National
Institutes of Health
Technology Assessment Conference Statement
October 16-18, 1995
This statement
is published as:
Integration of Behavioral and Relaxation
Approaches into the Treatment of Chronic Pain
and Insomnia. NIH Technol Assess Statement
1995 Oct 16-18:1-34For making bibliographic
reference to technology assessment conference
statement no. 17 in electronic form displayed
here, it is recommended that the following
format be used: Integration of Behavioral
and Relaxation Approaches into the Treatment
of Chronic Pain and Insomnia. NIH Technol
Statement Online 1995 Oct 16-18 [cited year
month day], 1-34.
Abstract
Objective
To provide physicians with a responsible
assessment of the integration of behavioral
and relaxation approaches into the treatment
of chronic pain and insomnia.
Participants
A non-Federal, nonadvocate, 12-member
panel representing the fields of family medicine,
social medicine, psychiatry, psychology, public
health, nursing, and epidemiology. In addition,
23 experts in behavioral medicine, pain medicine,
sleep medicine, psychiatry, nursing, psychology,
neurology, and behavioral and neurosciences
presented data to the panel and a conference
audience of 528.
Evidence
The literature was searched through Medline
and an extensive bibliography of references
was provided to the panel and the conference
audience. Experts prepared abstracts with
relevant citations from the literature. Scientific
evidence was given precedence over clinical
anecdotal experience.
Assessment
Process
The panel, answering predefined questions,
developed their conclusions based on the scientific
evidence presented in open forum and the scientific
literature. The panel composed a draft statement
that was read in its entirety and circulated
to the experts and the audience for comment.
Thereafter, the panel resolved conflicting
recommendations and released a revised statement
at the end of the conference. The panel finalized
the revisions within a few weeks after the
conference.
Conclusions
A number of well-defined behavioral and
relaxation interventions now exist and are
effective in the treatment of chronic pain
and insomnia. The panel found strong evidence
for the use of relaxation techniques in reducing
chronic pain in a variety of medical conditions
as well as strong evidence for the use of
hypnosis in alleviating pain associated with
cancer. The evidence was moderate for the
effectiveness of cognitive-behavioral techniques
and biofeedback in relieving chronic pain.
Regarding insomnia, behavioral techniques,
particularly relaxation and biofeedback, produce
improvements in some aspects of sleep, but
it is questionable whether the magnitude of
the improvement in sleep onset and total sleep
time is clinically significant.
Introduction
Chronic pain and insomnia
afflict millions of Americans. Despite the
acknowledged importance of psychosocial and
behavioral factors in these disorders, treatment
strategies have tended to focus on biomedical
interventions such as drugs and surgery. The
purpose of this conference was to examine
the usefulness of integrating behavioral and
relaxation approaches with biomedical interventions
in clinical and research settings to improve
the care of patients with chronic pain and
insomnia.
Assessments of more consistent
and effective integration of these approaches
required the development of precise definitions
of the most frequently used techniques, which
include relaxation, meditation, hypnosis,
biofeedback (BF), and cognitive-behavioral
therapy (CBT). It was also necessary to examine
how these approaches have been previously
used with medical therapies in the treatment
of chronic pain and insomnia and to evaluate
the efficacy of such integration to date.
To address these issues,
the Office of Alternative Medicine and the
Office of Medical Applications of Research,
National Institutes of Health, convened a
Technology Assessment Conference on Integration
of Behavioral and Relaxation Approaches into
the Treatment of Chronic Pain and Insomnia.
The conference was cosponsored by the National
Institute of Mental Health, the National Institute
of Dental Research, the National Heart, Lung,
and Blood Institute, the National Institute
on Aging, the National Cancer Institute, the
National Institute of Nursing Research, the
National Institute of Neurological Disorders
and Stroke, and the National Institute of
Arthritis and Musculoskeletal and Skin Diseases.
This technology assessment
conference (1) reviewed data on the relative
merits of specific behavioral and relaxation
interventions and identified biophysical and
psychological factors that might predict the
outcome of applying these techniques and (2)
examined the mechanisms by which behavioral
and relaxation approaches could lead to greater
clinical efficacy.
