Psychosocial therapies for neck pain

Phys Med Rehabil Clin N Am

14 (2003) 643–657

Psychosocial therapies for neck pain

Lisa Victor, PhDa,b,*, Steven M. Richeimer, MDa,b

aUniversity of Southern California Pain Center, 1510 San Pablo Street,

Suite 233, Los Angeles, CA 90033, USAbDepartments of Anesthesiology and Psychiatry, Keck School of Medicine,

University of Southern California, Los Angeles, CA, USA

Comment

The authors of ‘‘Psychosocial Therapies for Neck Pain’’ provide a mini-textbook of the issues and strategies appropriate to patients with chronic neckpain. We may recognize that we have learned much of what they have to saythrough our own experience in dealing with our patients and their problems, butwhat we may not have learned is the careful, structured approach that theyprovide for dealing with patients with chronic neck pain.

The authors give insight into the roles of cognitive-behavioral therapy,patient education, and biofeedback, together which can provide useful tools forpatients to manage the psychosocial aspects of their chronic pain syndrome.They remind us of the important role of the family as supportive but alsopotentially counter-productive participants in the task of helping the patient tocope and to gain independence and control over pain problems. Their overallphilosophy is to provide the patient with tools for self-management andstrategies to dissipate the pain, the suffering, or both to the extent possible,while simultaneously recognizing that their pain is a chronic condition. Patientswith chronic neck pain or other chronic pain syndromes must be given tounderstand that there will be exacerbations and that they can, with appropriateunderstanding and training, learn to cope with them.

–RLSIn the treatment of pain, the medical team traditionally focuses on

assessment of a physical basis for the pain, and when a physical basis isabsent or insufficient, it is assumed that causation is psychologic. Identifiedphysical pathology has not been predictive of pain severity or level ofdisability, however, and pain severity in turn does not necessarily predict the

* Corresponding author. USC Pain Center, 1510 San Pablo Street, Suite 233, Los

Angeles, CA 90033, USA.

E-mail address: [email protected] (L. Victor).

1047-9651/03/$ – see front matter � 2003 Elsevier Inc. All rights reserved.

doi:10.1016/S1047-9651(03)00034-2

mailto:[email protected]

644 L. Victor, S.M. Richeimer / Phys Med Rehabil Clin N Am 14 (2003) 643–657

amount of psychologic distress or extent of disability. Additionally, identicaltreatments for the same physical conditions often have highly diverseresults. Features of chronic pain conditions such as depression, sleepdisturbances, and social and occupational impairment were assumed by thedisease model to be secondary and likely to disappear once the conditionwas cured. The persistence of pain that proved refractory to medical orsurgical treatment, the variability in treatment response, and functionaldisability in excess of what might be expected based on physical pathology,contributed to a systematic attempt to study and to develop a morecomprehensive model of pain.

Pain research over the past 35 years has demonstrated the inadequacy ofdichotomizing pain into organic versus functional. With the revolutionarygate control theory of pain hypothesized by Melzack and his colleagues [1] in1965, came the understanding of the important modulating role played bycognitive, motivational, and affective factors on the sensory component ofpain. The work of Wilbert Fordyce [2] and others helped demonstrate thesignificant role of learning, reinforcement, and the environment on painbehaviors. Research on voluntary control of the autonomic and somaticnervous systems by Miller [3], Blanchard [4], and others demonstrated thatpsychologic factors are capable of influencing physiologic states and thatpeople can learn to control important physiologic functions associated withpain and stress. The integration of these insights by Turk, Meichenbaum,and Genest [5] then led to the development of a comprehensive clinicalmodel and approach to treatment that they labeled a cognitive-behavioralperspective [6].

The biopsychosocial model of pain

Whereas the biomedical model has focused on disease, an objective,disruptive biologic event caused by pathologic, anatomic, or physiologicchanges [7], the biopsychosocial model of pain now being applied in researchinto all types of chronic pain syndromes instead emphasizes illness. Illness isdefined as the subjective experience that disease is present, resulting in physicaldiscomfort, emotional distress, functional limitations, and psychosocialdisruption. It refers to how the patient, family members, and the social net-work around them receive and respond to the consequences of the symptoms.

