Chronic Pain Treatment

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  • Created by: Sarah
  • Created on: 29-04-16 15:58

Operant conditioning

  • The focus is on decreasing pain behavior rather than decreasing pain experience (Fordyce, 1987).
  • Positive reinforcement and rewards are used to encourage well behavior. Punishment and negative reinforcement are used to discourage illness behavior.
  • Medication is given as time contingent rather than pain contingent.
  • Bed rest, inactivity and dependence on others is discouraged.
  • Continuous reinforcement encourages the probability of behavior and intimittent reinforcement allows for maintainence of the behavior.
  • Graded activity is where a baseline of activity is set and then this is increased but is time rather than pain contingent, once again.
  • There are several limitations of this: it is demeaning to the P, it requires cooperation and targets behavior but overlooks pain experience.
  • Henschke et al. (2010) conducted a systematic review and meta analysis of 20 studies and 3500 Ps.
  • Operant conditioning was found to have a small effect size (-0.43) on outcome at short term, in comparison to waiting list.
  • It was not found to be effective in comparison to cognitive treatment or for long term. 
  • Also, only 47% had a low risk of bias, due to the nature of the treatment and the inability to blind with behavioral therapy. 
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  • Self control, relaxation, coping skills, self reinforcement and dysfunctional beliefs, illness behavior and their interactions.
  • This is important as dysfunctional beliefs will differ: 1. depressed individuals: see themselves as gulity, the world as a threat and future as hopeless. 2. pain depressed Ps: see themselves as suffering, others should help and future has hope for a cure.
  • Dysfunctional beliefs include e.g. black and white thinking, projecting onto others and attributing positivity to chance.
  • Cooperative commitment and contracting throughout.
  • 1. Identify maladaptive beliefs.
  • 2. reconceptualisation and value laden goals are set.
  • 3. Skills are learnt and trialed.
  • 4. Maintenance, generalisation and relapse prevention.
  • 5. Booster sessions and follow up. 
  • Eccleston et al. (2012) conducted a systematic review of 40 RCTs and 5000 Ps and found that CBT had a small to moderate effect imediately on disability, pain, mood and catastrophizing but all disapeared at follow up, apart from mood.
  • The studies included only had a 4.9/9 rating for quality. 
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In-vivo exposure

  • This treatment is based on the fear avoidance model of pain disorders. It is used to match Ps to a specific treatment program that is designed to suit them.
  • The fear avoidance model states that pain disorders occur in the following way: pain causes a fear of injury which causes a fear of activity which causes a lack of activity which causes disuse deconditioning syndrome which causes mental and physical deconditioning which adds to the pain.
  • In vivo exposure is based on the idea that exposure to activity will show Ps and allow them to experience the fact that their catastrophic beliefs about activity are incorrect. 
  • Linton et al. (2008) conducted an RCT with 50 Ps to test this treatment. It was found that the treatment had an effect for function, in comparison to TAU (0.6), but not for pain or fear.
  • A limitation of the study is that many Ps dropped out, perhaps due to the harsh nature of the treatment.
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Acceptance and MBSR

  • In vivo exposure explains pain disorders in terms of pathological processes and not motivational factors.
  • Instead, these treatments are based on the psychological flexibility model, which suggests that commitment allows for motivational engagement, perspective taking and acceptance.
  • MBSR is based on the idea of allowing thoughts to pass without judgment.
  • Veehof et al. (2011) conducted a meta analysis of 22 studies to investigate these treatments, with 1300 Ps. It was found that MBSR and ACT had a positive effect on pain (0.37) and on depression (0.32). This suggests that they are no better than CBT but are acceptable alternatives.
  • However, 12 of these studies were rated as having low quality methodology and only two of them had good methodology.
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Alternative evidence

  • Hill et al. (2011) conducted a study with 1600 Ps, which was an RCT. The Ps were matched to treatment based on their responses to the startback questionaire. The questionnaire includes 5 items on disability and also items on depression, fear, avoidance, bothersomeness and catastrophising. The questionaire is based on the risk factors outlined by Pincus et al. (2002). Then Ps were matched to treatment in the following way. Those who were at a low risk were given education. Those who were at moderate risk, were given physiotheraphy. Those who were at high risk, were given psychologically informed phsyiotherapy. The control was physio for all of the Ps without any matching. It was found that matching was effective with an effect size of 0.32 at 4 months and 0.12 at 12 months. However, the high risk group did not do better than the control Ps, which suggests that hey may need further help. 
  • A limitation of this study is that more Ps in the intervention group dropped out than those in the control group.
  • Palermo et al. (2013) conducted a meta analysis of 25 RCTs and 1200 Ps among youth with chronic pain. 
  • It was found that there was a large positive effect for all psychological treatments at imediate follow up (for CBT, relaxation and biofeedback).
  • However, there was heterogeneity in measuring pain outcome across the studies. 
  • Pincus et al. (2013) investigated 6 high quality studies and found that cognitive reasurance (advice, explanations etc.) led to reduced health care utilisation and affective reasurance (non specific help) led to increased burden and less symptoom improvement. 
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  • Treatment should take risk factors into account.
  • Treatment should be theory based.
  • Treatmnt should be tailored to the individual.
  • Psychological treatments are effective and psychological processes, rather than just physiological, are clearly involved. The current weaknesses are due to limitations of the existing models e.g. fear avoidance. 
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