Pain management programmes

Roxaneh Zarnegar MA MB BS MRCP FRCA

Clare Daniel D Clin Psy

Key points
Patients with chronic pain
commonly present with a
range of inter-related problems far beyond the pain itself.

Cognitive behavioural
intervention involves
identifying and challenging the
patients unhelpful beliefs,
thoughts, emotions and
behaviours and the
development of new, helpful
coping strategies.
Physical reconditioning,
patient education and working
towards long-term functional
and psychological goals are
the main components of
PMPs.
There is good evidence for the
efficacy of cognitive
behavioural intervention in
chronic pain.

Roxaneh Zarnegar MA MB BS MRCP

FRCA
Pain Fellow
Chronic Pain Service
Chelsea and Westminster Hospital
369 Fulham Road
London
SW10 9NH
Clare Daniel D Clin Psy
Consultant Clinical Psychologist and
Research Associate
Department of Anaesthetics and
Intensive Care
Imperial College London
Chelsea and Westminster Campus
369 Fulham Road
London SW10 9NH
Tel: 020 8746 8188
Fax: 020 8237 5109
E-mail: c.daniel@imperial.ac.uk
(for correspondence)

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Responses to pain and pain

behaviours
Pain behaviours are verbal and non-verbal
behaviours that communicate the presence of
pain to others. They include autonomic responses that are readily recognizable in acute
pain (e.g. tachycardia, perspiration) but habituate over time and are not a frequent feature
of persistent pain, as well as responses that are
more controllable by the individual ranging
from body postures and simple vocalizations
(e.g. sighs) to more complex verbal reports and
medication use. It is immediately obvious that
pain behaviours are not always maladaptive
and are at times encouraged by clinicians, especially in treating acute pain. Other responses to
pain include fear of movement and re-injury,1
low mood, anger and frustration.2 When pain
is acute and self-limiting, these responses generally resolve over time. However, when pain
persists, they may lead to unhelpful behavioural change.
Pain is generally thought of as a sign of
ongoing or impending harm. Medical help is
sought to identify the problem and provide a
remedy. This linear model of health care provision breaks down when applied to most people with chronic pain. Chronic pain is often
worsened by activity but unless associated
with a persistent inflammatory condition (e.g.
rheumatoid arthritis) is not an indicator of
damage. However, many patients find it difficult to relinquish the commonly perceived

association between pain and harm and

develop anxiety and fear not only associated
with pain itself but also in relation to the movements that exacerbate it. Fear of movement
combined with low mood caused by the experience of unremitting pain leads to reduced activity. Over time, physical deconditioning occurs
and attempts at increasing activity produces
more muscular pain or even the impression
of new problems as the patient notices reduced
physical endurance and agility. This not only
feeds into the belief that more rest is needed
in order to get better but may also introduce
anxiety about worsening undiagnosed pathology. Inactivity, anxiety, and low mood become
maintaining factors for disability and worsen
the pain experience.3 The combination of these
predisposes to social isolation, employment
problems and reduced self esteem as well as
increasing reliance on social and medical
services (Fig. 1).
The behavioural changes associated with
chronic pain are not consciously motivated
and it is important not to confuse them with
malingering, which is conscious and deliberate in nature. A thorough physical and psychological assessment is needed to ascertain
the existence of and the maintaining factors
behind pain behaviours. This practice is very
useful in planning future management but
is often not possible if behaviour is only
observed for a limited period in a short clinic
appointment.
By the time of presentation to the pain
clinic, there is often a history of successive
inconclusive investigations combined with
the experience of several failed treatments.
Some patients will have had their pain misinterpreted as psychological because of these
inconclusive findings; an often unhelpful message that may only serve to increase patients
distress. Most are left with no explanation
for either the symptoms or the treatment failures and feel dismissed and angry while
facing a constant demand to react and adapt
to pain. Chronic pain patients therefore commonly present with a range of inter-related
functional, psychological and social problems

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Pain management programmes (PMP) aim to reduce the

distress and disabilities
associated with chronic pain.

