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
• 
  

  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.

  • Next   How Successful Are These Approaches?