changing chronic pain experience

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Pain, 32 (1988) 165-172 Elsevier 165 PA1 01136 Changing chronic pain experience H.C. Philips Department of Psychology, Shaughnessy Hospital, Vancouver, BC V6H 3Nl (Canada) (Received 18 August 1986, revised received 22 June 1987, accepted 9 July 1987) S- Training in relaxation is a prominent component in multi-disciplinary approaches to the management of chronic pain, although its specific potency in modulating pain has not yet been established. Using a within-session design, the specific effects of relaxation induction were evaluated in a group of benign chronic pain patients (n = 24), and compared to similar patients undergoing a control procedure (n = 22). The results indicated that irrespective of the focus of pain complaint, induction of relaxation over a 20 min period led to significant and sizeable reductions in both sensory and affective pain experience. The overall intensity of pain was significantly reduced. These effects were shown to be reliable and independent of onset level of sensory experience or depression. No significant changes occurred in the control group over a comparable period. The implications of these results were discussed with respect to the process by which relaxation reduces pain. Key words: Relaxation; Chronic pain; Moderation of pain Introduction Relaxation is a common treatment component in multi-faceted approaches to the management of chronic pain. These pain management pro- grammes have proved sufficiently potent [14,15,19] to encourage analysis of the contributions made by the treatment components. Theoretical justifi- cations vary as to the reasons for the inclusion of relaxation training (muscular relaxation/reduc- tion of sensory input, control and calming of mental state, etc.), but its importance as a treat- ment technique is well established [l&24,29,32]. Despite the prominence and overall utility [34] of relaxation in managing chronic pain, its specific power in modulating chronic pain experience has not been established. Patients at a behaviourally oriented pain clinic rate a relaxation strategy Correspondence to: H.C. Philips, Department of Psy- chology, Shaughnessy Hospital, Vancouver, BC V6H 3N1, Canada. highest in utility over all other strategies taught in a psychologically directed outpatient service [27]. To what extent this reflects the technique’s capac- ity to lower episodes of pain experience and/or provides a greater sense of self-control of pain [10,11,27] is not clear. The aim of the current study was to evaluate the specific effects of relaxation induction on the experience of constant, chronic, benign pain in a population of individuals attending a chronic pain clinic. Thus, the within-session effects of this pro- cedure upon pain experience could be assessed. Operant approaches [cf., 12,291 have focused attention upon the assessment and modification of the behavioural indices of chronic pain (activity levels, complaint levels, etc.). Clinics with a pres- sure to prove themselves cost-efficient have in- cluded employment measures and analgesic use, etc. However, paramount to the applicant to the pain clinic is the extent to which he/she will be able to influence, attenuate, or modulate the pain experienced. 03043959/88/$03.50 0 1988 Elsevier Science Publishers B.V. (Biomedical Division)

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Page 1: Changing chronic pain experience

Pain, 32 (1988) 165-172 Elsevier

165

PA1 01136

Changing chronic pain experience

H.C. Philips

Department of Psychology, Shaughnessy Hospital, Vancouver, BC V6H 3Nl (Canada)

(Received 18 August 1986, revised received 22 June 1987, accepted 9 July 1987)

S- Training in relaxation is a prominent component in multi-disciplinary approaches to the management of chronic pain, although its specific potency in modulating pain has not yet been established. Using a within-session design, the specific effects of relaxation induction were evaluated in a group of benign chronic pain patients (n = 24), and compared to similar patients undergoing a control procedure (n = 22). The results indicated that irrespective of the focus of pain complaint, induction of relaxation over a 20 min period led to significant and sizeable reductions in both sensory and affective pain experience. The overall intensity of pain was significantly reduced. These effects were shown to be reliable and independent of onset level of sensory experience or depression. No significant changes occurred in the control group over a comparable period. The implications of these results were discussed with respect to the process by which relaxation reduces pain.

