Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. NIH Technol Assess Statement 1995 Oct 16-18:1-34

For 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
• Introduction
• 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?
• Technology Assessment Panel
• Speakers
• Planning Committee
• Conference Sponsors
• Conference Cosponsors
• Bibliography
• About the NIH Consensus Development Program
• Statement Availability

• 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.

  
   

  Technology Assessment Panel

  Julius Richmond, M.D.
  Conference and Panel Chairperson
  The John D. MacArthur Professor of Health Policy Emeritus
  Department of Social Medicine
  Harvard Medical School
  Boston, Massachusetts

  Brian M. Berman, M.D.
  Director
  Division of Complementary Medicine
  Department of Family Medicine
  University of Maryland School of Medicine
  Baltimore, Maryland

  John P. Docherty, M.D.
  Vice Chairman
  Department of Psychiatry
  Cornell University Medical College
  Associate Medical Director
  New York Hospital/Cornell University
  White Plains, New York

  Larry B. Goldstein, M.D.
  Associate Professor of Medicine
  Division of Neurology
  Department of Medicine
  Assistant Research Professor
  Center for Health Policy Research and Education
  Duke University Medical Center
  Durham VA Medical Center
  Durham, North Carolina

  Gary Kaplan, D.O.
  Clinical Faculty
  Department of Family and Community Medicine
  Georgetown University School of Medicine
  Family Practice Associates of Arlington
  Arlington, Virginia

  Julian E. Keil, Dr.P.H., F.A.C.C.
  Professor of Epidemiology, Emeritus
  Department of Biostatistics, Epidemiology, and Systems Science
  Medical University of South Carolina
  Charleston, South Carolina

  Stanley Krippner, Ph.D.
  Professor of Psychology
  Saybrook Institute Graduate School and Research Center
  San Francisco, California

  Sheila Lyne, R.S.M., M.B.A., M.S.
  Commissioner
  Chicago Department of Public Health
  DePaul Center
  Chicago, Illinois

  Frederick Mosteller, Ph.D.
  Professor of Mathematical Statistics, Emeritus
  Departments of Statistics and Health Policy and Management
  Harvard University
  Cambridge, Massachusetts

  Bonnie B. O'Connor, Ph.D.
  Assistant Professor
  Department of Community and Preventive Medicine
  Medical College of Pennsylvania and
  Hahnemann University School of Medicine
  Philadelphia, Pennsylvania

  Ellen B. Rudy, Ph.D., R.N., F.A.A.N.
  Dean
  School of Nursing
  University of Pittsburgh
  Pittsburgh, Pennsylvania

  Alan F. Schatzberg, M.D.
  Professor and Chairman
  Department of Psychiatry
  Stanford University School of Medicine
  Stanford, California

  Speakers

  Herbert Benson, M.D.
  "The Common Physiological Events That Occur When Behavioral and Relaxation Approaches Are Practiced by Patients"
  Chief, Division of Behavioral Medicine
  Deaconess Hospital
  Associate Professor of Medicine
  Mind/Body Medical Institute
  Boston, Massachusetts

  Edward B. Blanchard, Ph.D.
  "Biofeedback and its Role in the Treatment of Pain"
  Distinguished Professor of Psychology
  Center for Stress and Anxiety Disorders
  Department of Psychology
  University of Albany
  State University of New York
  Albany, New York

  Laurence A. Bradley, Ph.D.
  "Cognitive Intervention Strategies for Chronic Pain: Assumptions Underlying Cognitive Therapy"
  Professor of Medicine
  Department of Medicine
  Division of Clinical Immunology and Rheumatology
  University of Alabama at Birmingham School of Medicine
  Birmingham, Alabama

  Daniel J. Buysse, M.D.
  "Potential Mechanisms of Action of Behavioral and Relaxation Treatments in Insomnia"
  Associate Professor of Psychiatry
  Department of Psychiatry
  Western Psychiatric Institute and Clinic
  University of Pittsburgh Medical Center
  Pittsburgh, Pennsylvania

  Helen J. Crawford, Ph.D.
  "Use of Hypnotic Techniques in the Control of Pain: Neuropsychophysiological Foundation and Evidence"
  Department of Psychology
  College of Arts and Sciences
  Virginia Polytechnic Institute and State University
  Blacksburg, Virginia

  William C. Dement, M.D., Ph.D.
  "The Insomnia Problem: Definitions and Scope"
  Lowell W. and Josephine Q. Berry Professor of Psychiatry and Sleep Medicine
  Department of Psychiatry and Behavioral Sciences
  Director, Sleep Research Center
  Stanford University School of Medicine
  Palo Alto, California