The effect of psychologic and social factors on pain

Psychologic factors include the affective components of pain: depression,anxiety, and anger. These emotions can increase autonomic arousal, whichcan cause a chain reaction of increased release of adrenalin (epinephrine)and noradrenalin (norepinephrine), activation of damaged or sensitized painneurons, and increased pain. These emotions can also lead to decreased

645L. Victor, S.M. Richeimer / Phys Med Rehabil Clin N Am 14 (2003) 643–657

energy and motivation to participate in treatment, thus complicating therehabilitative process. Cognitive processes are equally significant in impact.Beliefs about the cause of the pain being undetected and malignant,unrealistic goals for treatment, negative thinking styles such as catastro-phizing, inadequate or maladaptive coping strategies, and lack of a sense ofself-efficacy can make treatment ineffective and can contribute to significantelevations in pain. Sympathetic nervous system activation, increased skeletalmuscle tone, spasm, and pain are all direct effects of cognitive factors [8].

Social factors also have profound impact on a patient’s pain experienceand response to treatment. These factors include social learning factors,sources of inadvertent and direct reinforcement of pain, current or recentstressors, and compensation or litigation issues. Social learning factors arethe attitudes about health, pain, and appropriate responses to injury orillness that one learns from one’s parents and social environment, whichoften determine whether one is likely to ignore or overrespond to symptoms.It has been found, for example, that children of chronic pain patients tendto feel less control over their health (Richard, 1985) [9]. Sources ofinadvertent reinforcement for pain behaviors include the avoidance ofaversive situations or activities, such as doing housework, returning to a jobthat was disliked, or having sex with one’s spouse when sex was previouslydisliked. Inadvertent reinforcement may also occur in the form of attention,assistance, or expressions of caring by significant persons in the patient’slife. Direct reinforcement of pain behaviors often results from anticipatorypain and thus immobilization or total deactivation of the affected part.Although the immediate avoidance of increased pain is gratifying, theultimate consequence is escalating loss of strength, stamina, or function.Current or recent sources of stress are also significant variables affecting theexperience of pain and the response to treatment. Concomitant with thepain or disability, the patient may be trying to cope with the illness, death,divorce, or another adverse event in the life of a family member or closefriend. The patient may be experiencing significant financial problems, socialisolation, cognitive limitations secondary to medication, or a host of otherlife problems, all of which combined have drained the patient’s copingresources and sabotaged the patient’s ability to benefit from treatment.Finally, compensation or litigation issues may interfere with treatment if thepatient believes that improvement will result in decreased financial benefit.

Application of the biopsychosocial model to neck pain

In an excellent review article, Linton [10] examined and summarizedthe results of 913 articles and studies published between 1967 and Septemberof 1998 on the role of psychologic factors in neck and back pain. The resultsof the review demonstrated that ‘‘psychological factors are related to neckand back pain from its inception to the chronic stage,’’ and that ‘‘the datareviewed distinctly show that psychosocial factors are also pivotal in the


transition from acute to chronic pain, as well as influential in the onset ofpain.’’ Moreover, the results indicate that psychosocial factors are not simplysome sort of overlay, but rather are ‘‘an integral part of a developmentalprocess that includes emotional, cognitive, and behavioral aspects.’’

A similar view is taken by Reitav and Hamovitch [11], who discussthe impact of affective, cognitive, and social factors on persistent benignheadaches and whiplash-associated pain. The authors strongly endorse in-clusion of a multidisciplinary approach toward provision of more effectiveand comprehensive treatment for this population of pain patients.

Treatment perspectives

The initial aspect of treatment from any model of pain is assessment. Inthe biopsychosocial model, assessment begins with identification of thenature and extent of organic pathology or tissue damage and thedetermination of appropriate medical or pharmacologic interventions. Thismodel further dictates the assessment and identification of the relevantpsychologic and social characteristics specific to the patient, towardinclusion of treatment components that maximize outcome. Although inmost cases medical interventions are sufficient to alleviate the pain, overtime psychosocial and behavioral factors can serve to exacerbate andmaintain pain and to influence adjustment and disability. The earliera potential factor is identified, the less entrenched and pervasive is itsinfluence on patient response to treatment. As Turk [12] has written,

Treatment from the biopsychosocial perspective focuses on providing the

patient with techniques to gain a sense of control over the effects of pain onhis or her life, as well as on actually modifying the affective, behavioral,cognitive, and sensory facets of the experience. Behavioral experiences[therapies] help to show patients that they are capable of more than they

assumed they were, thus increasing their sense of personal competence.Cognitive techniques help to place affective, behavioral, cognitive, andsensory responses under a patient’s control. The assumption is that long-

term maintenance of behavioral changes will occur only if the patient haslearned to attribute success to his or her own efforts.