Key words: Relaxation; Chronic pain; Moderation of pain

Introduction

Relaxation is a common treatment component in multi-faceted approaches to the management of chronic pain. These pain management pro- grammes have proved sufficiently potent [14,15,19] to encourage analysis of the contributions made by the treatment components. Theoretical justifi- cations vary as to the reasons for the inclusion of relaxation training (muscular relaxation/reduc- tion of sensory input, control and calming of mental state, etc.), but its importance as a treat- ment technique is well established [l&24,29,32].

Despite the prominence and overall utility [34] of relaxation in managing chronic pain, its specific power in modulating chronic pain experience has not been established. Patients at a behaviourally oriented pain clinic rate a relaxation strategy

Correspondence to: H.C. Philips, Department of Psy- chology, Shaughnessy Hospital, Vancouver, BC V6H 3N1, Canada.

highest in utility over all other strategies taught in a psychologically directed outpatient service [27]. To what extent this reflects the technique’s capac- ity to lower episodes of pain experience and/or provides a greater sense of self-control of pain [10,11,27] is not clear.

The aim of the current study was to evaluate the specific effects of relaxation induction on the experience of constant, chronic, benign pain in a population of individuals attending a chronic pain clinic. Thus, the within-session effects of this pro- cedure upon pain experience could be assessed.

Operant approaches [cf., 12,291 have focused attention upon the assessment and modification of the behavioural indices of chronic pain (activity levels, complaint levels, etc.). Clinics with a pres- sure to prove themselves cost-efficient have in- cluded employment measures and analgesic use, etc. However, paramount to the applicant to the pain clinic is the extent to which he/she will be able to influence, attenuate, or modulate the pain experienced.

03043959/88/$03.50 0 1988 Elsevier Science Publishers B.V. (Biomedical Division)

Page 2: Changing chronic pain experience

166

Fortunately, in the last few years, progress has been made in the measurement of pain experience.

Working with the useful preliminary step made by Melzack and Torgerson [22] in the development of

the McGill Pain Questionnaire, a new scale has recently been produced which further dis-

tinguishes aspects of sensory and affective experi- ence [16,17] and enables the comparison of re-

peated assessments. Although developed for a

headache population, it uses adjectives from the McGill Pain Questionnaire and is suitable for any

type of pain. The scale reliably distinguishes 5

separable clusters or aspects of sensory pain expe-

rience and two clusters or aspects of affective pain

experience. This scale has been found to be relia- ble and valid 1171. With a scale of this sort, it

becomes feasible to examine the specific effects of a procedure such as relaxation on pain experience

itself. The feasibility of‘ such an approach was

demonstrated in a study of Melzack and Perry [21]. Using the McGill Pain Questionnaire, they

demonstrated significant changes in both sensory

and affective dimensions of chronic pain as a result of alpha feedback and hypnotic training.

Component analyses of psychological treat-

ment approaches have yet to be published, prob- ably because of complex statistical problems raised

by the assessment of a multi-dimensional phe- nomenon treated with a multi-faceted approach. In the meantime, it is feasible to examine individ-

ual components of the treatment approaches and

assess their strengths in controlling pain experi- ence per se. A start is made in this study by

limiting the evaluation to within-session effects of

relaxation upon constant chronic pain experience.

TABLE I

Subjects

In all, 46 chronic pain patients attending chronic pain management service were studied.

Twenty-four of these patients (experimental group) were evaluated before and after a 20 min relaxa-

tion induction, while twenty-two (control group) were evaluated before and after a 20 min period in which they listened to a didactic presentation on

the nature of chronic pain. Table I below provides

details of the age, sex distribution. pain type. pain

chronicity, and average pain intensity in the two

groups.

