This is the 2007 version. Click here for the 2017 chapter 14 table of contents.

Behavioral Treatment of Pain

An example of cliinical behavioral medicine is the treatment of chronic pain by "unlearning" it. Some people suffer injuries, resulting in pain and disability, then they heal physically but the pain remains. In the 1940s and 1950s doctors tried all sorts of surgical interventions to eliminate the pain, including lobotomies, to no avail. Less drastic treatments, such as severing selective nerves between the affected part of the body and the brain, seldom worked. The pain always came back. "Chronic pain patients" became addicted to pain-killing medications. Gradually even these would lose their effectiveness. Often such people became totally unable to function, wracked with pain every day, their lives totally disrupted.

Why is chronic pain a challenging medical problem?

In the 1970s, behavioral psychologists tried a new approach. Their target population consisted of patients in whom the physical signs did not fit the complaints (there was no detectable tissue damage or disease) and in whom all acute pain treatments (drugs, surgeries) had failed. They assumed that the pain in such patients was somehow learned. Perhaps the pain started with a physical injury, then it took on a life of its own. Whatever the explanation, the pain was severe, and nothing was helping to eliminate it, so a radically new treatment plan was devised.

What were the assumptions behind the behavioral approach to chronic pain?

Chronic pain patients were brought into a clinic and given a thorough medical evaluation, to make sure doctors had not missed some biological ailment. Patients who checked out as physically healthy were told that Yes, their pain was real (it was not imaginary) but it was no longer based on a medical condition; now it was based on learning. So now they had to learn not to feel pain.

What were the basic techniques?

They were subjected to a strict regimen in the clinic. First, they were not allowed to complain. Moaning, commenting on pain, complaining to nurses—none of these behaviors was reinforced in the clinic. Second, patients were induced to exercise a little bit more every day, even if it hurt. They were told to ignore the pain and regain the use of their muscles. Third, patients were weaned off their pain-killing medications. Painkillers were mixed with cherry syrup, for example, and gradually the amount of medication was reduced, day by day, until only cherry syrup remained.

Were patients helped? What was the drawback to this approach?

Last but not least, patients were warmly reinforced for all steps toward progress, such as exercising without complaining. As their pain-related behaviors disappeared, they were permitted more family visits, more privileges, and eventually allowed to leave the program. This procedure eliminated or drastically reduced pain in a large percentage of chronic pain patients—if they completed the program. The main drawback was a high drop-out rate (Fordyce, 1976).

What idea did Taub and colleagues get from research on the brain?

Another example of behavioral medicine comes from Taub, Liepert, Miltner, and Weiller (1998). These researchers were aware of research showing that motor areas of the brain could expand or contract with use or disuse (p.64). They wondered if paralysis of a limb after a stroke was due to learned nonuse. Perhaps the brain damage itself did not cause the loss of limb movement. Rather, the patient stopped using the limb (because it was difficult or painful to move after the stroke) and eventually the brain re-allocated those portions of the motor cortex to other tasks. If so, perhaps the process could be reversed. If the patient had to use the limb again, the brain areas that formerly controlled those muscles could take control again.

What was the therapy and its results?

To encourage a revival of the brain's ability to move the "bad" arm, Taub and colleagues used a sling to immobilize the patient's good arm for 90% of the patient's waking hours. Each patient spent six hours a day for ten days in therapy that encouraged use of the bad arm. The result was improvement in all 73 patients treated, regardless of how much time had passed since the stroke. In fact, 30% of the patients regained full use of the formerly bad arm.

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