Behavioral conceptualization and treatment for chronic pain.

Abstract The current article offers a behavioral conceptualization for clinical pain, reviews the empirical evidence supporting this behavioral model, summarizes evidence-based behavioral treatments for chronic pain and supporting science, outlines treatment application limits, and summarizes research needs. Clinical pain is defined as an interacting cluster of overt, covert, and neurophysiological responses initially produced by relevant tissue damage or irritation, which can be maintain by other antecedent and consequent stimulus conditions through operant, respondent, and observational learning effects. Operant and respondent based treatment methods are reviewed, with existing research strongly supporting their efficacy with chronic low back, myofascial, and headache pain patients. These behavioral methods have limited application, due to insufficient research, when applied to acute or cancer pain states, geriatric pain patients, and to some extent pediatric patients. Research needs include continued empirical investigation of the behavioral conceptualization model presented, empirical demonstration of efficacy with those painful conditions and patient types with insufficient research support, treatment matching studies, comparative efficacy (including cost) studies, and efficacy with combined treatment approaches. It is strongly recommended that continued resource allocation be applied to sustain ongoing scientific efforts necessary to maintain and enhance behavioral approaches for managing clinical pain. Key words: Behavioral Conceptualization, Behavioral Treatment, Chronic Pain. ********** Behaviorally based approaches for chronic pain are now well-established in clinical practice (see, Lebovits, 2003). Since the pioneering work of Fordyce and his colleagues (e.g., Fordyce, 1976; Fordyce, Shelton, and Dunmore, 1982), there has been an impressive accumulation of research on and clinical application of behavioral/learning based methods for chronic pain patients. The current article offers a summary overview of this behavioral/learning based conceptualization and treatment of chronic pain, as well as the empirical science supporting it. (For more in-depth descriptions and reviews, the reader is referred to the reference list.) Also included is an evidence-based discussion of application limits, as well as research needs. Behavioral Conceptualization Defining Pain From a behavioral prospective, pain in its entirety can be defined as an interacting cluster of individualized overt, covert and neurophysiological responses resulting from tissue damage or irritation (Sanders, 2003). Table 1 outlines these response categories with examples. The fact that all of these pain resopnses are associated with the application of the aversive, nociceptive stimulus of tissue damage/irritation means that they can be considered as unconditioned and conditioned respondent behaviors (Flor & Hermann, 2004; Hollis, 1997; Reynolds, 1968) (e.g., grimacing, muscle tension, release of substance P), escape--avoidance behaviors (Vlaeyen, 2003) (e.g., limping, lying down, taking pain medications), and/or generalized emotional behaviors (Skinner, 1953; Sidman, 1962) (e.g., crying, yelling, fear of pain). From this definition of pain and the rich empirical history in behavioral psychology and therapy demonstrating that virtually all voluntary and many so-called involuntary (unconditioned) responses can be initiated and maintained by their antecedent and consequent stimuli, it is not surprising that the pain responses outlined in Table 1 might also be significantly influenced by such stimuli within a learning/conditioning model. Learning/Conditioning Effects on Pain Table 2 provides a representative functional analysis of acute and chronic clinical pain responses. It describes the combined potential conditioning effects across operant (Skinner, 1953), respondent (Pavlov, 1927), and observational (Bandura, 1986) models of learning for both the initiation and maintenance of pain behaviors (Sanders, 2003). …