An Introduction to the Behavioral Medicine Approach in a Multidisciplinary Pain Management Center
By John K. Kreymer, Psy.D., DAPA, Licensed Psychologist, St. John’s Center for Pain Management

Chronic pain is a very complicated, diverse area of practice that is often misunderstood by patients and health care providers alike.  Patients and providers often seek out fast and easy solutions for chronic pain conditions, and as one might expect easy solutions are often elusive, if not impossible. 

Chronic pain is distinctly different than acute pain, and is usually accompanied by co-morbid psychological and/or medical conditions (please see www.spine-health.org). 
 

There is the lingering belief that the cause(s) of chronic pain can [always] be directly identified in medical and/or radiological studies. Yet, it is not always possible to find a direct, physical cause of certain chronic pain conditions. Sometimes a treatable pain generator can be found. But when a true cause for chronic pain can’t be found, one option for treatment can include mind and body interventions. 
 

Medical care for chronic pain conditions can encompass a multitude of interventions that can include medications, injections, and/or other interventional procedures. Physical therapy can help with kinesiophobia in addition to neuro-sensory and mechanical issues associated with chronic pain disorders.  Physical therapy is an integral part of the chronic pain treatment process. Many intractable cases of chronic pain may also require psychological evaluation (and subsequent psychological treatment in the context of behavioral medicine) in addition to other appropriate treatment.
 

Psychological evaluation is often an appropriate step to assess underlying factors that may affect the chronic pain conditions. This may uncover psychopathology including depressive disorders, anxiety disorders to include Post Traumatic Stress Disorder (PTSD), somatic/somatization disorders, factitious disorders, substance abuse/dependence disorders, and/or other cognitive/neuropsychological deficits that may affect functioning (Block, Gatchel, Deardorff, & Guyer, 2003).
 

Research has indicated that patients may experience significant exacerbations in chronic pain symptomolgy and pain severity over time when depression, anger, anxiety/post traumatic stress, substance abuse, and chronic maladjustment are present (Block et. al, 2003).  These processes change how the brain interacts with and affects the body.
 

Patients need a treatment approach that integrates medical, physical therapy, and psychological interventions in order to treat the individual to entirety. Pain physicians and surgeons have begun to see connections between chronic pain related conditions, need/appropriateness for surgery, and post-surgical outcome potential as it relates to psychological conditions and psychological improvement. 

As early as 1975, there was notice of the relatedness between psychological factors and back surgery outcomes: 

A given patient’s response to pain is very much a psychological phenomenon. Even if the patient has objective findings which justify surgery, arrangements should be made for psychological counseling before and after surgery. If the patient has unfavorable findings by psychological testing, and few

objective findings, the surgeon should be very slow to resort to surgical treatment, since the symptoms are not likely to be relieved  (Wiltse and Rocchio, 1975, p. 482).

Given this viewpoint, it is interesting to note that many people look only to medications and/or surgical procedures as the one-and-only means to treat chronic pain conditions. These are certainly very important tools to be used in the treatment of chronic pain conditions. Yet, there are patients that don’t respond to multiple medications or surgical attempts. There are even those cases when surgery might actually be harmful to the patient. 
 

We know that medications and surgery don’t work for every patient.  What do you offer a patient when all those measures have failed thus far?  What do you do when your patient has problems with medication side effects or even substance abuse/dependence?  What do you do when your patient continues to fall deeper under the spell of chronic pain in spite of medication use or surgeries, becoming hopeless and more depressed? 
 

There has to be something else to offer your patient, and that “something” is not well understood.  Many people (patients and providers) don’t even know that St. John’s offers a multidisciplinary treatment approach that fulfills that “something” to help with chronic pain management. 
 

At St. John’s, the multidisciplinary pain management center is comprised of pain specialist physicians, neuro and orthopedic surgeons, nurses and nurse practitioners, physician assistants, physical therapists and physical therapy assistants, clinical [health] psychologists, and our respective administrative and support staff members. 
 

The psychological component of pain treatment, perhaps best considered in the context of behavioral medicine rather than in the traditional psychological context, is probably the least understood of the pain management treatment modalities.  Most patients and providers alike are more familiar with traditional interventions that include medications, surgeries, physical therapy interventions, etc.
 

Behavioral medicine has been described as “…the study, prevention, and treatment of medical and psychosomatic disorders and of undesirable behaviors, such as overeating and substance abuse, by the application of behavior therapy techniques, such as biofeedback, relaxation training, and hypnosis.”  
 

