- Cognitive Behavioral Therapy (CBT) is a biobehavioral, evidence-based treatment for chronic pain that effects physiological changes via cognitive, emotional, behavioral, and lifestyle changes (e.g., sleep, nutrition, exercise).
- Recommended as a first-line treatment by the CDC, Joint Commission, Pain Task Force of the Academic Consortium for Integrative Medicine and Health, Institute of Medicine (now Academy), NIH Interagency Pain Research Coordinating Committee.
- CBT has evidence of effectiveness for decreasing chronic pain and increasing functionality across populations and different medical conditions, and should be recommended prior to medications when considering a comprehensive pain treatment program.
- CBT addresses mal-adaptive beliefs about lower back pain, such as the belief that pain always indicates injury, which can trigger fear-avoidance behaviors.
- Behavioral therapy teaches individuals to identify and reduce behaviors that can trigger or worsen pain, while increasing “wellness” behaviors. Cognitive behavioral therapy (CBT) focuses on shifting the behavioral response to pain and therefore reinforce coping strategies to pain. This is shown to improve function and activity in the setting of pain.
- An example of how cognitive behavioral therapy can work is as follows: Imagine a patient has back pain that flares randomly throughout the day. He or she is concerned that the pain flare is linked to more injury in his back. Thus, the patient withdraws from weekly hobbies with friends such as golf, yoga, or tennis. The pain is no longer triggered by hobbies, however it now seems more random and more distressing than before. Cognitive behavioral therapy aids patients in recognizing triggers (physical activity can flare back pain), but helps patients redirect the negative response that causes withdrawal from activity. Rather than avoiding activity, CBT helps patients with a greater understanding of their pain flares, redirecting the urge to avoid activity by focusing on taking a mental break, then slowly returning to the activity progressively.
- For best results:
- CBT should be utilized in conjunction with pharmacotherapy
- A pain psychologist can prescribe or initiate a program lasting 12 weeks or more
- CBT can be delivered via individual or group sessions, virtually or in-person
Cognitive behavioral therapy (CBT)
Acupuncture
- Acupuncture is a non-pharmacologic modality that is patient-centered, effective and safe.
- Insurance companies may or may not cover the treatment, or may require your PCP’s prior authorization.
- For most patients, it is worth a trial of treatments (8-12 sessions) to see if they benefit with a qualified professional.
Biofeedback
- Pain itself cannot be easily detected or fed back by instruments, but body conditions associated with the pain can be. For example, there are machines that can detect the muscle tension or nerve activity on electromyography (EMG). For some patients with neck or pelvic pain, biofeedback can include training to recognize the signs of increased tension in different muscle groups.
- Biofeedback is less a “treatment” than a training technique. It involves creating an information loop between a physiological variable and the person’s awareness.
- By recognizing muscle tension, patients can intercept the trigger of tension by utilizing meditation, breathing, and other relaxation techniques.
- Common Outcomes after some sessions of biofeedback focused on pain:
- Better control over both pain intensity and response to pain (anxiety, depression, panic, anger)
- Reduced dependence on opioids and analgesics
- Having something to practice and improve upon (body control of some type)
- Improved quality of control over attention to pain, diminish anxiety and suffering
- Most biofeedback practitioners are psychologists, nurses, counselors, or physical therapists. Main certification body (not mandatory) is the Biofeedback Certification International Alliance. Practitioners should be licensed in a health-care profession. More information is at AAPB.ORG, BCIA.ORG, and BFE.ORG.
- It is wise to inquire about practitioner experience and outcomes in the disorder and in the modality being considered (muscle, breathing, circulation, etc.) No practitioner is skilled in all modalities or all disorders.
TENS (Vibration)
- Transcutaneous Electrical Nerve Stimulation (TENS) transmits low-voltage electric current of different frequencies through the skin to affect peripheral nerves for therapeutic purposes, such as relieving pain.
- A TENS unit consists of a battery-powered device that delivers electrical impulses through electrodes placed on the surface of the skin at or near nerves where the pain is located or at trigger points.
- Results from using TENS for pain relief have been variable and often inconclusive compared with “sham” controls.
- Efficacy may depend on many factors including the type of condition for which pain relief is sought, where electrodes are positioned on the skin, and the settings of the TENS unit itself (pulse frequency, duration, intensity, and type).
Aromatherapy
- UCSF has approved use of 6 essential oils for the promotion of well-being: mandarin orange, lemon, eucalyptus, ginger, lavender, and peppermint.
- Aromatherapy is provided based on patient preference by placing 1-3 drops on a cotton ball placed in a small, covered container for self-dosing.
- Aromatherapy is recommended for brief periods of inhalation only. It is not intended for application to skin or to be ingested.
Physical Therapy and Occupational Therapy
There is a reason that the first step in management of chronic back pain is physical therapy. For most patients, there is an imbalance in posture or musculature that leads to pain in the setting of age-related spine changes. Physical therapy and strength training can improve muscle mechanics, improve functionality, and return to physical activity. Ultimately, it is the increased activity that improves chronic pain.
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