  Howard L. Fields, M.D., Ph.D.
  "Brain Systems for Pain Modulation: Understanding the Neurobiology of the Therapeutic Process"
  Professor of Neurology and Physiology
  Department of Neurology
  School of Medicine
  University of California, San Francisco
  San Francisco, California

  David A. Fishbain, M.Sc., M.D., F.A.P.A.
  "Chronic Pain Treatment Meta-Analyses: A Mathematical and Qualitative Review and Patient-Specific Predictors of Response"
  Professor of Psychiatry and Neurological Surgery
  University of Miami School of Medicine and the University of Miami Comprehensive Pain Center
  Miami Beach, Florida

  Richard Friedman, Ph.D.
  "Conference Background"
  Professor of Psychiatry and Behavioral Science
  Department of Psychiatry
  State University of New York at Stony Brook
  Stony Brook, New York

  Rollin M. Gallagher, M.D.
  "The Comprehensive Pain Clinic: A Biobehavioral Approach to Pain Management and Rehabilitation"
  Associate Professor of Psychiatry and Family Medicine
  Director
  The Comprehensive Pain and Rehabilitation Center
  State University of New York at Stony Brook
  Stony Brook, New York

  J. David Haddox, D.D.S., M.D.
  "Overview of Pain"
  Assistant Professor
  Anesthesiology and Psychiatry
  Emory University School of Medicine
  Atlanta, Georgia

  Kristyna M. Hartse, Ph.D.
  "Intervention and Patient-Specific Response Rates"
  Director
  Sleep Disorders Center
  Associate Professor
  Department of Psychiatry and Human Behavior
  St. Louis University Health Sciences Center School of Medicine
  St. Louis, Missouri

  Peter J. Hauri, Ph.D.
  "Behavioral Treatment of Insomnia"
  Professor of Psychology
  Mayo Medical School
  Director, Insomnia Program
  Department of Psychology
  Sleep Disorders Center
  The Mayo Clinic
  Rochester, Minnesota

  Eileen C. Helzner, M.D.
  "Clinical Integration With Pharmacologic Treatments"
  Director, Clinical Development
  McNeil Consumer Products Company
  Johnson & Johnson
  Ft. Washington, Pennsylvania

  Ada Jacox, R.N., Ph.D.
  "Outcomes Research on Integration: Lessons From Cancer and Acute Pain"
  Professor and Independence Foundation
  Chair in Health Policy
  School of Nursing
  Johns Hopkins University
  Baltimore, Maryland

  Jeffrey M. Jonas, M.D.
  "Clinical Integration With Pharmacologic Treatments"
  Vice President of Clinical Development
  The Upjohn Company
  Kalamazoo, Michigan

  Francis J. Keefe, Ph.D.
  "Intervention-Specific Response Rates"
  Professor of Medical Psychology
  Pain Management Program
  Department of Psychiatry and Behavioral Sciences
  Duke University Medical Center
  Durham, North Carolina

  Kenneth L. Lichstein, Ph.D.
  "Defining Relaxation Approaches as They Relate to Biomedicine"
  Professor of Psychology
  Department of Psychology
  The University of Memphis
  Memphis, Tennessee

  John D. Loeser, M.D.
  "Integration of Behavioral and Relaxation Approaches With Surgery in the Treatment of Chronic Pain: A Clinical Perspective"
  Professor of Neurological Surgery and Anesthesia
  Director, Multidisciplinary Pain Center
  University of Washington School of Medicine
  Seattle, Washington

  Wallace B. Mendelson, M.D.
  "Integrating Pharmacologic and Nonpharmacologic Treatment of Insomnia"
  Director
  Sleep Disorders Center
  Section of Epilepsy and Sleep Disorders
  Department of Neurology
  The Cleveland Clinic Foundation
  Professor of Psychiatry
  Ohio State University
  Cleveland, Ohio

  David Orme-Johnson, Ph.D.
  "Meditation in the Treatment of Chronic Pain and Insomnia"
  Director of Research
  Chair, Department of Psychology
  Maharishi International University
  Fairfield, Iowa

  Thomas Roth, Ph.D.
  "Assessment and Methodological Problems in the Evaluation of Insomnia Treatment"
  Chief
  Division of Sleep Medicine
  Director
  Sleep Disorders and Research Center
  Department of Psychiatry
  Henry Ford Hospital
  Detroit, Michigan

  Dennis C. Turk, Ph.D.
  "Assessing People Reporting Pain Not Just the Pain"
  Professor of Psychiatry Anesthesiology, and Behavioral Science
  Director
  Pain Evaluation and Treatment Institute
  University of Pittsburgh School of Medicine
  Pittsburgh, Pennsylvania

  Next   Planning Committee