Medicine.Net defines Behavioral Medicine in a similar way:  “…an interdisciplinary field of research and practice that focuses on how people's thoughts and behavior affect their health and disease. Behavioral medicine is concerned, for example, with undesirable behaviors such as drug abuse and utilizes behavior therapy techniques such as biofeedback, relaxation training, and hypnosis.”  Thus, there is a consensus as to how to define the actual scope and practice of Behavioral Medicine.
 

Most pain conditions can be treated in the context of the Multidisciplinary approach utilizing medical, surgical, physical therapy, and psychological methods.  When traditional methods to treat chronic pain cases fail, behavioral medicine interventions still remain an option to engage the patient and provider alike.
 

Behavioral medicine interventions should be considered early in chronic pain treatment.  There can be significant improvement and cost savings with such an approach (Andrasik, 2005).  Andrasik (2005) specifically noted significant cost savings in particular through Behavior Medicine interventions

(to include biofeedback) when treating migraine headache conditions in addition to other pain related conditions.    
 

It is often worth having the patient engage behavioral medicine interventions before pursuing invasive methods.  Such treatment may enhance response to surgery, and possibly avoid costly invasive procedures that might not work if a patient is bogged down in depression, anxiety, or other psychological difficulties (Block et al, 2003; Andrasik, 2005).
 

Pain improvement is often observed when patients participate in behavioral medicine treatments.  Such involvement can address issues related to multiple pain syndromes and conditions, to include Complex Regional Pain Syndrome (CRPS), neuropathic pain, spinal conditions, extremity pain, lumbar and cervical pain, pelvic pain, migraine and tension headaches, and many other pain conditions (Linton, 2000). 
 

Behavioral Medicine examines the cognitive, emotional, and personality/behavioral factors that affect how a patient functions with co-existing medical and/or psychological problems, and influences these factors to facilitate recovery. As you might expect, patients may sometimes be defensive when they are referred to “psychology” for pain concerns.  Patients often express to us that "I’m not crazy, I just have pain.” 
 

Of course, we realize that, and we try to reassure them that we treat pain, and we do not believe they are “crazy.”  There is already a stigma against pursuing mental health treatment, but behavioral medicine at St. John's Pain Management Center focuses on management of pain and/or other physical concerns via psychological techniques. 
 

The clinical focus is towards helping people examine their thinking and decision making abilities; appropriateness of choices; address ways to improve quality of life; and to help with self-direction and self-regulation strategies to facilitate improvement in pain and life functioning (Pellino, Tluczek, Collins, Trimborn, Norwick, Engelke, et al, 1998).  Once the patient understands this philosophical and interventional difference, defensiveness often decreases, engagement increases, and improvements in pain report may then be observed.
 

At the Pain Management Center, we use non-invasive behavioral medicine methods and Physical Therapy practice, in addition to the more recognized medical invasive methods as performed by our medical providers, to help patients address their pain concerns and psychosocial stressors.  Psychological techniques (when used with patients in pain) help reduce the experiences (frequency and severity) of pain episodes in addition to helping with general adaptation and quality of life improvement (Andrasik, 2005; Linton, 2000). 
 

Some of the physical therapy interventions available to patients at the Pain Center include: gradual reintroduction of functional exercise, stretching, and muscle toning and strengthening; ultrasound and electrostimulation therapies; virtual body exercises; graded exposure for endurance and strength training; soft tissue mobilization exercises; spinal mobilization techniques; aquatic exercises; core stabilization techniques; recognition of limb laterality; mirror box therapy, and traditional physical therapy modalities. 
 

Behavioral medicine interventions available to patients include:  relaxation skills training via multiple modes of practice; mood and anxiety management via psychotherapy and/or psychopharmacology as appropriate; use of guided imagery, breathing techniques, diversionary strategies, and/or hypnosis; conventional biofeedback and neurofeedback strategies; trauma work allowing for the cognitive-emotional reprocessing of pain-trauma interactions; addressing thinking errors, decisions, attitudes, and self-direction via Cognitive Behavioral Psychotherapy (CBT); improving the coping skills repertoire, learning pain distraction techniques; lifestyle management, dietary consultation, and stress management education and skills development.  Both individual and group based therapies are available.   
 

Why the concern about psychological trauma (PTSD)?  What does this have to do with pain?  Traumatic experiences can set the stage for a heightened state of psychophysiological reactivity that augments pain response.  In fact, clinical research suggests that early and prolonged childhood physical and sexual abuse is a significant predictor of chronic pain experience later in life (Linton, 1997).  Psychological trauma also results from motor vehicle accidents and other kinds of injuries as well.