Design and instruments

The Headache Scale [16,17] was given to these patients before and after either the induction of

relaxation or the didactic presentation, in order to

get an evaluation by each patient of his/ her pain experience (occasion 1). This scale consists of 30

adjectives commonly utilized by those in pain, 27 being selected from the McGill Pain Question- naire [22]. Each adjective can be rated by the

subject from 0 to 3 (0 = not at all; 1 = mild; 2 = moderate; 3 = severe). Cluster analysis has re-

vealed 7 distinguishable clusters, 5 of which are sensory and the remaining 2 affective. These clus- ters have been labelled as follows: sensor)

‘ache’ (Sl), ‘sharp’ (S2). ‘tight’ (S3), ‘autonomic’

(S4). ‘dull’ (S5): affective - ‘discomfort’ (Al), ‘anxiety/depression’ (A2). This scale allows a di-

rect quantitative comparison of sensory and affec- tive components when the questionnaire is used

AGE, SEX DISTRIBUTION, CHRONICITY, SEVERITY, AND CHRONIC PAIN TYPE OF SUBJECTS (n = 46) DIVIDED

INTO RELAXATION (n = 24) AND CONTROL GROUPS (n = 22)

Age Sex dist.

(yr) (F/M)

Type

Back Head Other

chronicity

(yr)

Severity

(O-5)

Relaxation group (n = 24)

Control (n group = 22)

40.12 20/4 41% 29% 30% 1.7 2.6

(12.04) (6.80) (0.84)

38.0 18/4 31% 31% 38% 10.5 2.63

(9.3) (8.65) (@.%)

Page 3: Changing chronic pain experience

167

on repeated occasions. The latter is not possible using the McGill Pain Questionnaire.

In addition to this scale, subjects were asked to give overall pain intensity ratings using an ana- logue scale from 0 to 5 (the PPI-McGill Pain Questionnaire: 0 = no pain to 5 = intense and in- capacitating pain).

The experimental group (24) cases seen before and after the relaxation induction were assessed in an exactly replicable manner 1 week later using the same induction procedure (occasion 2). These 2 occasions will be referred to as occasion 1 and occasion 2. The control group (pre- and post-di- dactic presentation) was evaluated only on occa- sion 1 and provides the control data for this study.

Roeedure

Relaxation induction followed the guidelines of Bernstein and Borkovic [4], although a simplified 9 muscle group method was used on both occa- sions (transcript available from the author). Em- phasis was also placed on slow, regular, di- aphragmatic breathing which was to be used throughout. None of the patients had received any training in relaxation prior to this first session.

All patients, irrespective of group (control or experimental), were asked to fill in the Headache Scale at the onset in order to indicate their current pain level and its qualities. Immediately post-in- tervention (relaxation induction or didactic on pain, both of 20 min duration), they were asked again to use the scale to indicate their current pain level and its qualities. Neither group was given any expectations with respect to immediate effects of the interventions, both being presented as im- portant ingredients in a 9 week programme for the management of chronic pain.

The Headache Scale was analysed to give scores (range O-3) for each of the 5 sensory clusters and the 2 affective clusters [16].

Results

(I) Experimental and control group comparability The characteristics of the 2 groups of chronic

pain cases can be found in Table I. They are

typical of cases referred for treatment [27] both in the sex distribution, chronicity, and in pain inten- sity characteristics. The average severity estimates are obtained from 1 week of self-monitoring (O-5 ratings using the pain diaries [6]). They demon- strate the intensity of the daily chronic pain prob- lem endured by these individuals.

No significant difference was found between the two groups on any of these measures.

(2) Pre-intervention differences Below can be found a table of means (Table II)

for each of the sensory and affective clusters mea- sured by the Pain Questionnaire, and the pain intensity estimates (PPI O-5 scale) for the experi- mental groups on 2 separate occasions and for the control group.

