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Pain Management

Pain Management

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Published by: Homeopath Aamir Saleem on Aug 26, 2012
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10/24/2012

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Pain Management
Medical management is typically the initial approach to treating pain of various types andduration. Acute pain may require only a brief period of treatment with simple, short actingmedicines. Persistent pain may require extended care with constitutional drugs. In addition,Supportive psychological strategies, physical medicine and rehabilitative approaches may beneeded.
Psychological Approaches for Managing the Chronic Pain :
There are many psychological therapies for pain management but modern psychologistsaccepts-
 
Operational Behavioral Therapy
 
Cognitive Behavioral Therapy
 
Motivational Interviewing and Motivational Enhancement Therapy
Operant Behavioral Therapy
This therapy focuses on verbal (e.g., complaining) and nonverbal (e.g., limping, using acane or brace, grimacing, rubbing, general activity level, and consumption of medications tocontrol pain) pain behaviors (operants). According to this theory, pain behaviors that mayhave originated in the acute phase of an injury (e.g., inactivity) may come to occur totallyor in part in response to reinforcing environmental events (e.g., family members orcoworkers doing certain activities for patients rather than patients learning how to do theactivities appropriately). This happens when pain behaviors are rewarded or reinforced andwell behaviors (e.g., activity, working) are insufficiently reinforced. The result is not onlymaintenance of pain behaviors but also excessive suffering and disability.A basic process of operant behavioral treatment involves identifying target pain behaviors(or the lack of well behaviors), their controlling antecedent (discriminative stimuli), andconsequent reinforcers or punishments. Behaviors are identified through direct observationof patients, behavioral assessment questionnaires, interviews with patients and familymembers, and/or self-monitoring by patients. The resulting information is integrated with afull history and physical outlining patients' pathophysiology. Understanding patients'pathophysiology makes it possible to set realistic upper limits for overall physical function.The use of systematic removal of the contingent relationship between an overt behavior andits positive or negative consequences (i.e., extinction) to reduce overt pain behaviors is oneapplication of operant behavioral principles.
Cognitive Behavioral Therapy
 Although cognitive behavioral therapy (CBT) recognizes the role of affective, behavioral,cognitive, and sensory-physical dimensions of chronic pain, as well as the social context ingeneral, and the family context in particular, the role of patient beliefs about and meanings
 
attributed to various aspects of the experience of pain is considered most important. TheCBT approach to chronic pain is based on the idea that patients enter treatment with thebelief that many of their problems are unmanageable. Treatment goals are to help patientsdevelop the expectation that they can learn to manage their problems effectively, and thento provide them skills to respond effectively both to their current problems and to newdifficulties that might arise. Treatment focuses on providing patients techniques to gain asense of control over the effects of pain on daily living as well as modifying the affective,behavioral, cognitive, and sensory-physical dimensions of the experience. There is emphasison teaching coping self-statements, problem solving, and goal setting. There also isemphasis on helping patients acquire skills such as relaxation, imagery, biofeedback,pacing, and behavioral goal setting. Psychologists also help patients identify high-risksituations that are likely to tax their coping resources, identify the early signs of relapse(e.g., increase in pain or depression), rehearse cognitive and behavioral skills forresponding to these early relapse signs, and use self-reinforcement for effective coping withpossible relapse. Patients also are helped to view setbacks as cues for which they shoulduse their coping skills more effectively or for developing new goals and behavioralstrategies. Although CBT has effectively addressed the suffering and disability of manypatients with chronic pain, recent developments have called for an expansion of CBT thatwill include basic principles of psychopathology and a new model of human suffering. Thisexpansion places greater focus on helping patients develop psychological flexibility (i.e.,acceptance of their condition, capable of focusing on the present moment in anonjudgmental manner, allowing what is held as important to guide action, and not over-regulation by verbal/cognitive processes).
Motivational Interviewing and Motivational Enhancement Therapy
Despite the supportive evidence of operant behavioral therapy and CBT for chronic pain,there remain patients who do not improve or who improve and then relapse. A possibleexplanation is lack of sustained motivation on the part of patients. Hence, during the 1990sthere was a focus on using the principles and strategies of motivational interviewing (MI)and motivational enhancement therapy (MET) as complements to operant behavioraltherapy and CBT to help elicit patients' own motivation and solutions. Di Clemente andProchaska identified specific stages and challenges patients experience as they changemaladaptive behaviors into adaptive behaviors. To describe the stages of this model and theassociated clinicians' stage-specified tasks, physical inactivity can be considered as anexample of a possible maladaptive behavior for patients with chronic pain. In the pre-contemplation stage patients are not considering change from the current level of inactivity.At this stage, the clinicians' task is to increase the perception of the risks and problemsassociated with inactivity (e.g., weight gain, increased pain, social isolation, depression). Inthe next stage, contemplation, the goal is to help patients conclude that the risks of inactivity outweigh the perceived benefits. The next stage, preparation, requires clinicians tohelp patients determine the best course of action for becoming more active (e.g., identifyingan appropriate program or physical activity, such as structured physical therapy, flexiblegym program, or walking group). In the action stage, clinicians help patients to take stepstoward becoming more active in their selected activity. This stage is followed by

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