Not every chronic pain patient has been physically or sexually abused. The presence of PTSD can significantly contribute to pain experience, and appropriate behavioral medicine treatment should be considered as part of overall chronic pain treatment process.  Untreated and prolonged PTSD can lead to increases in psychophysiological reactions, chronic tension, worry, possible depression, and heightened fear reactions with magnification of pain-producing thoughts and mental images (Linton, 1997).
 

Concerns with psychophysiological reactivity and/or hyperarousal has lead to research focusing on Central [Nervous System] Sensitivity (Yunus, 2007).  There are changes in the central and autonomic nervous system that lead to heightened brain activity and nervous system dysregulation.  This may affect pain response, and may also relate to various other physical and psychological conditions.  This developing field of mind-body medicine called psychoneuroimmunology (Turk & Gatchel, 2002).

As discussed, Behavioral Medicine addresses the interconnections between psychological and physical connections. There is no doubt that depression, anxiety, sleep issues, substance abuse, and multiple other areas of mental health come into play and affect the onset, experience, and duration of chronic pain (Block et al, 2003).  One must treat both the psychological and physical in individuals suffering from chronic pain.    
 

Helping a patient with chronic pain learn to change their thinking can literally make direct impacts on pain experience and functional abilities.  In essence, the more you think about pain, the more pain you feel.  Helping patients change their mindset and learn diversionary thinking techniques is very helpful. Focus on general relaxation training via the use of guided imagery, progressive relaxation, diaphragmatic breathing, and various other self-regulatory and conditioning exercises have been shown to be very helpful (Benson, 1976, 2000; Andrasik, 2005; Whitehouse, 2005).  There is a great deal of clinical literature that addresses the importance of “the relaxation response” (e.g., diaphragmatic breathing and self-calming; Benson 1976, 2000) and its impact on pain, anxiety, cardiac conditions, and other stress related disorders.

In addition, biofeedback continues to show significant clinical gains in helping patients with a variety of physical and pain conditions.  Research continues to be published that documents the efficacy of biofeedback interventions (Andrasik, 2005; Whitehouse, 2005).  Biofeedback made its début in the 1960s then fell out of favor.  It is making a comeback due to structured protocols, improvement in relaxation effects for patients, use of proven psychological conditioning principles, and improvements in data collection, monitoring, and telemetry systems.
 

Levels of efficacy for biofeedback related treatments are rated on a scale of one to five, with five being the highest level (Level 1 = Not Empirically Supported; Level 2 = Possibly Efficacious; Level 3 = Probably Efficacious; Level 4 = Efficacious; Level 5 = Efficacious & Superior; Andrasik, 2005).  Some of the conditions noted to respond to biofeedback interventions include:  incontinence (5); anxiety disorders (4); Attention Deficit Hyperactivity Disorder (4); migraine and tension headaches (4); hypertension (4); temporomandibular conditions (4); alcohol-related disorders (3); arthritis (3); epilepsy (3); insomnia (3); and traumatic brain injury (3) (Andrasik, 2005).
 

Perhaps the newest and most promising biofeedback intervention is EEG-driven feedback (“neurofeedback”).  As is implied by the name, the use of electroencephalographic information can be provided to a patient in real time, and through the concurrent practice of relaxation and other cognitive strategies, changes in perceived pain may occur, and/or changes in the symptoms of other conditions have been noted as well (Hammond, 2005; Andrasik, 2005). 
 

A review of data collected on a limited subset of patients who have participated in individual care in our clinic to address psychophysiological arousal and chronic pain detailed some interesting findings.  Those patients participated in a course of individual treatment designed to reduce psychophysiological arousal through a combination of conjoint relaxation, cognitive awareness/emotional processing via CBT, and neurofeedback monitoring.  Data analysis yielded a 68.90 percent average pain reduction.  Pain improvement lasted for an average of three days after each treatment session.  Pain reports were based upon personal responses to the Visual-Analog Pain Scale. 
 

Limitations of this data and subsequent findings include limited sample size (N = 98 total treatment sessions; N = 37 patients; N = 2.64 average number of sessions per patient), and lack of control conditions.  Further study utilizing a larger sample and control conditions are needed.  Research and patient reports indicate continued pain improvement as the practice effect grows.  Improvements in self-regulation, mood, and self-control have also been noted.
 

Research on EEG-facilitated personal training, originally done in the 1960s (Robbins, 2001) and continued through today, has documented the ability to improve seizure response, attention deficit hyperactivity disorder, depression, anxiety disorders, chronic pain conditions, and peak performance training (www.eeginfo.com, www.eegspectrum.com, www.aapb.org). 
 