The conference brought
together experts in behavioral medicine, pain
medicine, sleep medicine, psychiatry, nursing,
psychology, neurology, behavioral science,
and neuroscience as well as representatives
from the public. After 1-1/2 days of presentations
and audience discussion, an independent, non-
Federal panel weighed the scientific evidence
and developed a draft statement that addressed
the following five questions:
- What behavioral and
relaxation approaches are used for conditions
such as chronic pain and insomnia?
- How successful are these
approaches?
- How do these approaches
work?
- Are there barriers to
the appropriate integration of these approaches
into health care?
- What are the significant
issues for future research and applications?
The suffering and disability
from these disorders result in a heavy burden
for individual patients, their families, and
their communities. There is also a burden
to the Nation in terms of billions of dollars
lost as a consequence of functional impairment.
To date, conventional medical and surgical
approaches have failed&emdash;at considerable
expense&emdash;to adequately address these
problems. It is hoped that this Consensus
Statement, which is based on rigorous examination
of current knowledge and practice and makes
recommendations for research and application,
will help reduce suffering and improve the
functional capacity of affected individuals.
What
Behavioral and Relaxation Approaches Are Used
for Conditions Such as Chronic Pain and Insomnia?
Pain
Pain is defined by the
International Association for the Study of Pain
as an unpleasant sensory experience associated
with actual or potential tissue damage or described
in terms of such damage. It is a complex, subjective,
perceptual phenomenon with a number of contributing
factors that are uniquely experienced by each
individual. Pain is typically classified as
acute, cancer- related, and chronic nonmalignant.
Acute pain is associated with a noxious event.
Its severity is generally proportional to the
degree of tissue injury and is expected to diminish
with healing and time. Chronic nonmalignant
pain frequently develops following an injury
but persists long after a reasonable period
of healing. Its underlying causes are often
not readily discernible, and the pain is disproportionate
to demonstrable tissue damage. It is frequently
accompanied by alteration of sleep; mood; and
sexual, vocational, and avocational function.
Insomnia
Insomnia may be defined
as a disturbance or perceived disturbance
of the usual sleep pattern of the individual
that has troublesome consequences. These consequences
may include daytime fatigue and drowsiness,
irritability, anxiety, depression, and somatic
complaints. Categories of disturbed sleep
are (1) inability to fall asleep, (2) inability
to maintain sleep, and (3) early awakening.
Selection
Criteria
A variety of behavioral
and relaxation approaches are used for conditions
such as chronic pain and insomnia. The specific
approaches that were addressed in this Technology
Assessment Conference were selected using three
important criteria. First, somatically directed
therapies with behavioral components (e.g.,
physical therapy, occupational therapy, acupuncture)
were not considered. Second, the approaches
were drawn from those reported in the scientific
literature. Many commonly used behavioral approaches
are not specifically incorporated into conventional
medical care. For example, religious and spiritual
approaches, which are the most commonly used
health-related actions by the U.S. population,
were not considered in this conference. Third,
the approaches are a subset of those discussed
in the literature and represent those selected
by the conference organizers as most commonly
used in clinical settings in the United States.
Several commonly used clinical interventions
such as music, dance, recreational, and art
therapies were not addressed.
Relaxation
Techniques
Relaxation techniques
are a group of behavioral therapeutic approaches
that differ widely in their philosophical
bases as well as in their methodologies and
techniques. Their primary objective is the
achievement of nondirected relaxation, rather
than direct achievement of a specific therapeutic
goal. They all share two basic components:
(1) repetitive focus on a word, sound, prayer,
phrase, body sensation, or muscular activity
and (2) the adoption of a passive attitude
toward intruding thoughts and a return to
the focus. These techniques induce a common
set of physiologic changes that result in
decreased metabolic activity. Relaxation techniques
may also be used in stress management (as
self-regulatory techniques) and have been
divided into deep and brief methods.