Treatment components of psychosocial therapy for neck pain

There are four components that comprise pain management treatmentfrom a psychosocial perspective. Each component is fundamentally didactic,in that the emphasis is on patient comprehension, implementation andpractice, and then maintenance of the cognitive, behavioral, and environ-mental changes that will contribute to emotional, physical, and functionalimprovement. These four components, which are discussed individually butwhich are interrelated, are (1) patient education, (2) cognitive-behavioraltherapy, (3) relaxation training and biofeedback, and (4) active adaptation.


Patient education

Patients referred to a pain center or pain psychologist almost always enterwith apprehension and resistance. Patients typically interpret the referral asan indication that their pain is perceived as primarily psychologic. Althoughthe patients may be depressed or anxious, they are frequently reluctant todiscuss their feelings in depth, thinking that doing so will serve to reinforce theview that they are ‘‘head cases.’’ Although they may be aware that their painis affected by stress or mood, they insist that the reverse is true, that the paincontrols how they feel. If medication use has been identified as one reason forreferral, defensiveness, rationalization, and resentment are part of the clinicalpresentation. They tend to lack information regarding the psychophysiologyof pain in general and about the mechanisms contributing to their specificpain problems. Almost always they have undergone a lengthy period of a hostof different attempts at treatment, none of which has resulted in significant orenduring relief. They now have been told that they will have to learn to livewith the pain, a statement that is understood asmeaning nothing can be done,contributing to the hopelessness and abdication of responsibility forattempting to implement or maintain any form of self-help regimen.

The goal of patient education, then, is to re-establish a sense of self-efficacy in a demoralized patient by providing information that reducesdefensiveness, enhances understanding of the potential for self-help, andmotivates the patient to try.

Chronic pain syndromeAn explanation of the typical experience of an individual who has chronic

pain reduces the patient’s sense of isolation, self-criticism, and failure andcontributes to the perception that the patient will be understood and treatedwith respect. Acknowledgment that depression, anxiety, low self-esteem,social isolation, physical deactivation, irritability, and a variety of othernegative consequences are part of the syndrome is in fact reassuring topatients. It is important to clarify the difference between pain that is acute(from the Latin, meaning needle or sharp) and pain that is chronic (from theGreek, meaning time) and to explain the distinction between harm and hurt.

PsychophysiologyDifferentiating psychosomatic from psychogenic or hypochondriacal is

the first lesson in helping patients to accept the concept that a mind-bodyinteraction exists. This concept is a building block on which the self-regulation training components of treatment depend. It includes an ex-planation of the autonomic nervous system, the body’s fight-or-flightresponse under stress, the limbic system or emotional center of the brain,and its influence over the hypothalamus-pituitary-adrenal (HPA) axis, andthe pedal-to-the-metal syndrome of chronic stress, with pain being one type


of stressor. The body’s systemic responses to chronic hyperarousal can bedelineated and shown to be paired with pain-increasing results such asmuscle tension and spasm. The relationship of thoughts and feelings to painvolume is a focus in every aspect of treatment, the emphasis always being onpatient actions that have the potential to turn down the volume or turn offthe connection.

The gate control theoryProviding patients with an explanation of the gate control theory of pain

establishes the rationale for many of the pain management principles andskills they will be taught. Comprehension of the mechanics by which painis communicated through the body ultimately facilitates application andmaintenance of pain management techniques. The sophistication of theexplanation must, of course, be tailored to the level of each patient. Themost important aspects to cover are the following:

1. There are different roads by which different types of pain travel.Pressure and touch are on a fast road (A-beta nerve fibers). Sharp,stabbing pain travels on a slower road (A-delta nerve fibers). The dull,aching, and burning pains, often associated with chronic painsyndromes, travel the slowest road (C nerve fibers). Giving patientsthe example that one instinctively rubs a knee that has bumped intoa sharp object (because sensations of touch or rubbing travel quicklyand beat sharp pain, which travels more slowly, to the brain; thusthe sensation of rubbing interferes with the sensation of sharp pain),illustrates a very basic pain management technique that applies thisinformation.

2. Pain is sent to the brain through the main concourse, the spinal track.This pain-to-brain pathway, called the ascending track, has two roads,a fast road and a slow road. The fast road, the route of sharp orstabbing pain, goes to the part of the brain called the cortex andproduces the experience, ‘‘ouch.’’ The slow road, the route of dull oraching chronic pain, goes to a different part of the brain, called thelimbic system, which is the emotional center, to produce the feeling ofdismay. The important differentiation between pain and sufferingoriginates with and should be elaborated upon as part of this lesson.