For each occasion, the null hypothesis was tested: that the mean (vector) in the experimental group, pre-intervention, was the same as that of the control. For the sensory and affective mea- sures (considered as multi-variate vector re- sponses), 2-sample Hotelling T2 tests were per- formed. Occasion 1: sensory vector Hotelling T2 = 5.27, P = 0.45; affective vector Hotelling T2 = 4.60, P = 0.12. Occasion 2: sensory vector Hotel- ling T2 = 2.87, P = 0.76; affective vector Hotel- ling T2 = 0.85, P = 0.66). Thus, no evidence was found of any significant differences between the

TABLE II

PRE-INTERVENTION: MEANS FOR SENSORY @l-5),

AFFECTIVE CLUSTERS (Al, 2) AND PPI (pain intensity)

ON THE TWO OCCASIONS FOR THE EXPERIMENTAL

GROUP AND FOR THE CONTROLS

Means at ‘ pre’:

Experimental Control

Occasion 1 Occasion 2

Sl 1.21 0.93

s2 0.72 0.52

s3 1.26 1.17

S4 0.64 0.50

SS 0.92 0.88

Al 1.85 1.48

A2 0.86 0.75

PPI 3.05 2.40

0.90

0.46

0.84

0.50

0.82

1.32

0.58

2.43

Page 4: Changing chronic pain experience

168

TABLE III

MEAN (vectors) OF DIFFERENCE BETWEEN PRE AND POST SCORES FOR THE TWO GROUPS (experiment and controls) ON OCCASION 1

hp. Control

Sensory Sl -0.400 0.064 s2 - 0.356 0.091 s3 - 0.571 - 0.107 s4 -9.211 0.062 s5 - 0.375 - 0.048

Affective Al - 0.963 0.119 A2 - 0.421 0.058

PPI -0.914 0.245

experimental and control subjects on either oCca- sion on the sensory or affective clusters.

The &in intensity (PPI) was analysed using a univariate, 2-sample t test (t = 1.479, df= 39, P = 0.09). This test also showed no evidence of any experimental/control differences pre-intervention.

(3) The eflects of relaxation induction To evaluate the experimental effect of relaxa-

tion, the experimental and control groups were compared at occasion 1, before, and after the 20 min interventions (relaxation induction versus di- dactic control). Taking a post-minus-pre vector of differences, the null hypothesis assessed that the mean vector of differences of both groups would be the same, Hotelling T2 (2 samples) were per- formed for both sensory and affective measures, while a univariate Z-sample t test evaluated PPI changes.

All tests were significant, indicating a specific shift in sensory and affective components of pain experience, as well as the overall PPI score (sensory Hotelling T2 = 24.14, P = 0.003; affective Hotel- ling T2= 26.9, P=O.OOO; PPI t =4.81, df= 29, P = 0.001 (two sided) in the experimental group).

The consistently negative differences on all measures for the experimental group (see Table III) indicate that relaxation leads to reduction in pain experience consistently across all measures. The control group shows very little change, most of which is in the direction of increased pain.

A comparison of the experimental group on occasion 2 with the controls allows an evaluation

of the repli~ability of the above results. Exactly

the same type of analyses were performed 3s pre- viously (see 3 above). Again, relaxation had a significant effect on ail 3 sets of measures (sensory

Hotelling T* = 11.36, P = 0.013: affective Hotel- ling T2 = 43.06. P = 0,000: PPI t = 4.09, Q’=- 39. P = 0.002 (two-sided)), A replication of the experi-

mental effect was evidenced.

(5) The difference between occasions in a relaxation effecr

If the magnitude of relaxation effect were the same on the 2 occasions, the difference (post minus pre) on the 2 occasions would be the same. To assess this, the difference between differences on the 2 occasions was taken. If the relaxation effect was the same in magnitude, this last mea- sure would be predicted to be zero. The Hotelling T2 tests for both sensory and affective measures were as follows: sensory Hotelling T* = 22.17, P = 0.017; affective Hotelling T2 = 1.09, P = 0.60. Thus the magnitude of effect for the sensory com- ponent differed between occasions while the affec- tive component showed no change. A comparable approach on the pain intensity (PPI) revealed the magnitude of the relaxation effect to be the same on the 2 occasions for this measure (t = 0.45, df = 15. P = 0.66 (two sided)).

(6~ Differences between pain groups with respect to the effect of relaxafion

No significant differences were found between the 3 types of pain in this population of chronic pain patients (back, headache, and other - facial, pelvic, multiple, etc. (Table I)) in their response to relaxation induction.