Deep
Methods
Deep methods include
autogenic training, meditation, and progressive
muscle relaxation (PMR). Autogenic training
consists of imagining a peaceful environment
and comforting bodily sensations. Six basic
focusing techniques are used: heaviness in the
limbs, warmth in the limbs, cardiac regulation,
centering on breathing, warmth in the upper
abdomen, and coolness in the forehead. Meditation
is a self-directed practice for relaxing the
body and calming the mind. A large variety of
meditation techniques are in common use; each
has its own proponents. Meditation generally
does not involve suggestion, autosuggestion,
or trance. The goal of mindfulness meditation
is development of a nonjudgmental awareness
of bodily sensations and mental activities occurring
in the present moment. Concentration meditation
trains the person to passively attend to a bodily
process, a word, and/or a stimulus. Transcendental
meditation focuses on a "suitable" sound or
thought (the mantra) without attempting to actually
concentrate on the sound or thought. There are
also many movement meditations, such as yoga
and the walking meditation of Zen Buddhism.
PMR focuses on reducing muscle tone in major
muscle groups. Each of 15 major muscle groups
is tensed and then relaxed in sequence.
Brief
Methods
The brief methods, which include self-control
relaxation, paced respiration, and deep breathing,
generally require less time to acquire or
practice and often represent abbreviated forms
of a corresponding deep method. For example,
self-control relaxation is an abbreviated
form of PMR. Autogenic training may be abbreviated
and converted to a self-control format. Paced
respiration teaches patients to maintain slow
breathing when anxiety threatens. Deep breathing
involves taking several deep breaths, holding
them for 5 seconds, and then exhaling slowly.
Hypnotic
Techniques
Hypnotic techniques induce states of selective
attentional focusing or diffusion combined
with enhanced imagery. They are often used
to induce relaxation and also may be a part
of CBT. The techniques have pre- and postsuggestion
components. The presuggestion component involves
attentional focusing through the use of imagery,
distraction, or relaxation, and has features
that are similar to other relaxation techniques.
Subjects focus on relaxation and passively
disregard intrusive thoughts. The suggestion
phase is characterized by introduction of
specific goals; for example, analgesia may
be specifically suggested. The postsuggestion
component involves continued use of the new
behavior following termination of hypnosis.
Individuals vary widely in their hypnotic
susceptibility and suggestibility, although
the reasons for these differences are incompletely
understood.
Biofeedback
Techniques
BF techniques are treatment methods that use
monitoring instruments of various degrees
of sophistication. BF techniques provide patients
with physiologic information that allows them
to reliably influence psychophysiological
responses of two kinds: (1) responses not
ordinarily under voluntary control and (2)
responses that ordinarily are easily regulated,
but for which regulation has broken down.
Technologies that are commonly used include
electromyography (EMG BF), electroencephalography,
thermometers (thermal BF), and galvanometry
(electrodermal-BF). BF techniques often induce
physiological responses similar to those of
other relaxation techniques.
Cognitive-Behavioral
Therapy
CBT attempts to alter patterns of negative
thoughts and dysfunctional attitudes in order
to foster more healthy and adaptive thoughts,
emotions, and actions. These interventions
share four basic components: education, skills
acquisition, cognitive and behavioral rehearsal,
and generalization and maintenance. Relaxation
techniques are frequently included as a behavioral
component in CBT programs. The specific programs
used to implement the four components can
vary considerably. Each of the aforementioned
therapeutic modalities may be practiced individually,
or they may be combined as part of multimodal
approaches to manage chronic pain or insomnia.
Relaxation
and Behavioral Techniques for Insomnia
Relaxation and behavioral techniques corresponding
to those used for chronic pain may also be
used for specific types of insomnia. Cognitive
relaxation, various forms of BF, and PMR may
all be used to treat insomnia. In addition,
the following behavioral approaches are generally
used to manage insomnia:
- Sleep hygiene, which
involves educating patients about behaviors
that may interfere with the sleep process,
with the hope that education about maladaptive
behaviors will lead to behavioral modification.
- Stimulus control therapy,
which seeks to create and protect conditioned
association between the bedroom and sleep.
Activities in the bedroom are restricted
to sleep and sex.
- Sleep restriction therapy,
in which patients provide a sleep log and
are then asked to stay in bed only as long
as they think they are currently sleeping.
