Behavioral and Psychological Interventions
Spine or other pain is experienced by each individual through a complex interaction of neurological (peripheral and central), psychological, and social variables. Pain elicits various autonomic, neuro-protective, and affective responses.  These physiologic and cognitive-behavioral responses can be altered with appropriate training and insight, leading to partial control of central processing of pain, or influence the activation of descending pain inhibition pathways. [2, 3] Training in one or more behavioral interventions for [chronic] pain might impart effective pain management tools and strategies for cervical radiculopathy (CR) or other pain patients. [4-8] Persson, et al  found that patients with CR often have concomitant behavioral or emotional dysfunction and suggested that treatment outcomes were enhanced by the inclusion of a cognitive-behavioral approach to the treatment program. It is clear that catastrophizing, fear of pain, and anxiety can have an impact on the pain experience.  There is evidence that catastrophizing has a biological influence on the endogenous opiod pain-control systems, systemic inflammatory processes, and may influence muscle tone, blood pressure, and heart contractility responses to pain. [11, 12] It is important to address depression, anxiety, and sleep disturbances as part of a comprehensive treatment program. [2, 13, 14]
Reviews of biopsychosocial rehabilitation  and patient education  programs for the treatment of neck pain have not revealed high quality studies which would support these approaches. Nevertheless, it is recommended that conservative care practitioners include behavioral interventions in their conservative treatment plans, and develop a network of behavioral intervention providers so that treatment options can be paired with the unique needs and preferences of each subject.
- Informal psychological inquiry may be carried out by a physiatrist or other qualified provider in order to screen for evidence of depression, anxiety, sleep disorder, high addiction potential, or other psychological disorders, which may influence subjects’ response to treatment. Patients may also be provided with educational written material, making them aware of some of the signs of depression, insomnia, or anxiety, as well as an introduction to some of the treatment strategies that may assist with pain management (Appendix). This will include an invitation to discuss these matters with their physician. Identified disorders should be treated with specific psychological, and possibly pharmacological, interventions.
- One or more of the following approaches may be offered to patients : cognitive behavioral therapy (CBT), habit reversal, relaxation training, biofeedback, meditation, hypnosis and guided imagery, assertiveness skills training, and patient education. Written educational material can also be provided to each patient (download available).
Appendix: Psychological Education Materials for Patients:
It is well known and accepted that your state of mind can have a significant impact on how you perceive and manage your pain. There are many non-medication strategies that can be used to gain some control over how you are affected by pain. Treating associated problems such as depression, anxiety, or insomnia, which frequently accompany pain, can also help reduce pain levels.
Recognizing the signs of depression is not always easy. If you are experiencing feelings of sadness, emotional ups and downs, have lost interest in social or other (previously) fun activities, have trouble getting out of bed in the morning, have lost your appetite or energy, have a sense of hopelessness, you feel agitated or anxious, then please do not hesitate to discuss these symptoms with your doctor. These may be signs of depression or another medical condition.
Anxiety, the frequent feeling of nervousness, fear, or feeling uptight, can be present with or worsen in response to pain. It, in turn, can make your experience of pain tougher to cope with. Also, a lack of restful sleep can have a negative effect on your ability to manage pain. If you are experiencing significant difficulty sleeping, whether it is from pain, worry, or other reasons, you should bring this to the attention of your doctor.
There are many ways to deal with pain or associated problems with mood, anxiety, or sleep. Aerobic (cardio) exercise can be very helpful because it causes the release of chemicals in the brain that are helpful for all of these problems. This makes exercise an ideal form of pain and stress management. Your goal should be to gradually increase the amount of weekly exercise to 2 ½ total hours of moderate to vigorous exercise. Choose a form of exercise that you can tolerate and enjoy, and consider mixing types. Biking, walking, swimming or pool walking, endurance strength training, yoga, Tai Chi, or Pilates are good examples. Seek guidance on the safety or appropriateness of these exercises for you, specifically, from your doctor or physical therapist.
Relaxation training can be done with the help of instructional recordings, biofeedback specialists, or pain psychologists. This can be an excellent way to control pain or anxiety, and to promote sleep.
Good sleep “hygiene” includes the avoidance of television or computer work in bed before sleep, stopping caffeine at or before lunch, and having a notepad by your bedside to write down any recurring thoughts or ideas so that you can “let them go”.
These and other useful ideas for managing your pain can be learned through the help of a pain psychologist, or by working with other specialists. Your doctor can help counsel you, or direct you to the approach or specialist that is right for you. Medications may occasionally be used to treat pain, depression, anxiety, or sleep disorders, as well.
1. Turk, D.C., K.S. Swanson, and H.D. Wilson, Psychological Aspects of Pain, in Bonica’s management of pain, S. Fishman, et al., Editors. 2010, Lippincott, Williams & Wilkins: Baltimore, MD. p. 74-85.
2. Fishman, S., et al., Bonica’s management of pain. 4th ed2010, Baltimore, MD: Lippincott, Williams & Wilkins. xxxiii, 1661 p.
3. Lorenz, J. and M. Hauck, Supraspinal Mechanisms of Pain and Nociception, in Bonica’s management of pain, S. Fishman, et al., Editors. 2010, Lippincott, Williams & Wilkins: Baltimore, MD. p. 61-73.
4. Argoff, C.E., et al., Multimodal analgesia for chronic pain: rationale and future directions. Pain Med, 2009. 10 Suppl 2: p. S53-66.
5. Jain, R., Pain and the brain: lower back pain. J Clin Psychiatry, 2009. 70(2): p. e41.
6. Jain, R., L. Culpepper, and V. Maletic, Pain and the brain 2: the recognition and management of chronic pain in primary care. J Clin Psychiatry, 2009. 70(11): p. e43.
7. van Tulder, M.W., et al., Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine (Phila Pa 1976), 2000. 25(20): p. 2688-99.
8. Henschke, N., et al., Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev, 2010(7): p. CD002014.
9. Persson, L.C. and A. Lilja, Pain, coping, emotional state and physical function in patients with chronic radicular neck pain. A comparison between patients treated with surgery, physiotherapy or neck collar–a blinded, prospective randomized study. Disabil Rehabil, 2001. 23(8): p. 325-35.
10. Hirsh, A.T., et al., Fear of pain, pain catastrophizing, and acute pain perception: relative prediction and timing of assessment. J Pain, 2008. 9(9): p. 806-12.
11. Campbell, C.M. and R.R. Edwards, Mind-body interactions in pain: the neurophysiology of anxious and catastrophic pain-related thoughts. Transl Res, 2009. 153(3): p. 97-101.
12. Quartana, P.J., C.M. Campbell, and R.R. Edwards, Pain catastrophizing: a critical review. Expert Rev Neurother, 2009. 9(5): p. 745-58.
13. Smith, M.T., et al., Mechanisms by which sleep disturbance contributes to osteoarthritis pain: a conceptual model. Curr Pain Headache Rep, 2009. 13(6): p. 447-54.
14. McCracken, L., Pain and Anxiety and Depression, in Bonica’s management of pain, S. Fishman, et al., Editors. 2010, Lippincott, Williams & Wilkins: Baltimore, MD. p. 1230-1237.
15. Karjalainen, K., et al., Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine (Phila Pa 1976), 2001. 26(2): p. 174-81.
16. Haines, T., et al., A Cochrane review of patient education for neck pain. Spine J, 2009. 9(10): p. 859-71.