Afton L. Hassett, PsyD
From the Department of Anesthesiology, University of Michigan, Ann Arbor, MI.
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• Objective: To provide an overview of the critical treatment domains for patients with chronic pain and describe nonpharmacologic strategies by which these domains can be addressed.
• Methods: A literature review was conducted to evaluate the evidence underlying commonly used nonpharmacologic strategies for the treatment of chronic pain, with a focus on interventions that require patient engagement.
• Results: Nonpharmacologic interventions that actively engage the patient in pain management, such as exercise, behavioral activation, sleep hygiene, and stress management, are relatively easy to implement and do not necessarily require the expertise of mental health professionals. Nonpharmacologic strategies can directly address pain and also address secondary complications, and thus serve to enhance treatment outcomes.
• Conclusion: The critical domains approach can be used to organize a comprehensive nonpharmacologic approach to treating widespread chronic pain.
According to the Institute of Medicine (IOM), chronic pain affects more Americans than coronary heart disease, diabetes, and cancer combined at an estimated cost of $635 billion per year . While it has been demonstrated that we have reasonably good ability to reduce acute pain, providing pharmacologic treatment with even modest effects when addressing chronic pain remains challenging . The ability to treat one form of pain successfully but not the other stems from the fact that chronic pain is not a simple extension of acute pain [2,3]; rather, the mechanisms differ and so must the treatments. The IOM report called for a cultural transformation in how pain is understood, assessed, and treated. In response, the National Pain Strategy  was developed. It was recommended that efficacious self-management strategies be used for individuals with chronic pain; such strategies are largely nonpharmacologic .
This article presents an approach to addressing chronic pain using nonpharmacologic strategies. While a number of nonpharmacologic treatments involve patients as passive recipients (eg, massage, acupuncture, balneotherapy or spa treatments), most require the patient to be engaged, eg, to exert physical energy, learn a new skill, and/or change a behavior. The approach presented here is organized around addressing critical domains, including the need to increase activity, deal with psychiatric comorbidities, address sleep problems, and tackle stress. The strategies suggested will be those that have the best evidence base and are predominantly ones that can be deployed by physicians and other health care professionals who do not necessarily have specialized training in behavioral health. A case is presented to illustrate this approach.
Lisa is a 42-year-old Caucasian woman with a 2-year history of chronic low back pain presenting to a primary care clinic. She reported that the back pain began when she was working as an office manager in a busy dental clinic. The onset was sudden, occurring when she lifted a heavy box of copier paper using a “leaning and twisting motion.” The pain is described as constant (rated as 5 out of 10) and she experiences periods of more intense pain or “flares” (rated as 9 out of 10); Lisa noted that “10 is reserved for childbirth.” The flares seem to coincide with periods of stress and can result in up to 2 days of immobility, causing her to miss work at the dental office.
The pain is described as deep, aching, and throbbing but does not radiate to her legs. It is made worse by sitting still for longer than an hour and gets better if she keeps moving and gets a good night of sleep. Her sleep is generally disturbed as she has trouble falling asleep and when she does sleep, she usually wakes up feeling unrefreshed and extremely irritable. Moreover, while she knows that activity makes her pain better, Lisa can rarely find the energy or motivation to exercise.
Various evaluations by specialists have been obtained and studies conducted, including a recent MRI. All were found to be negative for a clear-cut pathology. A visit to a rheumatologist 5 years ago resulted in a diagnosis of fibromyalgia that Lisa does not accept. Upon probing, she detailed what turns out to be an almost 20-year history of chronic pain. The back pain is only the latest diagnosis in an extensive list of painful conditions including premenstrual syndrome (PMS), headache, temporomandibular joint disorder (TMJ), and fibromyalgia. There are no aspects of her history or presentation that suggest a diagnosis other than chronic musculoskeletal pain.