3. The main concourse is a two-way highway. The spinal track hasa descending pathway also, the brain-to-pain route. The brain uses thistrack to attempt to counteract the pain message. The brain sends nerveimpulses or chemical messengers back down the spinal cord to close thegate to the messages coming upward from the site of the pain. Therapiesthat use the brain’s power to produce self-regulatory responses, such asbiofeedback and relaxation training, are examples of descending-trackpain management techniques.


4. Although pain management techniques are discussed as being directedat closing the gate to both the ascending pain-to-brain pathway and thedescending brain-to-pain pathway, the goal is to reduce the speed,strength, or volume of the transmission. Elimination of the pain is nottypically a realistic goal. Reduction of the pain or suffering, however, isboth realistic and possible.

NeurotransmittersUnderstanding that neurotransmitters are the chemical means by which

nerve cells communicate and that these chemical messengers influence bothmood and the experience of pain provides a framework from which issues ofmedication and exercise can be explained and by which patients can bemotivated to learn and apply the techniques they are being taught. Forexample, most patients have heard of endorphins and enkephalins, know thatthey are the body’s own natural painkillers, and know that they are promotedby exercise. Patients typically do not know that many other naturallyproduced neurotransmitters also affect pain or that these neurotransmitterscan increase or decrease the pain message. Pain management techniques suchas relaxation and cognitive reframing gain value when it is understood thatthey can stimulate release of neurotransmitters that decrease pain and inhibitrelease of those that increase it. Additionally, patients with medication issues,either refusing to try a potentially helpful medication or resisting reduction ofa narcotic, tend to become more cooperative when they are educated as to themechanismsbywhich themedicationswork.The impact of the introduction ofsynthetic neurotransmitters (medications) into the body can be examinedfrom the benefits (serotonin enhancement) and the costs (supplanting andultimately suppressing endorphin and enkaphalin production by opioids)involved. It should be explained that the role played by a neurotransmitter ormedication can vary, depending on location in the body of the nerve cells thatare communicating. One example is that mood improvement results from theaction of antidepressants on nerve cells in the brain, whereas pain reductionresults from their actions in the body. Such information also enhancespatients’ ability to recognize that some of their motivation tomaintain higher-than-desirable levels of a medication results from its action in the brain, andthus its effect on their mood, more than from its action in their body and ontheir pain. Many chronic pain patients become attached to hydrocodonecompounds, for example, because in some individuals these drugs boostenergy and enhance mood. This realization often promotes patients’ willing-ness to try alternative and more appropriate medication and opens them toconsidering the contributions of pain versus suffering in their pain experience.

Treatment goals in pain managementIt is of utmost importance to specify to patients early on that the goal of

pain management treatment is independent maintenance of the self-care


regimen they will be learning. It should be emphasized that the treatment isdidactic, focused on teaching them what they can do to help themselves, andthus passive modalities such as massage are excluded. The treatment teamcan be compared with a personal trainer who guides a person throughestablishing an appropriate workout, but the individual must walk thetreadmill or lift the weights to achieve successful results. Furthermore, itshould be explained that the goal is not to learn to live with the pain, butrather to learn to control the pain by altering or eliminating behaviors andthoughts that unwittingly increase the perception of pain and by learninghow to use techniques that have the potential to reduce the currentperception of pain. It should be explained that progress will not be linear;flare-ups or bad days are to be expected, and transient increases in painshould not be considered setbacks. Patients are taught to manage flare-upsby active application of their pain management skills, which includerecognizing and reframing cognitions that catastrophize and thus intensifyand lengthen the experience into a potential relapse.

Cognitive-behavioral therapy

Cognitive-behavioral therapy is a treatment approach that combinescognitive techniques, such as cognitive restructuring and thought-stopping,with behavioral techniques, such as role-playing and homework assign-ments. These combined techniques are applied to help patients acquire self-management skills that enable them to recognize and modify maladaptivethoughts and behaviors and consequently reduce negative emotions andtheir contribution to pain, suffering, and functional disability [6].

The cognitive-behavioral perspective makes three important assumptionsof relevance in the treatment of the chronic pain patient. The firstassumption is that therapeutic gain is best achieved when patients believethe responsibility for action is theirs, perceive a successful outcome as theresult of personal competence, and attribute the changes they are making tointernal motivation rather than external pressure. Treatment must thereforehelp patients to reconceptualize their pain experience as amenable to changeand to recognize that it is within their ability to alleviate much or some oftheir pain and suffering. Although this goal is partly accomplished throughdidactic components on the psychophysiology of pain, it is primarily learnedexperientially throughout the course of treatment. The focus is thereforeon active patient participation, emphasizing a collaborative and problem-solving approach between the patient and therapist. The goals are toprovide the patient with the ability to monitor and identify the relationshipbetween thoughts, feelings, behavior, and pain and to enable the patient todevelop and implement more effective and adaptive ways of thinking,feeling, and responding (Holtzman et al, 1986) [13].