This usually leads to sleep deprivation
and consolidation, which may be followed
by a gradual increase in the length of time
in bed.
- Paradoxical intention,
in which the patient is instructed not to
fall asleep, with the expectation that efforts
to avoid sleep will in fact induce it.
How
Successful Are These Approaches?
Pain
A plethora of studies
using a range of behavioral and relaxation approaches
to treat chronic pain is reported in the literature.
The measures of success reported in these studies
depend on the rigor of the research design,
the population studied, the length of followup,
and the outcome measures identified. As the
number of well-designed studies using a variety
of behavioral and relaxation techniques grows,
the use of meta-analysis as a means of demonstrating
overall effectiveness will increase. One carefully
analyzed review of studies on chronic pain,
including cancer pain, was prepared under the
auspices of the U.S. Agency for Health Care
Policy and Research (AHCPR) in 1990. A great
strength of the report was the careful categorization
of the evidential basis of each intervention.
The categorization was based on design of the
studies and consistency of findings among the
studies. These properties led to the development
of a 4-point scale that ranked the evidence
as strong, moderate, fair, or weak; this scale
was used by the panel to evaluate the AHCPR
studies.Evaluation of behavioral and relaxation
interventions for chronic pain reduction in
adults found the following:
- Relaxation: The evidence
is strong for the effectiveness of this
class of techniques in reducing chronic
pain in a variety of medical conditions.
- Hypnosis: The evidence
supporting the effectiveness of hypnosis
in alleviating chronic pain associated with
cancer seems strong. In addition, the panel
was presented with other data suggesting
the effectiveness of hypnosis in other chronic
pain conditions, which include irritable
bowel syndrome, oral mucositis, temporomandibular
disorders, and tension headaches.
- CBT: The evidence was
moderate for the usefulness of CBT in chronic
pain. In addition, a series of eight well-designed
studies found CBT superior to placebo and
to routine care for alleviating low back
pain and both rheumatoid arthritis and osteoarthritis-associated
pain, but inferior to hypnosis for oral
mucositis and to EMG BF for tension headache.
- BF: The evidence is
moderate for the effectiveness of BF in
relieving many types of chronic pain. Data
were also reviewed showing EMG BF to be
more effective than psychological placebo
for tension headache but equivalent in results
to relaxation. For migraine headache, BF
is better than relaxation therapy and better
than no treatment, but superiority to psychological
placebo is less clear.
- Multimodal Treatment:
Several meta-analyses examined the effectiveness
of multimodal treatments in clinical settings.
The results of these studies indicate a
consistent positive effect of these programs
on several categories of regional pain.
Back and neck pain, dental or facial pain,
joint pain, and migraine headaches have
all been treated effectively.
Although relatively
good evidence exists for the efficacy of several
behavioral and relaxation interventions in the
treatment of chronic pain, the data are insufficient
to conclude that one technique is usually more
effective than another for a given condition.
For any given individual patient, however, one
approach may indeed be more appropriate than
another.
Insomnia
Behavioral treatments
produce improvements in some aspects of sleep,
the most pronounced of which are for sleep
latency and time awake after sleep onset.
Relaxation and BF were both found to be effective
in alleviating insomnia. Cognitive forms of
relaxation such as meditation were slightly
better than somatic forms of relaxation such
as PMR. Sleep restriction, stimulus control,
and multimodal treatment were the three most
effective treatments in reducing insomnia.
No data were presented or reviewed on the
effectiveness of CBT or hypnosis. Improvements
seen at treatment completion were maintained
at followups averaging 6 months in duration.
Although these effects are statistically significant,
it is questionable whether the magnitude of
the improvements in sleep onset and total
sleep time are clinically meaningful. It is
possible that a patient-by- patient analysis
might show that the effects were clinically
valuable for a special set of patients, as
some studies suggest that patients who are
readily hypnotized benefited much more from
certain treatments than other patients did.
No data were available on the effects of these
improvements on patient self- assessment of
quality of life.
To adequately evaluate
the relative success of different treatment
modalities for insomnia, two major issues
need to be addressed. First, valid objective
measures of insomnia are needed. Some investigators
rely on self-reports by patients, whereas
others believe that insomnia must be documented
electrophysiologically. Second, what constitutes
a therapeutic outcome should be determined.
