Operant Interventions

In an operant model of pain, the primary focus of intervention is the behavior of the patient. Pain-related behaviors are thought to maintain pain past its expected duration. These behaviors can include either verbal expressions of pain (e.g., complaints of pain or requests for medication), gross motor movements that are indicators of pain (e.g., grimacing or limping), or avoidance of potential pain-generating activities. These observable behaviors are subject to the principles of operant conditioning, which state that a given behavior is highly influenced by the consequences of that behavior. Reinforcing consequences increase the likelihood that a behavior will occur in the future and neutral or punishing consequences decrease the likelihood that a behavior will occur. More specifically, these behaviors can be maintained through positive reinforcement (e.g., attention from a loved one), negative reinforcement (e.g., not having to go to an unpleasant job), or a lack of positive reinforcment. For example, when a patient grimaces and a loved one responds by expressing concern, grimacing may occur more frequently in the future when that loved one is present. In this case, the social attention in the form of concern positively reinforces the grimace. Alternatively, pain can serve as punishment (negative reinforcement) for engaging in an activity. If an individual experiences pain during or following standing or walking, this is likely to decrease the frequency of these activities. Furthermore, there has been research to suggest that operant conditioning may play a role in the level of pain-related disability.

The goal of operant interventions is to decrease learned pain behaviors and replace maladaptive responses associated with the pain and the sick role with more adaptive behaviors. Operant interventions ideally occur in an environment where there is the opportunity to control the social consequences of pain behaviors and shape new, more adaptive behaviors. Historically, most operant pain programs have been based on inpatient units where a level of control is possible; however, operant conditioning interventions can be incorporated into outpatient treatment as well. For example, “as needed” pain medication prescriptions are changed to fixed time intervals to remove the contingent relationship between complaints of pain (i.e., the pain behavior) and pain relief (i.e., the reinforcer). Vocalizations about pain intensity are largely ignored and more adaptive behaviors, including attending physical therapy and increasing activity level, are socially rewarded (i.e., reinforced). The focus of operant interventions is ideally on targeting the behavior and opposed to addressing pain intensity. In doing so, the desired outcome is an improved quality of life, above and beyond decreasing pain intensity. The initial phase of any behavioral intervention is a behavioral analysis. Once an understanding of the pain-related behaviors is established, a behavioral plan can be delineated and executed.

Pacing and behavioral activation are important components of operant behavioral pain management programs. When individuals push their activity levels to the point of pain exacerbation, they are more likely to decrease their activity over time. Operant programs designed to avoid this negative pattern have the following three components: (1) Establish a baseline. A specific target behavior is identified, for example, sitting at a desk. A baseline is established by measuring for several days the amount of time the individual can sit at the desk before his or her back pain is exacerbated (e.g., 30 minutes on average). (2) Begin time-contingent activity. Rather than having the individual sit until the pain becomes intolerable and then stop, an initial goal is set at 70%–80% of the baseline level (e.g., 20–24 minutes). The individual would start by sitting not more than 20 minutes, thus avoiding the punishment of pain exacerbation and obtaining the social reinforcement associated with success. (3) Gradually increase the level of the behavior, usually by not more than 5% per week, and instruct the patient to use time, not pain, as an indicator for stopping the activity. Over a period of weeks, the individual would increase the comfortable duration of sitting to perhaps 60 minutes without shifting position or standing up.

This process of gradually increasing the nature, frequency, and duration of a behavior is called “shaping.” The goal of such an intervention is to increase the adaptive behavior while managing the consequences, which include removing any punishment (e.g., pain) and introducing reinforcement (e.g., experience of success, social attention). The involvement of the significant other or family members in treatment is desirable so that they can be taught the principles of shaping behavior. Further, inclusion of others (i.e., family, friends, caregivers) in treatment can facilitate the generalization of treatment gains from the inpatient setting to the home environment.