The second important assumption for treatment derived from thecognitive-behavioral perspective is that patients are able to learn new waysof thinking and in doing so can alter affect and modify behavior. As patientsare helped to recognize their negative thoughts, the impact on pain, mood,and behavior becomes intuitively obvious and serves as a motivator ofchange. Identification of the patient’s cognitive response patterns to pain andstress is accompanied by an examination of the potential consequences ofsuch thinking. For example, polarized thinking, seeing everything in terms ofblack or white, good or bad, can result in denigration of any improvementthat is short of a total cure and can thus sabotage perseverance and furtherimprovement. Catastrophizing, a common negative thought pattern, pro-duces emotional and physical reactions commensurate with a worst-casescenario, severely and unnecessarily exacerbating pain and anxiety. The goalis not to help solve a specific problem but rather to help the patient acquirea method that enables self-management of dysfunctional thinking overa variety of situations. The various forms of irrational or negative thinkingare first presented and examined. Patients then monitor their thoughts inresponse to their pain or to stress. Initially this monitoring is accomplishedby questions from the therapist (eg, ‘‘How did that make you feel?’’) and laterby patient journaling. Responses are then discussed in terms of the ABCDmodel, which stands for activating event (stressor), belief (resulting thought)about the event, consequence (emotions resulting from the thought), anddispute (examining the negative thought pattern that produced the negativefeeling). The patient is then helped to generate alternate ways of thinkingabout ‘‘A’’ that reduce negative emotional consequences (‘‘C’’). They are alsodirected in assessment of their behavior in response to their feelings and arehelped to generate improved pain management options. This process isobviously not a one-session exercise but rather is an ongoing process overthe course of the therapy. Patients are taught numerous other cognitivetechniques, including thought-stopping, which entails replacing the negativethought with preplanned phrases, and benefit analysis, examining whathidden rewards contribute to maintaining the negative thought.

The third assumption for treatment inherent in the cognitive-behavioralperspective is that behaviors may be influenced by the environment but alsoshape environmental events. It is important for pain patients to recognizeand take responsibility for their potential influence on their environment, thedistinction between control and influence being central. Individuals do nothave the ability to control other individuals in their life, nor do they have thepower to control most events. They do, however, have potential control overthemselves, and by asserting control they improve the possibility of in-fluencing both. Control, often misunderstood in this context as meaningcurbing or restraining, instead refers to communicating or behaving ina manner that increases the likelihood of eliciting the desired response oroutcome. Pain patients often have difficulty asserting themselves, insteadcommunicating either passively or aggressively. Patients who are passive and


avoidant abdicate the possibility of affecting change in an aversive situationor interaction. Patients who explode often justify their anger as caused bytheir pain and then are surprised at the resentment and alienation with whichothers respond. The concept of exerting control or influence through self-management is a fundamental and recurring theme in therapy, and com-munication skills are an essential mechanism for achieving this goal.Assertiveness and communication training is therefore an important partof the cognitive-behavioral treatment plan. Patients are given instruction andexercises in identification of passive, aggressive, and assertive responses toa variety of scenarios, the benefits of assertive versus passive or aggressivebehavior becoming apparent. As in all aspects of cognitive-behavioraltreatment, patients are given assignments for home practice.

Given these three assumptions, cognitive-behavioral treatment is directedtoward three major objectives:

1. Patients will perceive themselves as having the ability and tools tomanage their pain, will attribute effort to motivation, and success topersonal competence.

2. Patients will recognize that cognitions determine mood and behaviorand will actively monitor and work to modify as needed the relationshipbetween thoughts, feelings, behavior, and pain.

3. Patients will seek to influence, rather than expect to control, theirenvironment, through appropriate, assertive communication and self-management.

These objectives are approached through didactic presentation ofinformation, collaborative investigation by the therapist and patient to iden-tify problem patterns, and skills training that uses role-playing, rehearsal,homework assignments, and ongoing assessment and modification.