Some investigators use time until sleep onset,
number of awakenings, and total sleep time
as outcome measures, whereas others believe
that impairment in daytime functioning is
perhaps another important outcome measure.
Both of these issues require resolution so
that research in the field can move forward.
CritiqueSeveral
cautions must be considered threats to the internal
and external validity of the study results.
The following problems pertain to internal validity:
(1) full and adequate comparability among treatment
contrast groups may be absent; (2) the sample
sizes are sometimes small, lessening the ability
to detect differences in efficacy; (3) complete
blinding, which would be ideal, is compromised
by patient and clinician awareness of the treatment;
(4) the treatments may not be well described,
and adequate procedures for standardization
such as therapy manuals, therapist training,
and reliable competency and integrity assessments
have not always been carried out; and (5) a
potential publication bias, in which authors
exclude studies with small effects and negative
results, is of concern in a field characterized
by studies with small numbers of patients. With
regard to the ability to generalize the findings
of these investigations, the following considerations
are important:
- The patients participating
in these studies are usually not cognitively
impaired. They must be capable not only
of participating in the study treatments
but also of fulfilling all the requirements
of participating in the study protocol.
- The therapists must
be adequately trained to competently conduct
the therapy.
- The cultural context
in which the treatment is conducted may
alter its acceptability and effectiveness.
In summary, this literature
offers substantial promise and suggests a need
for prompt translation into programs of health
care delivery. At the same time, the state of
the art of the methodology in the field of behavioral
and relaxation interventions indicates a need
for thoughtful interpretation of these findings.
It should be noted that similar criticisms can
be made of many conventional medical procedures.
How
Do These Approaches Work?
The mechanism of action
of behavioral and relaxation approaches can
be considered at two levels: (1) determining
how the procedure works to reduce cognitive
and physiological arousal and to promote the
most appropriate behavioral response and (2)
identifying effects at more basic levels of
functional anatomy, neurotransmitter and other
biochemical activity, and circadian rhythms.
The exact biological actions are generally
unknown.
Pain
There appear to be two pain transmission circuits.
Some data suggest that a spinal cord-thalamic-frontal
cortex-anterior cingulate pathway plays a role
in the subjective psychological and physiological
responses to pain, whereas a spinal cord- thalamic-somatosensory
cortex pathway plays a role in pain sensation.
A descending pathway involving the periaqueductal
gray region modulates pain signals (pain modulation
circuit). This system can augment or inhibit
pain transmission at the level of the dorsal
spinal cord. Endogenous opioids are particularly
concentrated in this pathway. At the level of
the spinal cord, serotonin and norepinephrine
appear to play important roles.
Relaxation techniques as
a group generally alter sympathetic activity
as indicated by decreases in oxygen consumption,
respiratory and heart rate, and blood pressure.
Increased electroencephalographic slow wave
activity has also been reported. Although
the mechanism for the decrease in sympathetic
activity is unclear, one may infer that decreased
arousal (due to alterations in catecholamines
or other neurochemical systems) plays a key
role.
Hypnosis, in part because
of its capacity for evoking intense relaxation,
has been reported to reduce several types
of pain (e.g., lower back and burn pain).
Hypnosis does not appear to influence endorphin
production, and its role in the production
of catecholamines is not known.
Hypnosis has been hypothesized
to block pain from entering consciousness
by activating the frontal-limbic attention
system to inhibit pain impulse transmission
from thalamic to cortical structures. Similarly,
other CBT may decrease transmission through
this pathway. Moreover, the overlap in brain
regions involved in pain modulation and anxiety
suggests a possible role for CBT approaches
affecting this area of function, although
data are still evolving.
CBT also appears to exert
a number of other effects that could alter
pain intensity. Depression and anxiety increase
subjective complaints of pain, and cognitive-behavioral
approaches are well documented for decreasing
these affective states. In addition, these
types of techniques may alter expectation,
which also plays a key role in subjective
experiences of pain intensity. They also may
augment analgesic responses through behavioral
conditioning. Finally, these techniques help
patients enhance their sense of self control
over their illness enabling them to be less
helpless and better able to deal with pain
sensations.
