For Pain Management
Hypnosis, biofeedback, cognitive behavioral therapy, and
various relaxation procedures have all been shown to be effective in
treating pain. A typical complementary medicine protocol for addressing
acute and chronic pain may include all of the above procedures and in
addition, use of aromatherapy (oil of lavender), acupuncture,
magneto-therapy, massage reflexology or polarity therapy, hydrotherapy,
and the use of standardized herbs.
Hypnosis in particular has been hypothesized to block pain
from entering consciousness by activating the frontal-limbic attention
system to inhibit pain impulse transmission from thalamic to cortical
structures. Cognitive behavioral techniques may decrease transmission of
pain through this pathway also.
Journal of the American Medical Association, July 24/31, 1996 -
Volume 276. No 4
A Positive Approach - Its
all in our Attitude
Our methods will specifically
assist clients with personal management not related to a medical or mental
health disorder. Doctor recommended clients are welcome to learn how
to apply these techniques. Learn to apply the technicues to alter
habits and increase motivation at work, in your productivity, in sports
activities and enhance creative, artistic and scholastic endeavors!
Crucial to anyones well
being is having a healthy and positive outlook.
Optimism, a positive outlook and a healthy immune system rank very
high importance to our holistic well being!
Managing our attitudes concerning pain depends on these important
aspects of our thought processes. A
virtual plethora of studies have been directed by physicians and
scientists - regarding the effects of endorphins and seratonin on our
mental and physical health.
Just about all pain will
respond to hypnosis. Pain from cancer, arthritis, headaches, back pain,
injury and other conditions can be reduced by hypnosis. The
more you use it the better it works for you and with practice you can
achieve incredible results. Self-Hypnosis
becomes an important component in this process.
Doctor recommended clients are
welcome to learn how to apply these techniques.
Virtually everyone experiences a bout with chronic or acute pain at
some period in his or her life. There are no side effects.
Hypnosis For Pain Management
is very relaxing and may replace pain medication.
Ask your doctor and read the studies about pain and hypnosis.
Often patients turn to medication to relieve the pain
At times the side effects of medication are almost as bad as the
pain itself. Some people will avoid drugs and will suffer with the pain.
The resulting pain can often cause personality changes by creating
angry, irritability, sadness and withdrawn individuals.
Progressively more people suffering with chronic pain are turning to
hypnosis. Hypnosis, along with medical treatment, has several advantages
in pain management:
it requires no drugs,
it has no harmful side effects,
it is not addicting,
it helps to reduce stress and adds relaxation,
it produces deep relaxation that helps relieve pain.
Some painful conditions, such as headaches or neck pain, are often
aggravated by stress and can be eased by relaxation alone. The effects can
be euphoric. Even those
conditions that are not directly stress related can often be helped with
hypnosis. Read what the National Institute of Health says.
Hypnosis can be used as part of a total pain management program. You
should always have your condition diagnosed by a qualified physician
before using hypnosis to control your pain.
Hypnosis is safe. All who suffer from chronic pain should explore
hypnosis. It is safe for adults and children.
We strongly recommend Hypnosis and guided imagery as an important
pain management intervention.
RECOMMENDED PAIN MANAGEMENT INTERVENTIONS
Acupuncture & Accupressure
Relaxation Response Training
Physical and occupational therapy
Aromatherapy - Aromatic oil of Lavender
Herbs including Ginger and Capiscum
Imagery & Relaxation Exercises
Neuro Linguistic Programming (NLP)
also encourage reading:
The Worldwide Congress on Pain Web Site at www.pain.com
The Cancer Pain Page Web Site at www.mdacc.tmc.edu/~acc
The Wellness Book by Herbert Benson, M.D. and Eileen M. Stuart, R.N.
Chronic Pain Control Workbook by E. M. Catalano, MA. and K. N. Hardin,
How To Cope With Chronic Pain by Nelson Hendler, M.D.
Managing Pain Before It Manages You by Margaret A. Caudill, MD., and Ph.D.
All Books written by Dr. Wayne Dyer.
can decrease pain with the power of YOUR mind.
