Seminars in Pain Medicine最新文献

The family context has been hypothesized to be particularly important in understanding, if not explaining, the development and perpetuation of chronic pain conditions. Family systems perspectives, the operant conditioning model of chronic pain, and cognitive-behavioral models have all encouraged investigation of the impact of chronic pain on the family and its members and, conversely, the potentially deleterious effects of maladaptive family responses in maintaining the disorder. This article offers a brief overview of relevant theoretical perspectives and the empirical research informed by them. A more detailed and critical review is presented of the few empirical investigations of the efficacy of pain treatment approaches involving the partner of the person experiencing pain. Implications of these studies for improving our understanding of the role of families in the perpetuation of chronic pain, particularly for the further refinement and evaluation of family and couples treatment approaches, are discussed.

This investigation provides a behavioral conceptualization for clinical pain, a summary of the research supporting such a model, and a more detailed review of the evidence supporting the clinical efficacy of operant learning/conditioning strategies. Within the behavioral model, clinical pain is defined as an interacting cluster of individualized overt, covert, and neurophysiological responses capable of being produced by relevant tissue damage-irritation, and produced and maintained by other antecedent and consequent stimulus conditions. Based on an extensive review of existing research, it is concluded that the behavioral conceptual model as a whole and that portion based on operant conditioning techniques have strong research evidence when applied to patients with chronic low back pain. In contrast, there is insufficient evidence to date supporting the efficacy of operant methods with other chronic painful conditions, acute pain states, pediatric and geriatric pain patients, cancer pain states, or across cultures. Continued research in these and others areas is recommended. Future possibilities and issues surrounding the use of operant conditioning techniques with pain patients, highlighting research needs, are discussed.

Cognitive-behavioral therapy (CBT) interventions are often used as adjunct treatments with standard medical care to help patients with chronic illnesses better manage their pain and distress or improve function. We review the primary assumptions and the four essential components that underlie all CBT interventions. We then examine the outcomes produced by CBT interventions for patients with two chronic illnesses for which the source of pain is well understood (rheumatoid arthritis and osteoarthritis of the knee) and three disorders characterized by “medically unexplained” pain and other symptoms (fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome). We employed American Psychological Association criteria for empirically validated treatments to evaluate the CBT intervention outcomes. Using these criteria, we conclude that CBT is a well-established adjunct treatment for patients with rheumatoid arthritis and is probably efficacious for patients with knee osteoarthritis, chronic fatigue syndrome, and irritable bowel syndrome. However, CBT interventions must be considered as an experimental therapy for patients with fibromyalgia. The negative findings associated with CBT for fibromyalgia may be due to several factors such as high levels of psychiatric morbidity or abnormal pain sensitivity among the patients. It is necessary for investigators to devote effort to identifying the factors that account for poor CBT outcomes and to modify current CBT protocols to address these factors.

Chronic pain is a prevalent and debilitating condition and can become quite recalcitrant. Poor outcomes from traditional medical, pharmacological, and surgical approaches have been an impetus to development of comprehensive pain programs (CPPs) in which pain specialists from multiple disciplines provide treatment for patients. With health-care costs continuing to rise, the clinical efficacy and cost-effectiveness of CPPs have been of greatly increased interest. In this study, evidence supporting the efficacy of CPP treatment for chronic pain is reviewed on the basis of multiple criteria. I also discuss additional treatment parameters (patient characteristics, treatment delivery, process variables) in considering the efficacy of CPPs. The literature generally supports positive results for CPPs for the various parameters. Furthermore, CPPs are likely to produce long-term cost-savings in health-care expenditures and indemnity costs.

Hypnosis and relaxation are prominent ancillary clinical techniques in the treatment of acute and chronic pain. This article evaluates the evidence and support for the use of these techniques as part of medical treatment. Questions are raised about the utility of grouping hypnosis and relaxation together and we review a continuum of self-regulation techniques upon which hypnosis and self regulation appear to be points. We conclude that we are not yet able to identify a continuum of effectiveness despite there being significant support for hypnotic interventions and some, but more modest, support for relaxation. In addition to clarifying methodological dilemmas we urge that future research must specifically assess hypnotic suggestibility independent of whether the intervention is or is not hypnosis, evaluate non-specific effects, and review dose effect as part of further investigation.

The present article reviews the history of biofeedback, with specific emphasis on the application of biofeedback procedures to the treatment of pain. Applications of biofeedback to different pain syndromes are discussed, as well as its effectiveness. As will be shown, although a great deal of past research has been somewhat mixed with regard to biofeedback’s ability to decrease pain, the results of this therapeutic modality are promising within the context of a more comprehensive interdisciplinary approach to pain management. As will be emphasized, with the growing popularity of the biopsychosocial approach to pain, the importance of teaching pain patients self-regulatory techniques such as biofeedback will increase as an adjuvant to other treatment modalities. The biopsychosocial model of pain, which is now accepted as the most heuristic approach to the understanding and treatment of pain disorders, views physical disorders such as pain as the result of a complex and dynamic interaction among physiologic, psychologic, and social factors, which perpetuates and may even worsen the clinical presentation. Every individual experiences pain uniquely and, therefore, treatment regimens need to be individually tailored for each patient. For many patients, biofeedback serves as an important component of this comprehensive biopsychosocial care approach.

Psychological interventions are an integral component of treatment programs for chronic pain in children and adolescents. However, the evidence base supporting their efficacy varies widely. Although strong and consistent evidence supports the efficacy of cognitive-behavioral interventions for relieving children’s headache, the evidence base supporting the use of cognitive and behavioral interventions for relieving other types of chronic pain is weak, as assessed by the number of controlled trials that have been conducted in children and by the few types of chronic pain that have been formally studied. Empirical support for most psychological interventions targeting nonheadache chronic pain derives from anecdotal reports and case studies. In this study we review this evidence, identify specific gaps in our knowledge base, and recommend practical strategies to obtain critical information about which therapies are best for which children and for which types of chronic pain.

Spinal metastasis is a frequent oncologic and neurosurgical emergency in patients with cancer. Most patients present with back pain and the diagnosis is established with a screening MRI of the spine. Treatment options include steroids, biphosphonates, radiation therapy, surgery and radiosurgery. Pain management is a very important aspect and includes opioids, anti-inflammatory agents, newer anticonvulsants and tricyclic anti-depressants, as well as placement of intrathecal morphine pumps in selected cases. Our experience with 45 patients with metastatic disease to the spine treated surgically at the H. Lee Moffitt Cancer Center and Research Institute is also reviewed. Current surgical techniques address both tumor resection and stabilization of the spine. In most instances, treatment must be individualized and take into consideration the patient’s wishes, and expected quality and duration of remainder life.

The treatment of pain associated with cancer that does not respond to oral pharmacological therapy has been greatly facilitated by the implementation of intraspinal techniques. The use of intrathecal catheters and programmable pumps provide an excellent alternative for these patients who are expected to survive for more than three months. However, it is recognized that neuropathic pain is the most frequent cause of failure when aggressive pharmacological therapy is implemented and as a result of it, the use of adjuvants such as bupivacaine and clonidine is necessary. This article deals with the steps to be implemented to guarantee a high degree of success when using this approach.