Lisa is a divorced mother of 2 adolescent children who are generally well-adjusted if not age-appropriately defiant. She is overweight (body mass index = 29) and admits to overeating when under stress. She says that the back pain has disrupted every aspect of her life and work is the only thing that gets adequate attention. Her salary is critical to her family’s financial stability, thus it is a priority. Lisa noted that she saves all of her energy for her job and has “nothing left in the tank” for her children or herself. She notes that, “I have zero joy in my life—I rarely go anywhere fun with my kids anymore, putter in my garden, and forget about going on dates. I can’t remember the last enjoyable thing I did!”
• What are aspects to consider in addressing this patient’s symptoms?
Lisa’s case is likely recognizable—she presents with a long history of pain in multiple areas of her body (eg, low back pain, PMS, headache, TMJ) without clear-cut pathology. She has multiple physical and social problems and limited resources. The diagnosis of fibromyalgia is likely correct. The low back pain is probably another manifestation of a broader “centralized pain” condition [5,6]. The term centralized pain refers to the amplification of pain via changes in the central nervous system [7,8]. This does not mean that peripheral nociceptive input (ie, tissue damage or inflammation) plays no role in the pain; however, it implies that any painful stimulus is experienced with greater intensity than would be expected [5,6]. Further, psychological, behavioral, and social elements tend to be key factors in centralized pain states due in part to the exhausting challenge of living with chronic pain, as well as genetic factors that predispose to both pain and mood disturbances .
Due to the often complex nature of chronic pain, successful treatment usually requires addressing multiple areas of concern, including addressing behavioral, cognitive, and affective processes. It is suggested that a plan for nonpharmacologic pain management could be built around 6 domains represented by the acronym ExPRESS , namely Exercise, Psychological distress, Regaining function, Emotional well-being, Sleep hygiene, and Stress management. This article provides a review of the literature that focuses on systematic reviews and meta-analyses to summarize a massive literature largely supporting the use of nonpharmacologic strategies such as exercise, cognitive-behavioral therapy, mindfulness-based treatments, behavioral self-management, resilience-based interventions, and education to address the ExPRESS  domains using Lisa’s case as an example.
• How effective is exercise for treating chronic pain and how should it be integrated into treatment?
Over the last 5 years, a number of meta-analyses have been conducted to evaluate a robust literature regarding exercise interventions for the treatment of chronic pain [11–14]. The evidence is strong that patients with chronic pain benefit from increased physical activity and in many cases the effect size is quite substantial . Meta-analytic data suggest that aerobic exercise results in significantly less pain and disability , improved physical fitness , less fatigue and better mood . Exercise can be land-based or water-based , be conducted at a slight to moderate intensity and/or even involve only a program of walking . Most established guidelines highlight the benefits of including exercise as part of the nonpharmacologic management of patients with chronic pain [15–18].
Data suggest that chronic pain patients should begin exercise training slowly starting at levels below capacity and increase duration and intensity over time until patients are exercising at low to moderate intensity (ie, 50% to 70% of age-adjusted maximum heart rate) for 20 to 30 minutes per session 2 to 3 times per week .
Obesity and deconditioning are common and are thought to contribute to pain sensitivity, poor sleep, and depressed mood . Lisa is overweight and inactive. She injured her back and reports generally avoiding any form of exercise. Getting her moving will be imperative as an increase in physical activity could not only help her to lose weight, but could have the added benefits of decreasing her pain and stiffness, helping her sleep better and improving her mood and self-esteem. Yet, she reports not having the time or motivation.
A reasonable approach would be to not prescribe formal exercise at first but rather encourage small and immediate changes in how she already goes about her day. One concrete step would be to encourage her to stand up and stretch every 20 minutes or so while working at her computer. This is something that she cites as directly contributing to her pain. Next, an increase in physical activity such as adding a few steps every day and doing regular activities with more vigor would be a great initial step.
One of the most formidable barriers to getting patients to exercise is the perception that they must go to the gym and begin a formal program in order to achieve any benefit. As an employed single mother with two children Lisa likely lacks the time and resources for a formal exercise program. She could instead, begin a walking program that starts with reasonable goals (eg, 6000 steps per day) and builds at a slow and steady pace (eg, add 100 steps per day). Activity trackers range in price, but a simple pedometer can be found for under $10. By initiating such a walking program, the things she does already such as chores around the house all count as physical activity. She could do these with more energy and mindfulness and incrementally add activity over time.