Distraction is a key element in soothing aches and pains. Hypnosis can
guide focus away from the source of the pain. Put it out of your
mind. relief can be achieved by distracting the pain from our
minds. Imagine a pleasant scene, imagine that one's body is numb in
the area of pain, focusing on breathing, or even singing a song.
Practice simple tasks that are able to take your mind off of the
pain that you are feeling. develop a method that becomes habit
forming! Practice creates habit!
Pain is the single most prevalent basis for going to a physician;
pain is the reason so many people take medication.
Hypnosis wasn't approved by the American Medical Association until 1958,
but doctors have been using it for medical treatment in place of an
anesthetic for many years. Hypnosis is a well-established element of
medical, dental, and psychological practice. HYPNOSIS is a valuable
SELF-HYPNOSIS gives an individual a distinct
advantage. This is hypnosis that you do for yourself.
When you are doing this by yourself, more seems to come to your mind in a
clearer sense than when someone else is giving you suggestions. When a
person learns to hypnotize themselves, they can induce relaxation any
time, in any place or in any situation. There are few people that have a
day go by without being under stress or have a headache from a hard day at
work, school, or home. With the help of self-hypnosis, issues such as
these can be resolved quickly on your own. Knowing & practicing
self-hypnosis can help you have a stress-free life. All it takes is
the three main components of hypnosis which are relaxation, concentration,
and auto-suggestion, the process of a person suggesting thoughts to
him/herself. A reduction of stress will make you a better person,
and those around you will enjoy your company.
Imagery is a wonderful tool. Our mind
is powerful you can control pain using your brain power. The
brain is the center of pain. You can tap into that area of the mind and
create an image of what is causing the pain. Simply picture throwing the
source of pain away. This puts the pain in your own hands, and you are in
control. Creating images is not the only way to control pain. Focusing
your mind on something other than the pain, know as dissociation, has the
same effect. Focus and concentration are vital. Very positive
approaches to pain resolution are achievable with the right tools at your
mind is powerful you can control pain using your brain power.
"Healing Rhythms uses biofeedback to access your innate healing abilities to restore your physical, mental and spiritual health."
Deepak Chopra, M.D.
Buy Healing Rhythms
read this very positive report from the NIH regarding approaches into the
treatment of Chronic Pain:
National Institute of Health Consensus Report:
Institutes of Health
Technology Assessment Conference Statement
October 16-18, 1995
This statement is published as:
Integration of Behavioral and Relaxation Approaches into the Treatment of
Chronic Pain and Insomnia. NIH Technol Assess Statement - 1995 Oct
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.
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
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.
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
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; at considerable expense 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 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
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.
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 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
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.
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 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.
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
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.
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
Successful Are These Approaches?
A plethora of studies using a range of behavioral and relaxation
approaches to treat chronic pain is reported in the literature. The
measures of success reported in these studies depend on the rigor of the
research design, the population studied, the length of followup, and the
outcome measures identified. As the number of well-designed studies using
a variety of behavioral and relaxation techniques grows, the use of
meta-analysis as a means of demonstrating overall effectiveness will
One carefully analyzed review of studies on chronic pain, including cancer
pain, was prepared under the auspices of the U.S. Agency for Health Care
Policy and Research (AHCPR) in 1990. A great strength of the report was
the careful categorization of the evidential basis of each intervention.
The categorization was based on design of the studies and consistency of
findings among the studies. These properties led to the development of a
4-point scale that ranked the evidence as strong, moderate, fair, or weak;
this scale was used by the panel to evaluate the AHCPR studies.