Insomnia
A cognitive-behavioral model for insomnia (see Figure 1)
elucidates the interaction of insomnia with
emotional, cognitive, and physiologic arousal;
dysfunctional conditions, such as worry over
sleep; maladaptive habits (e.g., excessive time
in bed and daytime napping); and the consequences
of insomnia (e.g., fatigue and impairment in
performance of activities).
In the treatment of insomnia,
relaxation techniques have been used to reduce
cognitive and physiological arousal and thus
assist the induction of sleep as well as decrease
awakenings during sleep.
Relaxation is also likely
to influence decreased activity in the entire
sympathetic system, permitting a more rapid
and effective "deafferentation" at sleep onset
at the level of the thalamus. Relaxation may
also enhance parasympathetic activity, which
in turn will further decrease autonomic tone.
In addition, it has been suggested that alterations
in cytokine activity (immune system) may play
a role in insomnia or in response to treatment.
Cognitive approaches may
decrease arousal and dysfunctional beliefs
and thus improve sleep. Behavioral techniques
including sleep restriction and stimulus control
can be helpful in reducing physiologic arousal,
reversing poor sleep habits, and shifting
circadian rhythms. These effects appear to
involve both cortical structures and deep
nuclei (e.g., locus ceruleus and suprachiasmatic
nucleus).
Knowing the mechanisms
of action would reinforce and expand use of
behavioral and relaxation techniques, but
incorporation of these approaches into the
treatment of chronic pain and insomnia can
proceed on the basis of clinical efficacy,
as has occurred with adoption of other practices
and products before their mode of action was
completely delineated.
Are
There Barriers To the Appropriate Integration
of These Approaches Into Health Care?
One barrier to the integration
of behavioral and relaxation techniques in
standard medical care has been the emphasis
solely on the biomedical model as the basis
of medical education. The biomedical model
defines disease in anatomic and pathophysiologic
terms. Expansion to a biopsychosocial model
would increase emphasis on a patient's experience
of disease and balance the anatomic/physiologic
needs of patients with their psychosocial
needs.
For example, of six factors
identified to correlate with treatment failures
of low back pain, all are psychosocial. Integration
of behavioral and relaxation therapies with
conventional medical procedures is necessary
for the successful treatment of such conditions.
Similarly, the importance of a comprehensive
evaluation of a patient is emphasized in the
field of insomnia where failure to identify
a condition such as sleep apnea will result
in inappropriate application of a behavioral
therapy. Therapy should be matched to the
illness and to the patient.
Integration of psychosocial
issues with conventional medical approaches
will necessitate the application of new methodologies
to assess the success or failure of the interventions.
Therefore, additional barriers to integration
include lack of standardization of outcome
measures, lack of standardization or agreement
on what constitutes successful outcome, and
lack of consensus on what constitutes appropriate
followup. Methodologies appropriate for the
evaluation of drugs may not be adequate for
the evaluation of some psychosocial interventions,
especially those involving patient experience
and quality of life. Psychosocial research
studies must maintain the high quality of
those methods that have been painstakingly
developed over the last few decades. Agreement
needs to be reached for standards governing
the demonstration of efficacy for psychosocial
interventions.
Psychosocial interventions
are often time intensive, creating potential
blocks to provider and patient acceptance
and compliance. Participation in BF training
typically includes up to 10-12 sessions of
approximately 45 minutes to 1 hour each. In
addition, home practice of these techniques
is usually required. Thus, patient compliance
and both patient and provider willingness
to participate in these therapies will have
to be addressed. Physicians will have to be
educated on the efficacy of these techniques.
They must also be willing to educate their
patients about the importance and potential
benefits of these interventions and to provide
encouragement for the patient through the
training processes.
Insurance companies provide
either a financial incentive or barrier to
access of care depending on their willingness
to provide reimbursement. Insurance companies
have traditionally been reluctant to reimburse
for some psychosocial interventions and reimburse
others at rates below those for standard medical
care. Psychosocial interventions for pain
and insomnia should be reimbursed as part
of comprehensive medical services at rates
comparable to those for other medical care,
particularly in view of data supporting their
effectiveness and data detailing the costs
of failed medical and surgical interventions.