Once a new habit of increased physical activity has been established, the strategy of branching out into new physical activities (or even more formal exercise) is usually more successful especially if they are enjoyable and feasible (ie, affordable, not too time consuming). The need to engage in more physical activity could be the impetus to encourage Lisa to do more activities with her children—walking to the park, flying a kite, and exploring the science museum are all activities that can provide physical, emotional and social benefits simultaneously.
• What interventions are helpful in addressing psychiatric comorbidity?
Comorbidity with mood and anxiety disorders is often observed and complicates treatment in patients with chronic pain states [21–23]. Patients with centralized pain conditions like fibromyalgia tend to have even higher rates of psychiatric comorbidity than those with other pain conditions like arthritis alone [24–26]. While estimates vary widely, we have recently reported that 36.2% of patients evaluated in our tertiary care setting meet case criteria for depression . Such psychiatric comorbidity has been shown to be associated with increased pain, worse functioning, higher costs and increased use of opioids [27–30]. Further, suicidal ideation is common in chronic pain populations, especially those with depression and anxiety, and should be carefully evaluated if suspected . The presence of psychiatric comorbidity takes a toll on the individual and society. One study found that pain patients with comorbid depression utilized twice the resources that other patients without depression utilized . Perhaps the most troubling element is that psychiatric comorbidity is too often not adequately addressed in medical settings .
Assessing for depression using a standardized measure like the PHQ-9  or anxiety using the GAD-7  can provide a sense of the severity of the psychiatric symptoms. More severe forms of depression and anxiety may require referral, but more mild depressive and/or anxiety symptoms may be treated by the medical personnel the patient already knows and trusts. Nonpharmacologic strategies that can be used to address depression, anxiety, and even pain in chronic pain populations include cognitive-behavioral therapy, exercise/physical activity, regulating sleep and behavioral activation (ie, getting patients engaged with valued activities, social support).
Perhaps the most effective strategy to address depression, anxiety, and pain in chronic pain populations is cognitive-behavioral therapy (CBT) [36–38]. CBT for pain consists of both cognitive and behavioral therapy interventions. Cognitive therapy proposes that modifying maladaptive thoughts will result in changes in emotions and behavior . Thus, errors in thinking like catastrophizing, overgeneralizing, and minimizing positives are confronted and changed to more realistic and helpful thoughts. This results in less emotional distress and fewer self-defeating behaviors. In cognitive therapy for chronic pain, catastrophic thoughts such as “My pain is terrible and nothing I do helps” are replaced by more adaptive thoughts like “Although my pain is severe, there still are a few things I can do to make it a little better.” Several behavioral techniques are also employed such as behavioral activation (getting patients moving again), activity pacing (not overdoing it on days patients feel good and remaining active on days they feel bad), sleep hygiene (identifying then changing behaviors know to disrupt sleep), and relaxation skills (eg, breathing, imagery, progressive muscle relaxation). Meta-analyses have shown that CBT has empirical support for its effectiveness in treating patients with chronic pain [40,41].
During the visit, Lisa reported a loss of joy in her life and then began crying. Such a report should prompt a more formal exploration of the potential for depression. She would likely benefit from antidepressant medication and behavioral intervention. The physical activity prescribed above will also pertain to treating her depressive symptoms as will strategies to improve her emotional well-being, sleep and stress noted below. Perhaps the most beneficial strategy would be to refer her to CBT for pain and depressive symptoms. CBT for pain would help Lisa acquire the skills required to address many ExPRESS  domains including increasing physical activity, improving mood, decreasing stress, and improving sleep.
• What strategy can be recommended to help patients regain function?
Pain is disruptive. Patients with pain may avoid activity due to fear of re-injury or making the pain worse. Pain may keep them awake at night and lead to daytime fatigue. Pain can be so bad that a patient cannot even do simple tasks, One of the most important goals in successfully managing pain is to move away from trying to cure the pain and instead focus on regaining function—helping the patient do some of the things he/she really wants to do despite the pain. The patient may not be able to all the things he/she used to do, but new ways to do many of these activities can be found. Patients can also identify new rewarding activities to do now that things have changed.