Evaluation of behavioral and relaxation interventions for chronic pain
reduction in adults found the following:
Relaxation: The evidence is strong for the effectiveness of this
class of techniques in reducing chronic pain in a variety of medical
Hypnosis: The evidence supporting the effectiveness of hypnosis
in alleviating chronic pain associated with cancer seems strong. In
addition, the panel was presented with other data suggesting the
effectiveness of hypnosis in other chronic pain conditions, which include
irritable bowel syndrome, oral mucositis, temporomandibular disorders, and
CBT: The evidence was moderate for the usefulness of CBT in
chronic pain. In addition, a series of eight well-designed studies found
CBT superior to placebo and to routine care for alleviating low back pain
and both rheumatoid arthritis and osteoarthritis-associated pain, but
inferior to hypnosis for oral mucositis and to EMG BF for tension
BF: The evidence is moderate for the effectiveness of BF
in relieving many types of chronic pain. Data were also reviewed showing
EMG BF to be more effective than psychological placebo for tension
headache but equivalent in results to relaxation. For migraine headache,
BF is better than relaxation therapy and better than no treatment, but
superiority to psychological placebo is less clear.
Multimodal Treatment: Several meta-analyses examined the effectiveness of
multimodal treatments in clinical settings. The results of these studies
indicate a consistent positive effect of these programs on several
categories of regional pain. Back and neck pain, dental or facial pain,
joint pain, and migraine headaches have all been treated effectively.
Although relatively good evidence exists for the efficacy of several
behavioral and relaxation interventions in the treatment of chronic pain,
the data are insufficient to conclude that one technique is usually more
effective than another for a given condition. For any given individual
patient, however, one approach may indeed be more appropriate than
Behavioral treatments produce improvements in some aspects of sleep, the
most pronounced of which are for sleep latency and time awake after sleep
onset. Relaxation and BF were both found to be effective in alleviating
insomnia. Cognitive forms of relaxation such as meditation were slightly
better than somatic forms of relaxation such as PMR. Sleep restriction,
stimulus control, and multimodal treatment were the three most effective
treatments in reducing insomnia. No data were presented or reviewed on the
effectiveness of CBT or hypnosis. Improvements seen at treatment
completion were maintained at followups averaging 6 months in duration.
Although these effects are statistically significant, it is questionable
whether the magnitude of the improvements in sleep onset and total sleep
time are clinically meaningful. It is possible that a patient-by- patient
analysis might show that the effects were clinically valuable for a
special set of patients, as some studies suggest that patients who are
readily hypnotized benefited much more from certain treatments than other
patients did. No data were available on the effects of these improvements
on patient self- assessment of quality of life.
To adequately evaluate the relative success of different treatment
modalities for insomnia, two major issues need to be addressed. First,
valid objective measures of insomnia are needed. Some investigators rely
on self-reports by patients, whereas others believe that insomnia must be
documented electrophysiologically. Second, what constitutes a therapeutic
outcome should be determined. Some investigators use time until sleep
onset, number of awakenings, and total sleep time as outcome measures,
whereas others believe that impairment in daytime functioning is perhaps
another important outcome measure. Both of these issues require resolution
so that research in the field can move forward.
Several cautions must be considered threats to the internal and external
validity of the study results. The following problems pertain to internal
validity: (1) full and adequate comparability among treatment contrast
groups may be absent; (2) the sample sizes are sometimes small, lessening
the ability to detect differences in efficacy; (3) complete blinding,
which would be ideal, is compromised by patient and clinician awareness of
the treatment; (4) the treatments may not be well described, and adequate
procedures for standardization such as therapy manuals, therapist
training, and reliable competency and integrity assessments have not
always been carried out; and (5) a potential publication bias, in which
authors exclude studies with small effects and negative results, is of
concern in a field characterized by studies with small numbers of
With regard to the ability to generalize the findings of these
investigations, the following considerations are important:
· The patients participating in these studies are usually not cognitively
impaired. They must be capable not only of participating in the study
treatments but also of fulfilling all the requirements of participating in
the study protocol.
· The therapists must be adequately trained to competently conduct the
· The cultural context in which the treatment is conducted may alter its
acceptability and effectiveness.
In summary, this literature offers substantial promise and suggests a need
for prompt translation into programs of health care delivery. At the same
time, the state of the art of the methodology in the field of behavioral
and relaxation interventions indicates a need for thoughtful
interpretation of these findings. It should be noted that similar
criticisms can be made of many conventional medical procedures.
How Do These Approaches Work?