Relaxation training and biofeedback

Relaxation training emphasizes the understanding that it is a skill, muchlike playing a musical instrument, that develops with practice, and that itcan provide a patient with the ability to exert voluntary control over manyof the functions regulated by the autonomic nervous system that contributeto pain and suffering. The individual is taught about the relationshipbetween pain and stress, the physiologic and emotional changes that areconsequent to a prolonged stressor such as chronic pain, and the role of theautonomic nervous system in this cycle. The goals of relaxation traininginclude reduction of maladaptive neuromuscular behaviors, such as bracingagainst pain or tensing specific muscle groups in response to stress, and thereduction of autonomic arousal in general, leading to decreased anxiety anddepression, to improved stress management, and to an enhanced perceptionof self-efficacy through the patient’s experience of having the ability to affectphysical and emotional states profoundly.


A common misperception by both patients and health care practitionersis that biofeedback training and relaxation training are identical. Patientsoften report they tried biofeedback unsuccessfully in the past. Relaxationtraining refers to a variety of exercises taught to the patient, which thenrequire a regular, devoted, independent, at-home practice regimen forproficiency to develop. The acquisition of competence depends solely onthe patient’s compliance with such a regimen. Biofeedback refers to theinstrumentation that can be used in conjunction with relaxation training andthat enhances skill acquisition by providing immediate information(feedback) as to the successful production of the desired physical change.Biofeedback instruments monitor selected body systems through electrodesor sensors that transform changes into visual or auditory signals, thusreinforcing that voluntary control has been achieved. Although biofeedbackinstruments are valuable assistive devices, it is through the patient’s effort,not use of the equipment, that skill develops. The three types of biofeedbackmost commonly used in training with chronic pain patients are electromyo-gram (EMG) training, thermograph (temperature) training, and galvanicskin response (GSR) (also known as skin conductance level [SCL] training).

In EMG training, two electrodes (sensors) are placed at an appropriatedistance on the skin over the site being measured, with a third electrode(sensor) placed on a neutral point, usually over a bone, to serve as an electricalreference point. This type of feedback monitors skeletal muscle tension, partof the voluntary nervous system. The trapezius, masseter, and frontalismuscle groups are most commonly used for this training because these groupstypically tense under stress and because they can be isolated for measurementwithout interference from other muscle groups. This type of feedback is usedfor specific muscle tension disorders such as neck pain or tension headaches,as well as for general relaxation training for insomnia, anxiety, and generalpsychosomatic disorders such as hypertension, ulcers, or colitis.

Thermograph training monitors fluctuations in peripheral temperature (inthe finger, hand, or foot) through attachment of a sensor that is a heat-sensitive semiconductor. The goal is the voluntary raising of skin temperature,thus reversing the peripheral vasoconstriction, controlled by the autonomicnervous system, that occurs under stress. Migraine headaches and vascularproblems, such as Reynauds syndrome are best treated with thermographfeedback.

Sympathetic activity can be monitored through minute (millivolt) changesin the concentration of salt and water in skin cells, thus affecting the electricalpotential of the skin to conduct. Typically, GSR training is used in con-junction with EMG and temperature training for decreasing autonomicnervous system activity and thus decreasing anxiety or phobic states.

Before being introduced to the use of the biofeedback equipment, patientsare taught the basic technique of diaphragmatic breathing and are assigneda home-practice regimen. As the underpinning of all relaxation techniques,diaphragmatic breathing is easy to learn, has immediately experienced


benefit, and makes heuristic sense to patients. They are reminded that, of allthe functions under control of the autonomic nervous system, only breathingis subject to one’s immediate, although partial, conscious control. By slowingand deepening one’s breathing, thus imitating the relaxed breathing beforeonset of sleep, one can influence other functions mediated by the autonomicnervous system and with practice can produce a generalized result. Further,deep breathing from the diaphragm better oxygenates the blood andeliminates the reflexive tensing of the neck, shoulders, and upper chestconsequent to the quick, shallow breathing associated with stress andanxiety. Patients practice for 20 minutes two to three times daily to developan ability to perform this exercise. They are also taught to monitor muscletension or bracing in response to pain or stress throughout the day and areinstructed in use of the breathing for short, stress-reducing applications.

As patients become proficient in diaphragmatic breathing, additionalexercises are introduced, along with the biofeedback instrumentation todocument for the patients the physical changes they are able to accomplishthrough application of the techniques. Often the exercises are used incombination with multiple types of feedback instrumentation, especiallywhen a generalized relaxation response is the focus. The primary relaxationtraining exercises include autogenic relaxation, progressive relaxation,imagery, and visualization.