To regain function, an evidence-based strategy comes from behavior therapy and is known as graded activation [42–46]. Here the patient is assigned one very small, manageable and incremental step towards achieving a goal. As these small goals are met, the patient feels motivated to engage in more and larger goals.
Lisa specifically mentioned giving up valued activities in light of her chronic pain. To help her re-engage a graded task assignment approach can be taken. For example, Lisa would be encouraged to first identify an activity she would like to get back to doing again. If she were to say “gardening,” then she is to next identify one small, specific, and easily achievable goal for the short term, such as “garden for 20 minutes at least once in the next week.” Help her identify the roadblocks to completing this small goal and brainstorm solutions such as “My kids have soccer and basketball practices 5 days next week so I will ask my ex-husband take them to practice at least one day next week so I can spend time in my garden.” Lisa will be told to schedule time to garden as if it were an appointment with a doctor.
Another important issue to consider is the tendency for inconsistent levels of activities across days that are predicated on how one feels that particular day. On “good days” often patients inadvertently engage in more activity than personal limitations allow and as a consequence experience several “bad days” of pain and other symptom flare up which can result in lost productivity and worse self-esteem. The goal is to have patients engage in a moderate amount of activity every day and avoid activity “binges” or days with little of no activity. Graded activation is a method of pacing that can improve physical functioning while minimizing the likelihood of pain flare-ups.
• What simple strategies can be used to improve patients’ emotional well-being?
Psychological distress and emotional well-being occur along a continuum. Eliminating psychological distress only returns one to a state of being without distress. That is not the same as experiencing emotional well-being or happiness. People with chronic pain who also have higher levels of emotional well-being (or happiness) have decreased pain severity, fewer symptoms, better levels of functioning, and greater life satisfaction [47–49].
Recent studies provide preliminary evidence suggesting that resilience-based interventions such as keeping a gratitude journal or scheduling time to engage in pleasant activities boast equivalence or even superiority to CBT for the treatment of mood with effects that persist over time [50,51]. Two recent meta-analyses have shown that resilience-based interventions have been used to treat healthy individuals and a range of clinical conditions with a mean effect size for improving well-being ranging between 0.34 to 0.61 (ie, moderate-large effects [Cohen’s d]) [52,53]. Positive activities interventions are thought to function by increasing positive affect, which in turn, enables creativity, problem-solving, perspective-taking, and other beneficial states . Such states are conducive to better mood [55,56], behavioral activation/increased physical activity [57–60], better sleep [61–63], increased social support [54,64] and physiological changes (eg, improved vagal tone, lower blood pressure, more adaptive immune responses) [57,65–69]. Recent studies have successfully adapted resilience-based interventions and shown them to be effective for individuals with pain [70–72]. Resilience-based interventions may be particularly helpful for chronic pain patients given that depression and sleep disturbances are frequent comorbidities [5,21–26,28,73,74].
Lisa stated, “I have zero joy in my life…” and later burst into tears. It is easy to surmise that her emotional well-being is quite poor. She also noted that she saves all of her energy for her job and has “nothing left in the tank” for her children or herself. This is a common picture for individuals with chronic pain. Valued life activities like spending quality time with loved ones, going to sporting events or doing a hobby are put aside in favor of obligatory (eg, activities of daily living) and committed (eg, work, school) activities. While this strategy might help one survive, it certainly is not conducive to thriving. To help Lisa improve her emotional well-being, there are good data supporting pleasant activity scheduling amongst other strategies. For pleasant activity scheduling Lisa would be directed to set aside time a few days a week (at least an hour) to do things that she enjoys. This time should be placed on her calendar and treated with the same level of commitment as going to work or to an appointment with her physician.
• What nonpharmacologic options are available to help improve patients’ sleep?
Lisa indicated that she has trouble falling asleep and then when she does sleep, she usually wakes up feeling unrefreshed and irritable. This is a common complaint amongst individuals with chronic pain who often report difficulty falling asleep, being awakened by pain or discomfort and awakening feeling unrefreshed and unrestored . Sleep, pain and mood form a symptomatic triad such that when one aspect is affected the others are impacted. For example, when Lisa does not sleep well, her pain and mood worsen, as well. Conversely, when her pain is better, she likely sleeps better and wakes up feeling less irritable and experiences less pain.