More and more research controlled studies continue show that that biofeedback improves headache, pelvic pain, back pain, incontinence, phantom limb pain, anxiety and affective disorders, and also assists in stroke/cognitive rehabilitation (Hammond, 2005).  Phantom limb pain treatment also shows promise through a new physical therapy technique called “Mirror Therapy,” which is in use in our St. John’s Clinic (see the New England Journal of Medicine Article).
 

Examine of research into some of the methods we employ yields a large body of data.  An OVID-MEDLINE and OVID-PsycINFO search turns up over 1,641 studies detailing various aspects of EEG-driven (neurofeedback) treatment (some of these may be duplicated in the reference list, however).  A search for Mirror Therapy details 525 references available.  A search for Cognitive Behavioral Therapy (CBT), the mainstay of treating the maladaptive cognitions that can promote ineffective pain coping, yields 4,387 references (this is using a small subset of the online journal searching tool).  And, a search for Eye Movement Desensitization and Reprocessing (EMDR) yields 581 references.  More specific detail about EMDR (as derived by Francine Shapiro, Ph.D.) can be viewed at The EMDR Institute.
 

In addition to the interventions already noted, a significant focus of treatment in the Multidisciplinary Pain Management clinic is a group-based model that addressed pain education, self-regulation, relaxation, and peer modeling and learning.  Physical Therapy and Behavioral Medicine providers conduct the groups we offer.  The balance of Physical Therapy and Behavioral Medicine offer patients opportunities to modify physical, cognitive, and emotional factors that may generate or heighten their chronic pain experiences. 
 

An internal clinic study reviewed emergency room/urgent care visits for chronic pain patients (pre versus post participation in the chronic pain groups for MHP-insured patients).  The results of that study detailed a 64 percent reduction in emergency room visits following participation in the chronic pain treatment group.  This study suggests that there may indeed be improvement in self-regulation and cost savings to the patient and to payor sources when patients participate in such treatment.  Allowing the patient to address their pain conditions in a means that teaches them more of what they can do to help themselves offers chances for improvement, self-efficacy, self-direction, and health care cost savings.
 

It is impossible to comment here on every method or condition we utilize or address in the multidisciplinary pain clinic, nor can we cite every research study in such a short article.  The techniques utilized in the multidisciplinary the context of behavioral medicine and physical therapy are well detailed in the research literature. 
 

It is hoped that this introduction offers a glimpse into the treatments available at the clinic. Our focus remains on helping each person improve their self-direction, coping abilities, pain level, and emotional concerns to enhance their quality of life.
 

Please contact us at 417-820-2170 if we can be of assistance to you and your patient. You may also visit us online at stjohns.com/neuroscience/pain.

 

References
 

Andrasik, F. (2005, April 21). Audiovisual presentation. In How can biofeedback improve US healthcare? Andrasik Science Forum, Institute for Human and Machine Cognition, University of West Florida-Pensacola.

Benson, H. (1976, 2000). The relaxation response. New York, NY: HarperCollins.

Block, A. R., Gatchel, R. J., Deardorff, W. W., & Guyer, R. D. (2003). The psychology of spine surgery. Washington, D.C.: American Psychological Association.

Hammond, D. C. (2005). Neurofeedback with anxiety and affective disorders. Child and Adolescent Psychiatric Clinics of North America, 14, 105-123.

Linton, S. J. (1997). A population-based study of the relationship between sexual abuse and back pain: Establishing a link. Pain, 73, 47-53.

Linton, S. J. (2000). A review of psychological risk factors in back and neck pain. Spine, 25, 1148-1156.
 

Pellino, T., Tluczek, A., Collins, M., Trimborn, S., Norwick, H., Engelke, Z. K. et al. (1998, August 1). Increasing self-efficacy through empowerment: Preoperative education for orthopedic patients. Orthopedic Nursing, pp. 48-59.

Robbins, J. (2001). A symphony in the brain. New York, NY: Grove Press/Atlantic.

Shalen, P. R. (2000). Pain management. Retrieved February 22 2008, from Spine-Health: http://www.spine-health.com/Pain-Management.html.

Turk, D. C., & Gatchel, R. J. (2002). Psychological approaches to pain management: A practitioner's handbook. second edition. New York, NY: Guildford Press.

Whitehouse, B. (2005, April 25). Biofeedback. [Congressional briefing and science forum], United States Congress, Washington, D.C.

Wiltse, L. L., & Rocchio, P. D. (1975). Preoperative psychological tests as predictions of success of chemonucleolysis in the treatment of low-back syndrome. Journal of Bone and Joint Surgery (American Ed.), 75, 478-483.

Yunus, M. B. (2007, June 1). Fibromyalgia and overlapping disorders: The unifying concept of central sensitivity syndromes. Seminars in Arthritis and Rheumatism, 36(6), 339-356.