(7) Aspects of the pain experience The inventory used allows analysis of the vari-

ous clusters that comprise the pain experience dividing into sensory and affective aspects. Pre-in- tervention, the affective cluster was significantly higher than the sensory cluster score when occa- sions 1 and 2 were summed (F = 67.8, 1, 23. P -z 0.0000). The sensory factor total at onset was

Page 5: Changing chronic pain experience

169

TABLE IV

INTERRELATION OF CHANGE SCORES FOR SENSORY AND AFFECTIVE PAIN EXPERIENCE TOTALS OF PAIN INTENSITY RATINGS

Sensory Affective PPI

Sensory total -

Affective total

PPI

r = 0.72 r = 0.56 P < 0.000 P < 0.02

r = 0.39 ns

not significantly correlated, however, with changed scores (post-pre-relaxation). However, for the af- fective total, the association was significant (r = -0.52, P < 0.01). Thus the higher the affective scores at onset, the smaller the reduction pro- duced by relaxation induction.

The table above (Table IV) gives the correla- tions between change scores. Sensory and affective component changes have 52% of variance in com- mon. The relationship of overall intensity ratings and sensory/affective component change scores is much weaker. Pain intensity changes appear to be unrelated to the affective shift that occurs.

The mean depression score for the total group of experimental subjects was 16.17 on the Beck Depression Inventory thus placing them in the mild depression range [2]. The depression scores were significantly associated with the affective and sensory pain totals prior to occasion 1 (affective total: r = 0.67, P < 0.0000; sensory cluster: r = 0.61, P < 0.001). Higher depression scores were found with higher pain levels, as assessed on the sensory or affective dimension. However, no rela- tionships between depression scores and change scores were found for either dimension.

Discussion

The characteristics of the chronic pain patients evaluated in this study are representative of the level and type of distress found in individuals who are battling constant pain experience over ex- tended periods of time. The larger proportion of females in this study reflects the clinic’s exclusion- ary criteria which screen out all individuals cur- rently involved in litigation.

The inventory used to assess pain experience allows the differentiation of sensory and affective aspects of pain experience. These individuals show a much higher level of affective pain experience than sensory, though both are at a clinically sig- nificant level. The raised affective component em- phasizes the importance of pain management ap- proaches focusing upon, and developing, tech- niques to help individuals to deal with this emo- tional reaction to prolonged pain.

As has been noted frequently in the past [cf., 301, these chronic pain patients reveal mild levels of depression. The latter is significantly and posi- tively correlated with the level of pain experience be it affective or sensory in quality.

Irrespective of the focus of the pain complaint, the induction of relaxation over a 20 min period in previously untrained chronic pain patients led to a significant and sizeable reduction both in sensory and in affective pain experience. In addition to the lowering of the level of both of these dimensions, the overall intensity of pain (PPI) was also signifi- cantly reduced. The use of the inventory allowed this more usual and blunt evaluation of pain to be extended to the many types of experience that are incorporated in an intensity index. It appears that the reductions produced by relaxation occur across all the clusters assessed by the inventory, be they sensory or affective in quality. Gracely et al. [13] have been able to show that the common minor tranquilliser (diazepam) can affect pain experience in a specific way. The sensory component of the pain experience remains unchanged while the af- fective emotional reaction to pain was signifi- cantly reduced. In this case, with a relaxation induction, both the sensory and the affective reac- tion were significantly affected suggesting that relaxation induction entails more than a minor tranquillising effect. It appears to significantly alter the sensory/ discriminative dimension of chronic pain, influencing as it does many types of sensation: tightness, aching, sharpness, etc.

This experimental effect produced by the sim- ple induction of relaxation was shown to be relia- ble by its replication 1 week later in the experi- mental group. The size of effect on the affective component and on the pain intensity rating was comparable on these 2 occasions, although there is

Page 6: Changing chronic pain experience

170

some suggestion that there is some change in the focus of the sensory change on the second occa-

sion. Although the shift remains significant, the relevant contribution of the 5 sensory components

varied to some extent. To what extent this is a learning effect, as the subjects become more profi-

cient at relaxation induction, will need to be fur- ther investigated.