Autogenic relaxation is a passive relaxation technique that encouragesblood flow to the extremities. This exercise consists of repeating to oneselfa series of statements promoting the sensations of heaviness and warmth,focusing individually on four areas of the body: (1) feet, calves, thighs, andbuttocks; (2) chest, stomach, and lower back; (3) hands and arms; and (4)shoulders, neck, throat, face, and head.

Progressive relaxation is an effective tool for helping patients identify andrelease muscle tension. The exercise involves contracting and holding tense,then slowly releasing that tension, in the same four major muscle groupsused in autogenic relaxation. Patients must be cautioned against overtensingthe injured area and the muscles surrounding it. This exercise is particularlyhelpful with patients who unwittingly are engaging in bracing patterns, suchas teeth clenching, contributory to their pain syndrome.

In using imagery as a relaxation technique, the patient selects an image orsymbol that represents the pain and then visualizes a therapeutic image orprocess that releases the pain. Using a deep relaxation technique, such asdiaphragmatic breathing, the positive image is visualized as replacing thepain image. For example, pain might be visualized as the color red, and thecalming color of blue is imagined as slowly absorbing the red.

An extension of the use of imagery, visualization is a form of self-hypnosisin which the patient first uses a deep-relaxation technique in preparation andthen imagines a pain-reducing scenario. The scenario initially is one given bythe therapist or presented on tape, with patients being encouraged to developtheir own. The patient can imagine reducing the pain sensation, for example,


by picturing it as sound emanating from a radio which they walk to andadjust the volume. They can fill their senses with the distraction of a specialplace, such as a lemon grove in bloom through which they are strolling.Visualization techniques range from scenes that relocate the pain, anesthetizethe pain, or allow the individual to change the pain sensation or todisassociate from the pain. The goal of the exercise can be general relaxationand reduction of autonomic arousal as well as reduction of pain.

Active adaptation

The fourth component of psychosocial pain management treatmentfocuses on aspects of the patient’s environment or lifestyle that have thepotential either to support or to interfere with progress and maintenance ofthe gains achieved from therapy. Although there may be many additionalidentified targets specific to an individual patient, the three generalcategories addressed are significant others, exercise, and relapse prevention.

The significant other is typically the spouse or life partner of the patient;however, children, parents, roommates, or other individuals with whom thepatient lives and interacts daily may be as important to include in treatmentas the spouse. Inclusion begins with the initial evaluation, usually in aseparate interview from that with the patient. This interview providescomparison data for the self-reported information by the patient and alsoa glimpse into the attitudes and responses of others and how they influencethe patient. Involvement in the treatment process itself becomes importantfor several reasons:

1. Persons who are frequently in contact with the patient may in-advertently reinforce pain behavior by providing pain-contingentrewards, such as attention, assistance, or sympathy.

2. Their expectations may unwittingly discourage efforts at reactivation(eg, assuming that one successful completion of an abandoned choresignifies the patient’s ability to resume daily responsibility for it).

3. They may be urging the patient to continue to search for a cure andconsequently undermining efforts to use the self-regulatory techniquesbeing taught.

Educating significant others about the psychophysiology of pain, theobjectives of treatment, and the ways in which they can support rather thaninhibit progress contributes to successful treatment outcome. Furthermore,recognition and acknowledgment that those close to the patient have alsosuffered consequences, such as changes in assignment of householdresponsibilities, reduced or vanished social activities, and financial prob-lems, promotes mutual efforts by patient and family at healing the re-sentments that can accumulate. A conjoint or family session is typicallyscheduled within the first weeks of treatment, during which assessment forneed of additional sessions occurs.


Exercise, the second category comprising the active adaptation compo-nent of psychosocial therapy, is addressed from a motivational perspectivethat has the goals of decreasing resistance and encouraging effort and ofassisting in establishment of a regimen that will be independently maintainedafter discharge. Although the specific exercise regimen is determined andsupervised by the treating pain-specialist physical therapist, pain patients areoften reluctant or fearful about activation, and they self-sabotage by eithernot completing homework assigned by the physical therapist or by overdoingand consequently confirming their belief that exercise will exacerbate theirpain. In many cases inactivity or immobilization has been directly reinforcedby an initial reduction in pain, which over time leads to muscle atrophy, sothat periodic efforts at activity or use of the injured part results in more painand thus to a greater likelihood of immobilization. This factor is particularlytrue of neck pain, where decreased range of motion resulting from pain isoften treated with a cervical collar on which the patient becomes dependent.Helping patients recognize that some amount of increased pain temporarilyand necessarily accompanies increased exercise, reminding them of thedifference between hurt and harm, and teaching them to use both therelaxation skills and the cognitive-reframing techniques they are being taughtfacilitates the patients’ persistence in the effort required for improvement.Using the patient education components as reference, patients can be shownhow exercise can decrease depression, reduce insomnia, promote productionof endorphins, assist in management of stress, control weight, and, byincreasing muscle tone and circulation, improve their health in general.