Relaxation Interventions

An extensive literature documents the benefits of developing a relaxation response, particularly in the areas of anxiety and stress management. The potential utility of targeting negative emotions (e.g., stress, anxiety, depression) in managing chronic pain is a key component of treatment given the well-established relationship between one’s pain experience and affective state. The goal of most techniques is nondirected relaxation accomplished through two common components : first, repetitive focus on a word, body sensation, or muscle activity and, second, a passive attitude toward thoughts unrelated to the attentional focus. Common methods used for teaching relaxation include systematically tensing and relaxing specific muscle groups (e.g., progressive muscle relaxation), focusing on breathing and enhancing diaphragmatic breathing, and using guided imagery. A psychophysiologic model of pain, which has received some empirical support, suggests that stress or pain leads to subtle increases in muscle tension, which can exacerbate pain at the site of an injury. A primary goal of relaxation training is to break the cycle between pain and muscle tension. Expert panels and meta-analyses have summarized empirical support for the use of these techniques in pain management and recommended the broad integration of relaxation techniques with biomedical interventions for pain management.

Biofeedback

Biofeedback provides the individual with detailed information about a physiologic process that is typically not within his or her awareness. Through this detailed feedback, the individual can learn voluntary control over usually involuntary processes. Biofeedback for pain management usually entails providing feedback about muscle tension, typically using electromyographic (EMG) feedback from the site of the pain or a standard location such as the frontalis muscles, or feedback about skin temperature, typically using thermistors attached to the fingers. Empirical support for the efficacy of biofeedback for pain management exists for several specific painful conditions, including the Raynaud phenomenon, tension and migraine headaches, vulvar vestibulitis, and low back pain. Although biofeedback is widely used within the field of pain medicine, particularly in conjunction with relaxation training, empirical support for its specific efficacy beyond the general effects of relaxation strategies has not been widely demonstrated except in the treatment of headaches. Biofeedback has been demonstrated to have greater efficacy than relaxation alone for tension headaches. For patients who have difficulty recognizing the physiologic changes that may accompany pain or stress, biofeedback may be useful in helping them to recognize these changes. Further, patients who are drawn to technology or who conceptualize their pain experience as a primarily physical phenomenon may prefer a biofeedback approach to relaxation training.

Coping Skills Training

Coping skills training has been shown to be a useful aspect of CBT with pain populations. Patients engage in a range of coping responses to manage pain and related stressors. Some coping responses (e.g., activity avoidance) are associated with increased distress and suffering, while others (e.g., problem solving) are linked to better emotional and physical functioning. Specific coping skills are highly adaptive and effective for individuals with chronic pain, often including some of the strategies already outlined, particularly relaxation and pacing of activity level. The primary goals of coping skills training are to increase perceptions of pain as a controllable experience and decreasing the use of maladaptive coping strategies. In this approach the emphasis is on skill development and refinement. In the case of skill development, a new skill is introduced and patients are encouraged to develop and refine the skill during low pain periods before attempting to implement the coping skill during an actual period of pain exacerbation. The skill is shaped over time, so that the skill is gradually applied to increasingly challenging (i.e., painful) episodes as the individual becomes more proficient in that skill. A similar approach is taken to the application of many pain coping skills, including cognitive or behavioral distraction, relaxation, pacing of activities, and the appropriate use of social support. Attention is paid to factors that increase or decrease pain and these factors guide the application of pain coping skills.

Cognitive Restructuring

Cognitive restructuring focuses on the role of cognitive factors, such as attitudes, thoughts, and beliefs, in determining emotional and behavioral responses to pain. These interventions challenge negative self-talk, such as catastrophizing (e.g., “I can’t stand the pain anymore”), and replace these self-statements with more positive statements that reduce negative affect, emphasize control, and encourage adaptive coping (e.g., “This is a challenge that I have faced before and I can handle it this time”). Catastrophizing is a particularly maladaptive response to pain, which has been shown to correlate with depression and disability. In the context of treatment, patients are frequently asked to monitor their thoughts about their pain or pain-related situations, identify negative thoughts, and generate more accurate, adaptive thoughts to replace the negative thoughts. The emphasis is on balanced thinking, not necessarily positive thinking. This self-monitoring process is supplemented with more in-depth discussions of the underlying attitudes and beliefs contributing to the negative thoughts. The potential utility for cognitive restructuring is highlighted by an exploration of thoughts associated with chronic pain. For example, when an individual’s expectations of pain relief are greatly below what they view as beneficial, there may be poor engagement in interventions. Therefore, if one’s beliefs and attitudes could be restructured, increased engagement in interventions may lead to improved outcomes.