Chronic pain patients with different pain prob- lems benefitted equally from the induction of re-

laxation procedures. There is no suggestion that

one pain type benefitted more from learning to

relax. This fact has implications for those working

with chronic pain patients and wishing to utilize a

group format. It appears to be a technique which will be useful for all chronic pain patients and, as

it can readily be induced in a group, can be utilized as an important strategy which will help individuals in that group irrespective of the dif-

ferences in pain focus. The size of the response to relaxation was in-

dependent of the onset levels of sensory experi-

ence or of depression. Thus, extremely high levels of sensory experience or depressive scores, at least

in the mild range, would not appear to be ap-

propriate reasons for excluding individuals from pain management approaches that utilize a relaxa-

tion technique. On the other hand, the affective

change produced by relaxation was smaller when the affective component was higher. Individuals

with extremely high affective scores pre treatment may need more than relaxation training to manage their problems.

The high correlation between sensory and af- fective change suggests the integrated way in which relaxation influences pain experience. The failure

of pain intensity rating changes to correlate highly

with sensory or affective changes underlines the bluntness of this simple rating scale to assess the changes in experience. Interestingly, this overall rating seems to be most influenced by the sensory dimension of pain experience, and its bluntness may well be predominantly related to its inability to accurately reflect the changes in affective pain experience. Prior to the relaxation induction, the overall pain intensity (PPI) was significantly re- lated to affective total (r = 0.59; P < 0.005) and to sensory total (r = 0.65; P c 0.001). Although

reflecting to some extent sensory and ;tffective qualities, the weakness of PPI is much more evi- dent in its inability to reflect changes in the

affective emotional reaction to pain. at least in this context.

In summary, it appears that relaxation without former training can have a specific muting or attenuating effect upon persisting chronic pain experience. This suggests the importance of in-

cluding progressive relaxation techniques in the training battery for chronic pain patients, both as

a general component in training as well as a

specific episodic control strategy which can be

utilized when pain levels peak beyond a point

where they can be disregarded. Further training in

relaxation may well produce more sizeable reduc- tions as well as quicker ones. The relative potency

of relaxation at difference levels of pain experi- ence would be an interesting further investigation to clarify the relative potency of relaxation induc- tion for these patients.

To further clarify the process by which progres-

sive relaxation leads to changes in pain experience concurrent psychophysiological assessment and

ratings of subject arousal/anxiety must be in- cluded in future studies. This additional informa-

tion would help unravel the way in which such a simple intervention as relaxation modulates a

long-standing and continuing pain problem. Some researchers have presumed relaxation induction to

be effective in its capacity to reduce sensory dis- criminative input [1,32]. However, as relaxation

has been shown to reduce arousal and anxiety. it is possible that relaxation produces its effect via modulation of the affective/motivational dimen- sion of pain experience. Recently it has been shown that pain perception is significantly in-

fluenced by the induction of relevant anxieties [35]. The correlation between sensory and affec-

tive pain experience would suggest that in order to further clarify this issue, independent measures of anxiety and muscle tension would be a useful step to take in teasing out the focus of effect produced by relaxation induction.

In conclusion, this study has made clear the relevance and importance of training any type of chronic pain patient in the use of relaxation proce- dures. Relaxation produced consistent reductions

Page 7: Changing chronic pain experience

in all aspects of the pain experience, be they sensory or affective. As this study evaluated the effects of only the first 2 sessions of relaxation training, it is possible that the speed of reduction and/or its size may be further increased as train- ing continues. The demonstration to patients that they can, over a short period, modulate their dis- tress by a simple technique is of great potency at the onset of training.

Acknowledgements 16

Thanks are due to Tania Deans for preparing the manuscript, and to the Statistics Department at the University of British Columbia for their advice in data analysis.

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