The evidence suggests that
sleep disorders are significantly underdiagnosed.
The prevalence and possible consequences of
insomnia have begun to be documented. There
are substantial disparities between patient
reports of insomnia and the number of insomnia
diagnoses, as well as between the number of
prescriptions written for sleep medications
and the number of recorded diagnoses of insomnia.
Data indicate that insomnia is widespread,
but the morbidity and mortality of this condition
are not well understood. Without this information,
it remains difficult for physicians to gauge
how aggressive their intervention should be
in the treatment of this disorder. In addition,
the efficacy of the behavioral approaches
for treating this condition has not been adequately
disseminated to the medical community.
Finally, who should be
administering these therapies? Problems with
credentialing and training have yet to be
completely addressed in the field. Although
the initial studies have been done by qualified
and highly trained practitioners, the question
remains as to how this will best translate
into delivery of care in the community. Decisions
will have to be made about which practitioners
are best qualified and most cost-effective
to provide these psychosocial interventions.
What
Are the Significant Issues for Future Research
and Applications?
Research efforts on these
therapies should include additional efficacy
and effectiveness studies, cost-effectiveness
studies, and efforts to replicate existing
studies. Several specific issues should be
addressed:
Outcomes
- Outcome measures should
be reliable, valid, and standardized for
behavioral and relaxation interventions
research in each area (chronic pain, insomnia)
so that studies can be compared and combined.
- Qualitative research
is needed to help determine patients' experiences
with both insomnia and chronic pain and
the impact of treatments.
- Future research should
include examination of consequences/outcomes
of untreated chronic pain and insomnia;
chronic pain and insomnia treated pharmacologically
versus with behavioral and relaxation therapies;
and combinations of pharmacologic and psychosocial
treatments for chronic pain and insomnia.
Mechanism(s)
of Action
- Advances in the neurobiological
sciences and psychoneuroimmunology are providing
an improved scientific base for understanding
mechanisms of action of behavioral and relaxation
techniques and need to be further investigated.
Covariates
- Chronic pain and insomnia,
as well as behavioral and relaxation therapies,
involve factors such as values, beliefs,
expectations, and behaviors, all of which
are strongly shaped by one's culture. Research
is needed to assess cross-cultural applicability,
efficacy, and modifications of psychosocial
therapeutic modalities.
- Research studies that
examine the effectiveness of behavioral
and relaxation approaches to insomnia and
chronic pain should consider the influence
of age, race, gender, religious belief,
and socioeconomic status on treatment effectiveness.
Health
Services
- The most effective timing
of the introduction of behavioral interventions
into the course of treatment should be studied.
- Research is needed to
optimize the match between specific behavioral
and relaxation techniques and specific patient
groups and treatment settings.
Integration
Into Clinical Care and Medical Education
- New and innovative methods
of introducing psychosocial treatments into
health care curricula and practice should
be implemented.
Conclusions
A number of well-defined
behavioral and relaxation interventions are
now available, some of which are commonly used
to treat chronic pain and insomnia. Available
data support the effectiveness of these interventions
in relieving chronic pain and in achieving some
reduction in insomnia. Data are currently insufficient
to conclude with confidence that one technique
is more effective than another for a given condition.
For any given individual patient, however, one
approach may indeed be more appropriate than
another.
Behavioral and relaxation
interventions clearly reduce arousal, and
hypnosis reduces pain perception. However,
the exact biological underpinnings of these
effects require further study, as is often
the case with medical therapies. The literature
demonstrates treatment effectiveness, although
the state of the art of the methodologies
in this field indicates a need for thoughtful
interpretation of the findings along with
prompt translation into programs of health
care delivery.
Although specific structural,
bureaucratic, financial, and attitudinal barriers
exist to the integration of these techniques,
all are potentially surmountable with education
and additional research, as patients shift
from being passive participants in their treatment
to becoming responsible, active partners in
their rehabilitation.
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