Despite these studies, there is insufficient evidence at this time to assess the efficacy of these interventions in chronic pain. Future studies are needed to understand the long-term impact of tai chi and its application in various chronic pain conditions.44

Acupuncture: This form of alternative medicine originated in China over 3000 years ago and is frequently used in the management of pain conditions. Practitioners believe that Qi disruptions create imbalances in the body’s energy which can lead to illness and pain. The goal of acupuncture is to promote the flow of Qi with needles. Various RCT have demonstrated improvement in measures of pain and quality of life scores with different acupuncture techniques. In studies comparing acupuncture to sham acupuncture (using needles without penetration of acupuncture points), patients also report lower pain scores, suggesting that acupuncture has more than a placebo effect and there is an actual physiologic mechanism lending to its efficacy.44

Osteopathic manipulative medicine (OMT): The Journal of Family Practice defines OMT as “the process by which DOs use their hands to diagnose illness and injury and mobilize a patient’s joints and soft tissues using techniques that include muscle activation, stretching, joint articulation, and gentle pressure to encourage the body’s natural tendency to heal itself.” Like the other alternative medicine techniques, OMT has been shown to be effective in the short-term management of pain, although data regarding its long-term efficacy is sparse.44

In summary, it cannot be concluded that alternative therapies are a replacement for pharmaceutical treatment of chronic pain. However, they may play a role as adjuvant therapy.

Adjuvant analgesic pharmacotherapy

Some antidepressant drugs have been found to exhibit analgesic properties which are unrelated to their anti-depressant effects. In addition to the treatment of co-morbid depression and sleep issues, these drugs are particularly effective in treatment of neuropathic pain and fibromyalgia where opioid medications are typically ineffective. Tricyclic antidepressants (TCAs) and serotonin and noradrenaline reuptake inhibitors (SNRIs), which both act to prevent the reuptake of noradrenaline and serotonin in the brain and spinal cord, are the most effective. The mechanism of their effects remains unclear, but they are thought to provide analgesia by increasing endogenous pain control and activity of the descending inhibitory pathway.45

Cutting Edge/ Emerging and Unique Concepts and Practice

As stated above, there are numerous psychological interventions available for implementation in patients with chronic pain. The intractable nature of chronic pain may make adaptation difficult as attempts to control pain through conventional psychotherapeutic domains may ultimately become ineffectual, potentially contributing to greater psychological distress.29 There is, however, encouraging data coming out with use of these conventional techniques through modern day application utilizing the internet and other “smart devices.” 

Mobile-health technology (e.g., smartphone applications, text messaging, interactive voice response) are emerging means of monitoring and optimizing psychological interventions of chronic pain. A recent multicenter study in patients with end-stage knee OA showed that app-delivered education resulted in lower pain levels and showed significant improvement in physical functioning, quality of life, and self-reported ability to perform physical therapy exercises. A systematic review of almost 20 RCTs also demonstrated that e-health and mobile-health applications (e.g., Internet-delivered pain self-management or CBT-CP treatment programs) have a beneficial effect in pain intensity, physical function, and psychosocial function in patients with chronic pain. In another systematic literature review of 20 articles, 8 of which were RCTs, ACT treatment through online implementation has been demonstrated to be effective in patients dealing with chronic pain.  These findings highlight the potential benefits of app-delivered treatments for pain in a variety of settings. Despite these benefits, access to mobile technology is a concern. For those individuals who have access to technology, security, privacy, and confidentiality are challenging issues in mobile-health interventions that will need to be addressed. Lastly, tailoring these online therapies to their appropriate target treatment populations will require additional time and attention in the future.46,47

Distraction therapy employing Virtual Reality has been employed successfully in pediatric burn patients undergoing painful dressing changes.  Distraction was associated with decreased activity in the cingulo-frontal cortex including orbitofrontal region, anterior cingulate cortex, periaqueductal gray (PAG) nucleus, and posterior thalamus. Higher cortical areas may exert a descending influence on PAG and posterior thalamus to modulate pain during distraction.48

Guided motor imagery (GMI) is a modality that has become more widely implemented.  Initially developed to treat phantom limb pain, it has more recently been expanded to treat several other chronic pain conditions including complex regional pain syndrome. GMI posits that certain chronic pain states are a result of amplification of neural signaling, causing pain hypersensitivity or central sensitization that can also result in disrupted somatotropic processing within the body.  GMI focuses on revamping neural organization or fostering cortical remapping of an aberrant system.  There are typically three steps involved in GMI: left/right judgment training, motor imagery, and mirror therapy.49

It is critically important to recognize that pain cannot be interpreted solely as an isolated objective sensory neurophysiologic event. It is equally, if not more impactfully, a perceptual experience that is unique to everyone. However, with the emergence of new technologies such as functional MRI (fMRI), functional networks in the brain intricately involved in the subjective (emotional, affective, motivational) aspects of pain, objective (sensory, discriminative) aspects of pain, as well as loci associated with pain processing and modulation, can now be objectively imaged. fMRI research has been instrumental in identifying the four regions of the brain (primary and secondary somatosensory cortex (S1 and S2), anterior cingulate cortex (ACC), and insula) that are consistently activated in pain states. As we learn more about fMRI, functional connectivity patterns could emerge as biomarkers for specific pain conditions.50

Gaps in the Evidence-Based Knowledge

Currently, it is not well-understood why some patients transition from acute to chronic pain and disability. One interesting area of research is genetics, and its contributory role in the development and experience of chronic pain. There are several published studies which suggest that genetics may play a pivotal role in how individuals experience and respond to pain and physical illness. Some of these studies suggest that specific genes are linked to various psychiatric and psychological disorders associated with chronic pain conditions51. Other studies have identified various genetic mutations that result in aberrant voltage gated ion channels that affect how pain is transmitted from the peripheral nervous system.52 

Opioid prescribing and understanding its role in contributing to the development of chronic pain is especially important. This issue is especially relevant regarding patients going under the knife. 10% of all surgeries result in chronic postsurgical pain (CPSP). The prognosis is of CPSP condition is not well understood but inappropriate use of opioids has been linked to its development.53  Opioids have been shown to alter pathways in the brain in mice related to the nucleus acumens, medial prefrontal cortex, and corticotropin-releasing factor. This alteration increased the reward state from morphine in mice with chronic neuropathic pain.54 The implication of these findings highlights the ongoing judicious use of opioid prescribing. It is evident that we have only just scratched the surface in terms of our current state of knowledge of the biological, societal, and genetic components of pain as well as the affective dimensions and cognitive appraisal inextricably intertwined with pain and other physical disorders complicated by co-morbid psychologic distress. With further research and understanding of these relationships, we can anticipate the emergence of more successful treatments, prescribing practices, and targets for intervention.

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Original Version of the Topic

Armando S. Miciano, MD. Psychological factors affecting physical disorders Part 2: A general approach to treatment. 9/20/2014

Previous Revision(s) of the Topic

Bosco Francisco Soares, MD, David Niumatalolo, MD. Psychological factors affecting physical disorders Part 2: A general approach to treatment. 11/5/2019

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