The idea that chronic pain is a multi-faceted

problem that needs intervention from a range
of specialists in different disciplines is well
established. Pain management programmes
(PMP) bring the skills of various disciplines
together in the management of patients whose
life is affected by the problem of persistent pain.
In this article, we will first consider the cognitive and behavioural responses to chronic pain
that are subject to intervention in PMPs and
then provide an overview of the principle components of most programmes and the rationale
behind them.

Pain management programmes

Table 1 A summary of the aims of pain management programmes

Pain
Unhelpful thoughts and
beliefs about re-injury,
damage etc.

Fear and
anxiety

Secondary physical effects

Reduced cardiorespiratory
fitness, muscle weakness,
poor balance and posture,
joint stiffness

Rest and
avoidance

Psychosocial effects
e.g. disengagement with valued
activities, low mood, frustration,
reduced self esteem

Fig. 1 The biopsychosocial effects of chronic pain.

far beyond the pain itself. Multidisciplinary assessment is imperative in most cases.

What are pain management programmes?

PMPs provide cognitive-behavioural multidisciplinary interventions that aim to help patients learn self management strategies to
reduce the distress and disabilities associated with chronic pain
and improve function and quality of life (Table 1). They do this by
increasing patients understanding of chronic pain and bringing
about change in unhelpful behaviours, beliefs and thoughts
through cognitivebehavioural intervention (CBI). CBI is the
main thread that runs through all aspects of a PMP and is practised
by all the therapists involved in it.
Pain relief is not the primary goal of the PMP. However,
improvements in overall pain levels may occur indirectly through
encouraging time-contingent rather than pain-contingent activity.
PMPs are defined, time-limited programmes that are delivered
in a group setting and may be in-patient- or out-patient-based. At
present, they vary in their content and the number of disciplines
involved. This variation is a product of the needs of the patients
attending the programme as well as differing levels of resources
and skills that are locally available. At minimum, the team is
comprised of the patient, a pain physician, a clinical psychologist
and a physiotherapist but many PMPs also involve a specialist
nurse and an occupational therapist. There is as yet insufficient
evidence for the required components of PMPs to be fully
defined.4 However, physical reconditioning, patient education
and working towards long-term functional and psychological
goals form the back bone of most programmes. The beliefs, behaviour and distress of significant others in a patients life can reinforce certain behaviour patterns. Some programmes involve the
patients families in selected sessions in order to facilitate behavioural change in everyday life.

Cognitive-behavioural intervention
CBI is the cornerstone of all PMPs. The initial phase of any CBI
process constitutes the patient and the therapist working together
to identify and evaluate the unhelpful thoughts, emotions and
behaviours that contribute to the patients difficulties. Before
starting a PMP, patients are assessed in terms of their beliefs
about the causes of pain, the cognitions, affect and behaviours
associated with it, the coping strategies employed and the effects
of pain on the patients life. This will help identify goals and targets
for intervention. Chronic pain patients are often focused on a
medical approach to their problems and have sought and received
various medical treatments for long periods of time. The team
needs to help the patient understand the self management
approach and ensure that the patient has realistic expectations
of themselves and the programme.
The relationship between thoughts, emotions and biological
and behavioural responses are well recognized and responses to
pain are no exception. Unhelpful beliefs and thoughts, for example
pain means that I am damaging my body or moving will damage
my body further and cause pain lead to anxiety and fear about
movement and any accompanying pain. They can therefore form
formidable barriers to return to activity, contributing significantly
to disability in many patients.
Once the unhelpful thoughts, beliefs and emotions are identified, CBI helps patients understand the relationship between these
and behavioural responses to pain and recognize how they contribute to disability and overall distress. With assistance from
the therapist, patients are then encouraged to re-evaluate their
thoughts and beliefs. This may involve engaging in feared activities, reflecting on the outcome and developing new, more helpful
beliefs. In chronic pain patients, CBI also aims to tackle unhelpful
coping strategies such as excessive reliance on family members
or prolonged rest, which patients often assume to be helpful
but are in fact exacerbating their problems.
Overall, patients are encouraged to adopt more helpful beliefs,
behaviours and coping strategies that lead to less emotional distress, disability and therefore dependence.