The mechanism of action of behavioral and relaxation approaches can be
considered at two levels: (1) determining how the procedure works to
reduce cognitive and physiological arousal and to promote the most
appropriate behavioral response and (2) identifying effects at more basic
levels of functional anatomy, neurotransmitter and other biochemical
activity, and circadian rhythms. The exact biological actions are
There appear to be two pain transmission circuits. Some data suggest that
a spinal cord-thalamic-frontal cortex-anterior cingulate pathway plays a
role in the subjective psychological and physiological responses to pain,
whereas a spinal cord- thalamic-somatosensory cortex pathway plays a role
in pain sensation. A descending pathway involving the periaqueductal gray
region modulates pain signals (pain modulation circuit). This system can
augment or inhibit pain transmission at the level of the dorsal spinal
cord. Endogenous opioids are particularly concentrated in this pathway. At
the level of the spinal cord, serotonin and norepinephrine appear to play
Relaxation techniques as a group generally alter sympathetic activity as
indicated by decreases in oxygen consumption, respiratory and heart rate,
and blood pressure. Increased electroencephalographic slow wave activity
has also been reported. Although the mechanism for the decrease in
sympathetic activity is unclear, one may infer that decreased arousal (due
to alterations in catecholamines or other neurochemical systems) plays a
Hypnosis, in part because of its capacity for evoking intense relaxation,
has been reported to reduce several types of pain (e.g., lower back and
burn pain). Hypnosis does not appear to influence endorphin production,
and its role in the production of catecholamines is not known.
Hypnosis has been hypothesized to block pain from entering consciousness
by activating the frontal-limbic attention system to inhibit pain impulse
transmission from thalamic to cortical structures. Similarly, other CBT
may decrease transmission through this pathway. Moreover, the overlap in
brain regions involved in pain modulation and anxiety suggests a possible
role for CBT approaches affecting this area of function, although data are
CBT also appears to exert a number of other effects that could alter pain
intensity. Depression and anxiety increase subjective complaints of pain,
and cognitive-behavioral approaches are well documented for decreasing
these affective states. In addition, these types of techniques may alter
expectation, which also plays a key role in subjective experiences of pain
intensity. They also may augment analgesic responses through behavioral
conditioning. Finally, these techniques help patients enhance their sense
of self control over their illness enabling them to be less helpless and
better able to deal with pain sensations.
A cognitive-behavioral model for insomnia (see Figure 1) elucidates the
interaction of insomnia with emotional, cognitive, and physiologic
arousal; dysfunctional conditions, such as worry over sleep; maladaptive
habits (e.g., excessive time in bed and daytime napping); and the
consequences of insomnia (e.g., fatigue and impairment in performance of
In the treatment of insomnia, relaxation techniques have been used to
reduce cognitive and physiological arousal and thus assist the induction
of sleep as well as decrease awakenings during sleep.
Relaxation is also likely to influence decreased activity in the entire
sympathetic system, permitting a more rapid and effective "deafferentation"
at sleep onset at the level of the thalamus. Relaxation may also enhance
parasympathetic activity, which in turn will further decrease autonomic
tone. In addition, it has been suggested that alterations in cytokine
activity (immune system) may play a role in insomnia or in response to
Cognitive approaches may decrease arousal and dysfunctional beliefs and
thus improve sleep. Behavioral techniques including sleep restriction and
stimulus control can be helpful in reducing physiologic arousal, reversing
poor sleep habits, and shifting circadian rhythms. These effects appear to
involve both cortical structures and deep nuclei (e.g., locus ceruleus and
Knowing the mechanisms of action would reinforce and expand use of
behavioral and relaxation techniques, but incorporation of these
approaches into the treatment of chronic pain and insomnia can proceed on
the basis of clinical efficacy, as has occurred with adoption of other
practices and products before their mode of action was completely
Are There Barriers To the Appropriate Integration of These Approaches Into
One barrier to the integration of behavioral and relaxation techniques in
standard medical care has been the emphasis solely on the biomedical model
as the basis of medical education. The biomedical model defines disease in
anatomic and pathophysiologic terms. Expansion to a biopsychosocial model
would increase emphasis on a patient's experience of disease and balance
the anatomic/physiologic needs of patients with their psychosocial needs.
