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Dealing with Chronic Pain: The Mind Body Solution Hilary Tindle, M.D., M.P.H. Dr. Hilary Tindle is Assistant Professor of Medicine, University of Pittsburgh School of Medicine. Introduction When medical professionals talk about "persistent" or "chronic pain," they are referring to debilitating, day-in-and-day-out pain that is difficult or impossible to cure. Persistent and chronic pain affects approximately 30% of the United States population;1,2 for a significant portion of them, the pain is centered on the back, joints or other part of the musculoskeletal system. While this kind of pain remains a frustrating and difficult-to-treat condition, our understanding of what pain is and how it works has advanced greatly in recent years, leading to innovative and effective treatments. Many of these are so-called "mind body" therapies that aim to help people to control their own pain response. The groundbreaking gate control theory of pain helped explain how psychological factors influence pain perception.3 Put forward in 1962, gate control theory says that physical pain is not a direct result of an assault from the outside on the pain producing neurons, (as is the case when you bang your elbow or break a leg), but rather the result of interaction between different parts of the brain and nervous system. The bottom line is that the brain controls the perception of pain quite directly, and has a proven ability to moderate or even turn on and off certain forms of pain. In earlier theories of neurochemistry, the role of the brain had not been taken into account; pain was thought to be a sort of one-way "alarm system" that always responded in the same way to the same stimuli. Also, in accordance with the biopsychosocial model of disease, a late 20th-century alternative to the traditional ("biomedical") model of disease,4,5 in which medical conditions are seen as having biological, psychological and sociological aspects, there is now increasing attention on pain as not only a physiologic, but also a psychological phenomenon. This broader understanding of the complex interaction of mind and body has resulted in new approaches to pain treatment.6,7,8,9 The Advantages of Mind Body Medicine in Treating Pain In 1996, the NIH Consensus Panel on the Integration of Behavioral and Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia recommended the use of mind body therapies for chronic pain.10 Since that time, increasing evidence has supported the use of mind body therapies.11,12,13,14,15 In addition, many mind body therapies are relatively inexpensive16,17,18 When used appropriately, mind body therapies are generally safe.19 Finally, to the extent that mind body therapies emphasize self-care, they are economical and result in decreased utilization of the health care system. Definitions Mind Body Medicine Mind body medicine, as defined by the National Center for Complementary and Alternative Medicine (NCCAM) "focuses on the interactions among the brain, mind, body, and behavior, and the powerful ways in which emotional, mental, social, spiritual, and behavioral factors can directly affect health."20 Mind body medicine is one of the five major domains of complementary and alternative medicine,21 and mind body therapies are some of the most commonly used CAM therapies among US adults.22 Mind Body Therapies Mind body therapies are characterized by NCCAM as "techniques designed to enhance the mind's capacity to affect bodily function and symptoms."23 ) Common examples include (see also Table 1):
Table 1. Description of Common Mind Body Therapies.
While most mind body therapies are considered to be part of complementary and alternative medicine, cognitive behavioral therapy is an example of a mind body therapy that has gone main stream. Like other mind body therapies, cognitive behavioral therapy addresses the associated cognitive and emotional issues that accompany or enhance pain symptoms, such as a person's feelings of helplessness or associated depression. Complementary and alternative therapies such as Qi Gong, Tai Chi and yoga share many of the features of mind body therapies (e.g., the use of imagery and breathing techniques) but are not always classified as such. For the purposes of this article, we will focus on the more classical mind body therapies in Table 1. Similarly, prayer also meets the criteria for a mind body therapy and is widely used by U.S. adults for health reasons. However, in research studies of mind body therapies and health, prayer is often considered separately because the characteristics of respondents who pray and the reasons for use of prayer may differ from those of other mind body therapies. How do People Receive Mind Body Therapies? Mind body therapies may involve group or one-on-one therapy, but they also lend themselves well to self-care. For example, many forms of relaxation techniques combine practitioner-based instruction, often on video or CD, with a home-study program. There are no hard and fast rules for types of mind body therapies to avoid, because they are generally safe. Therapies such as guided imagery or meditation may not be appropriate for those with untreated psychiatric conditions, (such as uncontrolled depression or active hallucinations), although one recent study safely used a mindfulness-based therapy for people with active depression and anxiety.29,30,31 Mind Body Therapies Are in Widespread Use According to three large, nationwide surveys, the use of mind body medicine by U.S. adults is surprisingly common. In 1997, one study surveyed 2,055 