Education
Education is an integral part of all PMPs. A consultant pain
physician should explain the complex aetiology and natural history of pain, acknowledging present short comings in our understanding of chronic pain. As a credible source of information to
most patients, the pain consultant can also clarify the rationale

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Increased reliance
on social and
medical services

Improve patients understanding of their pain and the behaviours and cognitions that
may be increasing or maintaining their distress and difficulties
Reduce pain-related distress
Improve physical functioning and reduce disability
Return to valued activities
Review and reduce medication
Develop ways to manage exacerbations in pain

Pain management programmes

Physical reconditioning
For many chronic pain patients the pattern of physical activity
constitutes prolonged episodes of under-activity, owing to
exacerbation of pain or fear of re-injury, interrupted by bouts
of over-activity during a period of temporary reduction of
pain. Over-activity describes activity that continues beyond
the patients tolerance resulting in an increase in pain. It may
follow an intervention that has temporarily reduced pain intensity
or be associated with beliefs and thoughts for example I must do
the house work before my partner returns. Over-activity exacerbates pain as well as bringing out the symptoms of an unfit cardiorespiratory system. Gradually, the bouts of activity become less
frequent and the rest periods become longer as fitness levels and
physical tolerance decline. Successive failures in performing tasks,
owing to increase in pain or de-conditioning, predispose to negative psychological effects such as depression, frustration and low
self-esteem.
During a PMP, patients are encouraged to engage in a graded
exercise programme in the context of education about the benefits of activity and the detrimental consequences of disuse. This
is combined with pacing, a technique that encourages timecontingent rather than symptom-contingent activity with gradual
and planned increase in work load. Its aim is for patients to
increase their level of function and fitness and achieve a balanced
pattern of activity.

Maintenance of goals and preparing for

challenging times
A successful PMP equips patients not only with the skills that
are needed to reach their specific goals but also the skills that

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are required to maintain their achievements and manage situations

that could precipitate an exacerbation in pain and disability. During a PMP, patients are encouraged to formulate a plan for selfmanagement of exacerbations so that their detrimental impact on
life is reduced. This may include prioritizing of activities, relaxation techniques and re-evaluating unhelpful thoughts and beliefs.
Most patients are easily able to identify situations that are
likely to put them under strain and may trigger exacerbations
these may be events such as a childs illness that increases the
emotional and/or physical demands on the patient. They can
then be introduced to the idea that stressful events can be planned
for, using similar techniques to those mentioned above, so that an
exacerbation of pain becomes less likely to occur.

Evidence for cognitive-behavioural intervention and

future research
A recent systematic review of CBI for chronic pain has showed
that, compared with waiting list controls, CBI is effective in reducing disability and unhelpful pain related behaviours, restoring
function and improving mood. Compared with treatments
provided through the pain clinic and physiotherapy, CBI is
more effective in improving cognitive strategies to self-manage
pain, social and physical function, mood and pain experience
(defined in terms of intensity, sensation and unpleasantness).6
The chronic pain patient population is heterogeneous. Even
when patients suffer from similar symptoms, there are differences
in underlying pathology, existing coping mechanisms, general
health and social and cultural background. This heterogeneity
makes research into the area difficult and, when combined with
variation between PMPs, we should be cautious in extrapolating
the results of any one study. Current evidence suggests that
psychological characteristics are more reliable determinants of
outcome from CBI than demographic data, medical diagnosis
or physical findings. Highly negative perceptions of pain, greater
perceived disability and loss of control are associated with poorer
outcome. In contrast, during the process of CBI, reductions in
perceived disability, helplessness and pain-related anxiety are predictors of a more positive outcome.7
Organizations that pay for health care expect PMPs to be
cost-effective. Historically, factors such as return to employment
and reduced use of health care or social service resources have been
cited as desirable outcome measures for PMPs but they are
more complex than they appear in the first instance. Accurate
information about use of services is often difficult to obtain
and use can shift from one type of service to another. In terms
of employment, the number of people returning to work at the
same level of productivity and income after a long period of absence is low and many start a different type of work altogether.
Other outcomes such as improved quality of life, psychological
well-being and better social and family relationships undoubtedly
have socioeconomic value but this is difficult to measure. There is
evidence to suggest that programmes in which re-employment is
the main focus are more effective in achieving this goal than