Relapse prevention is the third focus of the active adaptation phase oftreatment. Patients are taught the importance of cognitions to both affectand behavior, are instructed to expect periodic and transient increases inpain, and are directed to think of these episodes as flare-ups rather thansetbacks. Through experience during treatment, they come to understandthat response to a flare-up has less aversive impact, and that they have beenequipped with tools to ameliorate rather than inflame the flare-up. Inaddition to teaching an adaptive response set to pain fluctuations, relapseprevention is primarily aimed at prevention, the relevant adage shared withpatients being, ‘‘An ounce of prevention is worth a pound of cure.’’ Oftenworking in concert with a pain-specialist occupational therapist, patients areinstructed in time management and pacing. They are shown, for example,how attempting to outrace pain on good days in service of task completioncontributes to occurrence and prolongation of a flare-up. Through use ofdaily schedules, they are helped to implement and maintain appropriateregimens that include exercise and relaxation. Patients are also giveninstruction in sleep hygiene, because insomnia is such a common problemfor pain patients. They are helped to establish regular hours for sleep,eliminating naps during the day, and are directed not to eat, read, or watchtelevision in bed. The negative effects of activation, such as eating orexercising, before attempting sleep are reviewed. Relaxation exercises


designed specifically for sleep enhancement are taught, and tapes with theexercises are given to the patients for nightly use. Stress management trainingis another important topic in relapse prevention. Patients learn how tomodify and use the relaxation and cognitive techniques for stress reduction,and the role of exercise and nutrition is explained. Communication skillstraining and assertiveness training are incorporated into this aspect of thetreatment plan as well. All aspects of relapse prevention emphasize ongoingpatient awareness and responsibility for application and maintenance of allthey have learned, and thus responsibility for management of their pain.

Summary

The biopsychosocial approach provides the necessary framework forunderstanding and treating chronic pain. Through education, cognitive-behavioral therapy, relaxation training, and active adaptation, the biopsy-chosocial approach allows patients to learn to control their internalenvironments (pain-related thoughts and emotions) and to influence theirresponses to the external environment (physical condition, work, significantothers, and other stresses). This education-based model of therapy combinesnaturally with the medical model and medical care.

References

[1] Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;50:971–9.

[2] Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: Mosby; 1976.

[3] Miller NE. Learning of visceral and glandular responses. Science 1969;16:434–45.

[4] Blanchard EB. Long term effects of behavioral treatment of chronic headaches. Behav Ther

1987;18:375–85.

[5] Turk DC, Meichenbaum D, Genest M. Pain and behavioral medicine: a cognitive-

behavioral perspective. New York: Guilford Press; 1983.

[6] Turk DC, Gatchell RJ. Psychosocial factors and pain: revolution and evolution. In:

Gatchell RJ, Turk DC, editors. Psychosocial factors in pain: critical perspectives. New

York: The Guilford Press; 1999. p. 481–93.

[7] Mechanic D. Illness behavior: an overview. In: McHugh MS, Vallis TM, editors. Illness

behavior: a multidisciplinary model. New York: Plenum Press; 1986. p. 101–10.

[8] Flor H, Birbaumer N, Schugens MM, et al. Symptom-specific psychophysiological

responses in chronic pain patients. Psychophysiology 1992;29:452–60.

[9] Richard K. The occurrence of maladaptive health-related behaviors and teacher-related

conduct problems in children of chronic low back pain patients. J Behav Med 1985;11:

107–16.

[10] Linton SJ. A review of psychological risk factors in back and neck pain. Spine

2000;25(9):1148–56.

[11] Reitav J, Hamovitch G. Psychological aspects of head and neck pain. In: Vernon H, editor.

The cranio-cervical syndrome: mechanisms, assessment and treatment. Oxford: Butter-

worth-Heinmann; 2001.

[12] Gatchell RJ, Turk DC, editors. Psychological approaches to pain management,

a practitioner’s handbook. New York: The Guilford Press; 1996. p. 24.

[13] Holzman AD, Turk DC, Kerns RD. The cognitive-behavioral approach to the

management of chronic pain. In: Holzman AD, Turk DC, editors. Pain management:

a handbook of psychological treatment approaches. Pergamon Press; 1986. p. 31–49.

Documents

Psychosocial therapies for neck pain