For example, of six factors identified to correlate with treatment
failures of low back pain, all are psychosocial. Integration of behavioral
and relaxation therapies with conventional medical procedures is necessary
for the successful treatment of such conditions. Similarly, the importance
of a comprehensive evaluation of a patient is emphasized in the field of
insomnia where failure to identify a condition such as sleep apnea will
result in inappropriate application of a behavioral therapy. Therapy
should be matched to the illness and to the patient.
Integration of psychosocial issues with conventional medical approaches
will necessitate the application of new methodologies to assess the
success or failure of the interventions. Therefore, additional barriers to
integration include lack of standardization of outcome measures, lack of
standardization or agreement on what constitutes successful outcome, and
lack of consensus on what constitutes appropriate followup. Methodologies
appropriate for the evaluation of drugs may not be adequate for the
evaluation of some psychosocial interventions, especially those involving
patient experience and quality of life. Psychosocial research studies must
maintain the high quality of those methods that have been painstakingly
developed over the last few decades. Agreement needs to be reached for
standards governing the demonstration of efficacy for psychosocial
Psychosocial interventions are often time intensive, creating potential
blocks to provider and patient acceptance and compliance. Participation in
BF training typically includes up to 10-12 sessions of approximately 45
minutes to 1 hour each. In addition, home practice of these techniques is
usually required. Thus, patient compliance and both patient and provider
willingness to participate in these therapies will have to be addressed.
Physicians will have to be educated on the efficacy of these techniques.
They must also be willing to educate their patients about the importance
and potential benefits of these interventions and to provide encouragement
for the patient through the training processes.
Insurance companies provide either a financial incentive or barrier to
access of care depending on their willingness to provide reimbursement.
Insurance companies have traditionally been reluctant to reimburse for
some psychosocial interventions and reimburse others at rates below those
for standard medical care. Psychosocial interventions for pain and
insomnia should be reimbursed as part of comprehensive medical services at
rates comparable to those for other medical care, particularly in view of
data supporting their effectiveness and data detailing the costs of failed
medical and surgical interventions.
The evidence suggests that sleep disorders are significantly
underdiagnosed. The prevalence and possible consequences of insomnia have
begun to be documented. There are substantial disparities between patient
reports of insomnia and the number of insomnia diagnoses, as well as
between the number of prescriptions written for sleep medications and the
number of recorded diagnoses of insomnia. Data indicate that insomnia is
widespread, but the morbidity and mortality of this condition are not well
understood. Without this information, it remains difficult for physicians
to gauge how aggressive their intervention should be in the treatment of
this disorder. In addition, the efficacy of the behavioral approaches for
treating this condition has not been adequately disseminated to the
Finally, who should be administering these therapies? Problems with
credentialing and training have yet to be completely addressed in the
field. Although the initial studies have been done by qualified and highly
trained practitioners, the question remains as to how this will best
translate into delivery of care in the community. Decisions will have to
be made about which practitioners are best qualified and most
cost-effective to provide these psychosocial interventions.
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:
· 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
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
· 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.
· 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
Integration Into Clinical Care and Medical Education
· New and innovative methods of introducing psychosocial treatments into
health care curricula and practice should be implemented.
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.
About the NIH Consensus Development Program:
NIH Consensus Development Conferences are convened to evaluate available
scientific information and resolve safety and efficacy issues related to a
biomedical technology. The resultant NIH Consensus Statements are intended
to advance understanding of the technology or issue in question and to be
useful to health professionals and the public.
NIH Consensus Statements are prepared by a nonadvocate, non- Federal panel
of experts, based on (1) presentations by investigators working in areas
relevant to the consensus questions during a 2-day public session, (2)
questions and statements from conference attendees during open discussion
periods that are part of the public session, and (3) closed deliberations
by the panel during the remainder of the second day and morning of the
third. This statement is an independent report of the panel and is not a
policy statement of the NIH or the Federal Government.