individuals and found that 16.3% used relaxation techniques such as meditation or the relaxation response. Chronic pain was the third-most common reason (19.5%) to use mind body therapies and was reported to be "very useful" for that condition by 55% of users.32,33,34 Chronic pain may lead people to seek out mind body therapies. The 1999 and 2002 National Health Interview Surveys (NHIS) were conducted by the Census Bureau for the National Center for Health Statistics. In 1999, 30,801 U.S. adults were asked if they had persistent joint pain during the past year and if they had used a mind body therapy (including relaxation techniques, guided imagery, hypnosis and biofeedback) during the past year. People with musculoskeletal pain were almost twice as likely as those without pain to use mind body medicine and prayer.35 The 9% who used mind body medicine represents about 3.5 million U.S. adults. The Effectiveness of Mind Body Therapies for Musculoskeletal Pain Back Pain Back pain is an area where we are beginning to have some data on the effectiveness of alternative therapies for pain. One study of behavioral therapy (such as cognitive behavioral therapy) for chronic low back pain in people ages 18 - 65 was conducted to determine if behavioral therapies were effective, and which therapies were most effective. 36,37,38 The results suggested that there was strong evidence to support respondent therapy (e.g., relaxation techniques or guided imagery) for a medium effect on pain. There was moderate evidence suggesting that progressive relaxation had a large effect on both pain and behavioral outcomes, but only in the short term. Interestingly, there was no evidence that one behavioral therapy was more effective than another for pain-related outcomes. Breath therapy (a mind body therapy integrating body awareness, breathing, meditation and movement) for treatment of chronic low back pain was about as effective as physical therapy both in the short and in the long term in one study.40 Mindfulness meditation resulted in significant improvements in pain acceptance and physical function in a study of 37 older adults with chronic low back pain.41 Headaches, Arthritis and Other Musculoskeletal Pain Mind body therapies appear to be effective for some types of headache. Relaxation training, electromyography (EMG) biofeedback (the recoding of muscle activity at rest and while contracting) and a combination of the two therapies reduced the severity of tension headaches by half.42,43 Relaxation and biofeedback were as effective as the drug propranolol for the treatment of migraine. Fibromyalgia is one area where mind body therapies have not been yet shown to be effective, or to have very limited effectiveness.45 Several mind body therapies have also been studied for arthritis (both rheumatoid and osteoarthritis). The Arthritis Self Management Program uses cognitive therapy and relaxation techniques. People who used this self-management program had reduced pain and disability, though a study reviewing the overall results of over 20 trials of mind body therapies 46 for rheumatoid arthritis found significant effects in the short-term on pain, functional disability, psychological status and coping with pain, but on follow up only moderate effectiveness for psychological status and coping with pain. How Mind Body Therapies Treat Pain The mechanism by which mind body therapies alleviate pain is not well understood, but it may result from their effect of increasing sufferers' sense of self control, which is known to influence how pain is experienced.47,48 Similarly, there is emerging evidence that mind body therapies facilitate a sense of empowerment.49 Mind body therapies may also modify the cognitive and emotional components of pain perception known as pain unpleasantness and pain affect;50,51 these are distinct from pain sensation52,53 and contribute significantly to suffering.54 The emotional components of pain often have the effect of magnifying pain severity.55 Pain as a Complex Sensory Experience Pain is not only sensory; it has a very powerful and unpleasant emotional effect. Pain researcher Troels Statehelin Jensen underscores the complexity of pain when he asks, "What is pain: a sensation, an experience, a symptom, or even a disease?"56 Where We Are At the Moment Mind body therapies are generally safe, inexpensive and already used widely by the U.S. public. Despite this, the effectiveness of most mind body therapies for pain has not been well tested and studied. While their effectiveness for musculoskeletal pain appears to be limited to moderate when used alone, when applied in combination with standard therapies, they may be considerably more useful. Further study is needed to understand more fully how hypnosis and other mind body therapies for pain work in general and in particular. Some experts in the field have argued that the demonstrated effectiveness of many mind body therapies is more or less a "placebo effect." More studies need to be done to determine if this is the case, and to find the brain areas that are more or less active when mind body therapies are applied. Finally, mind body therapies may be particularly suitable to certain populations, such as the elderly, where there is a higher risk of medication interactions,64 or in populations who prefer to use alternative therapies. This latter population is substantial, considering that in 2002 about 29 million people used relaxation techniques.65 Resources For those seeking more information about mindfulness meditation and guided imagery.
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