Behavioral strategies for improving sleep, if used on a regular basis, can help individuals get needed restorative sleep with the additional benefits of improving mood, pain, fatigue, and mental clarity . Some of these behavioral strategies focus on maintaining regular sleep routines (go to bed at the same time every night even on weekends), engaging in sleep conducive behaviors (eg, attempting to sleep only when in feeling sleepy), and avoiding stimulating activities (eg, watching action movies, or consuming nicotine or caffeine). Studies have shown that behavioral strategies targeting sleep appear to have a direct impact on pain symptoms and on functional interference resulting from nonrestorative sleep [77,78].
A good place to start would be directing Lisa to keep a sleep diary for one week. Here she would note the times she went to bed, how long it takes for her to fall asleep, how many times she awakens and gets up during the night, how long she sleeps and how she feels upon waking up (refreshed or still exhausted). Next, a list of behaviors that can help her sleep better can be offered (Table 1). She can be asked, “What new good sleep habits from the list might you be willing to try?”
• What stress reduction strategies can be recommended to the patient?
Stress management has long been a target of treatment in patients with chronic pain. Progressive muscle relaxation (PRM)  and autogenic training have typically served as an important foundation of behavioral intervention for chronic pain  although there are no randomized controlled trials for PRM as a stand-alone intervention and two separate trials of autogenic training failed to find superiority for this intervention [81,82]. Despite the lack of direct evidence, clinical experience and the knowledge that both relaxation techniques are commonly part of CBT for chronic pain, their efficacy is generally accepted.
An emerging area of nonpharmacologic treatment is mindfulness-based interventions , which can include mindfulness-based stress reduction (MBSR) and Acceptance and Commitment Therapy , which can be considered a hybrid between mindfulness meditation and CBT. These interventions are still relatively new and larger, better controlled studies are needed. In MBSR, the patient is directed to focus on one thing such as a sound, a pleasant scene or their own breathing. The practitioner is encouraged to keep thoughts present oriented and analytical concerns are to be gently dismissed in favor of focusing on the sounds, scene, or breath. A recent meta-analysis evaluating 15 studies in clinical populations reported that there were small to medium effect sizes for patients with chronic pain . In another new meta-analysis evaluating only studies in chronic pain the authors reported that sleep quality and pain acceptance were the 2 variables with the largest effect sizes based on the 11 studies they evaluated . Similarly, a meta-analysis that included both MBSR and ACT found that 22 studies of varying quality suggest significant but small effect sizes for pain (ES = 0.37) and depression (ES = 0.32) . They concluded the mindfulness-based treatments were not superior to CBT but could be a viable alternative.
For Lisa and many other chronic pain patients, the symptom flares seem to coincide with periods of stress. These flare ups are not inconsequential and have cost her days of lost productivity and potentially put her employment at risk. Moreover, she has identified stress as a trigger for over-eating which certainly contributes to her weight problems and low self-esteem. MBSR can be learned in a structured class or online–many of the principles can be taught by lay instructors.
While it is likely that health care professionals will continue to rely on pharmacological therapies in treating chronic pain, it is important to be aware that reliance on medications and procedural interventions alone is unlikely to bring adequate relief to individuals living with chronic pain . Optimal pain management appears to be achieved by using a combination of both pharmacologic and nonpharmacologic approaches. Nonpharmacologic interventions that actively engage the patient in pain management such as exercise, behavioral activation, sleep hygiene and stress management are relatively easy to implement and do not necessarily require the expertise of mental health professionals. The challenge is considering pain in its biopsychosocial contexts and defining an approach that is both comprehensive and feasible. Using the ExPRESS domains to help guide care can provide a road map.
Corresponding author: Afton L. Hassett, PsyD, 24 Frank Lloyd Wright Drive, Lobby M, CPFRC, Ann Arbor, MI 48106, email@example.com.
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