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behind treatments and investigations and answer questions about

the limitations of medical therapies. A separate session is often
devoted to analgesics, how they should be used and methods for
rationalizing or reducing their intake.
Educational sessions are shared with a physiotherapist who
explains the basics of anatomy, posture and mechanisms of healing after injury as well as discussing physical fitness and the consequences of deconditioning. Patients are often surprised that
during periods of temporary reduction in pain, they are unable
to return to the level of activity that they had before the onset of
their chronic symptoms. Many also have anxieties about pain and
other symptoms after exercise signalling the occurrence of damage
to the body. Educational sessions are an appropriate forum for
addressing these concerns.
Education in itself is not necessarily effective in producing
sustained changes in beliefs and behaviour.5 However, this may
be the first time that the patients have had the opportunity to have
a frank discussion with a physician or therapist about many of the
issues surrounding their persistent pain without the inherent time
pressures and psychological constraints of the clinic environment. Educational sessions will often make patients more receptive to the self-management approach.

Pain management programmes

The evidence for this approach has so far been extremely

promising.

References
1. Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic
musculoskeletal pain: a state of the art. Pain 2000; 85: 31732
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3. Turk DC and Monarch ES. Biopsychosocial perspective on chronic pain. In:
Gatchel RJ, Turk DC, eds. Psychological Approaches to Pain Management, a
Practitioners Handbook, 2 Edn. London: Guilford Press, 2002; 329
4. Morley S. Process and change in cognitive behaviour therapy for chronic
pain. Pain 2004; 109: 2056
5. de Jong JR, Vlaeyen JW, Onghena P, Goossens ME, Geilen MP,
Mulder HO. Fear of movement/(re)injury in chronic low back pain:
education or exposure in vivo as mediator to fear reduction? Clin J Pain
2005; 21: 917
6. Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of
randomized controlled trials of cognitive behaviour therapy and behaviour
therapy for chronic pain in adults, excluding headache. Pain 1999; 80: 113
7. McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment
for chronic pain. Spine 2002; 27: 256473
8. Watson PJ, Booker CK, Moores L, Main CJ. Returning the chronically
unemployed with low back pain to employment. Eur J Pain 2004; 8:
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See multiple choice questions 6265.

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general PMPs.8 It is possible that PMPs need to be more tailored to

individual needs and characteristics in order to increase their
effectiveness.9
Maintenance of the improvements gained during a programme
is another critical issue. How long do the perceived benefits
from a PMP last in the face of ongoing symptoms or changes
in a patients health, social and environmental factors? Are
follow-up programmes of any benefit? These questions remain
largely unanswered. Although PMPs have been shown to produce
good outcomes in the short-term, most studies in this area have
only followed patients up for around 1 year.
Patients who attend PMPs have generally already been through
a range of medical interventions. At present, ongoing medical
intervention is an exclusion criterion for most PMPs. This is
thought to help patients move away from the medical model of
pain relief and encourage the self management approach, but its
necessity is under question. Theoretically, there are few reasons
why cognitivebehavioural pain management should not be introduced to patients while medication changes and interventional
treatments are on-going. The issue of whether PMPs have a
role earlier in pain management rather than being used as a
last resort has important implications in terms of how it may
be viewed by both patients and health care professionals.
Chronic pain has a wide range of adverse physical, psychological and behavioural effects on a patients life. PMPs are CBIs
that offer patients ways to move away from these detrimental
effects and self-manage their symptoms; resulting in reduced
disability, distress and reliance on health and social services.