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International Updates

Pain

Issue 88

LIPCHIK and NASH, St. Vincent Rehabilitation Services, 3413 Cherry Street, Erie, PA 16508, USA, Glipchik@aol.com, review (63 references) cognitive-behavioural issues in the treatment of chronic headache.
Background: Chronic daily headache is a heterogenous group of daily or near-daily headaches that affects about 5% of the general population and accounts for 35% to 40% of patients in headache clinics.
Results and conclusions: Drug or cognitive-behavioural therapies alone have minimal impact on the frequency or severity of headaches. However combined drug and cognitive-behavioural therapy shows promise in benefiting this often otherwise intractable condition. Cognitive-behavioural therapy focuses on preventing mild pain from becoming disabling pain, improving headache-related disability, affective distress, and quality of life, and on reducing overreliance on medication. For this therapy to be effective, it is important to address complicating factors including medication overuse, psychiatric co-morbidity, stress, poor coping skills, and sleep disturbances.
Lipchik GL, Nash JM. Cognitive-behavioral issues in the treatment and management of chronic daily headache. Current Pain and Headache Reports 6 (6): 473-479, Dec 2002.

SMITH and colleagues, University of Southern Maine, USA, report on the effects of integrating therapeutic touch with a cognitive behavioural pain treatment programme.
Background: The purpose of this pilot study was to investigate the effect of offering Therapeutic Touch (TT) as an adjunct to cognitive-behavioural therapy (CBT) to chronic pain patients.
Methods: Patients were randomized to control group and experimental group, receiving relaxation training only or TT plus relaxation training, respectively. Both groups subsequently attended a CBT programme. Pre treatment and post treatment pain intensity, self-efficacy, unitary power, disability, and perceived distress were assessed. In addition, patterns of attrition were examined.
Results: Patients who received TT fared better in terms of enhanced self-efficacy and unitary power. They also had lower attrition rates. Trends associated TT with less distress and lower disability.
Conclusions: This pilot study suggests that TT as an adjunct to CBT may help to improve clinical outcomes, reduce attrition, and promote unitary power in those who suffer with chronic pain.
Smith DW, Arnstein P, Rosa KC, Wells-Federman C. Effects of integrating therapeutic touch into a cognitive behavioural pain treatment program. Report of a pilot clinical trial. Journal of Holistic Nursing 20 (4): 367-387, Dec 2002.

Comments: The above studies demonstrate the efficacy of a number of approaches to pain control, including cognitive hehavioural therapy (CBT), biofeedback and therapeutic touch combined with CBT.

Issue 87

SUN and colleagues, Department of Psychiatry, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC, present a case study of mindfulness meditation for the control of severe headaches.
Background: Mindfulness meditation has been used by people experiencing pain and illness. It involves observation of bodily sensations including pain.
Methods: Case study of a man who was prone to developing severe headaches.
Results: The man learned to control his pain and discomfort through mindfulness meditation, although initially the practice induced headaches.
Conclusions: Mindfulness meditation may be a medically superior and cost-effective way of controlling pain with no obvious organic cause in highly motivated patients.
Sun TF, Kuo CC, Chiu NM, et al. Mindfulness meditation in the control of severe headache. Chang Gung Medical Journal 25 (8): 538-541, Aug 2002.

ALLAIS and colleagues, Woman’s Headache Center, Department of Gynecology and Obstetrics, University of Turin, Turin, Italy, conducted a trial of acupuncture in the prophylactic treatment if migraine by comparison with the drug flunarizine.
Background: In this randomized controlled trial over a period of six months, the effectiveness of acupuncture versus flunarizine was evaluated as a treatment for migraine without aura.
Methods: 160 women suffering from migraines were randomly assigned to receive either acupuncture or oral medicine (flunarizine). Acupuncture was carried out on 80 women in weekly sessions for the first two months and then monthly for the next four months. The same acupoints were used at each treatment. In the control group of 80 women, 10 mg of flunarizine were given daily for the first two months and then for 20 days per month for the next four months. The frequency of attacks, pain intensity during attacks, and consumption of analgesic drugs were recorded.
Results: The frequency of migraine attacks and consumption of analgesic drugs decreased in both groups during treatment. The number of attacks was significantly lower in the acupuncture group after 2 and 4 months. Analgesic consumption was significantly lower in the acupuncture group after 2 months of treatment. After 6 months, these differences had disappeared. Pain intensity was significantly lowered only by the acupuncture treatment. Side effects were significantly less frequent in the acupuncture group.
Conclusions: Acupuncture proved to be an adequate treatment for migraine prophylaxis. Compared to drug treatment, it showed greater effectiveness in the first months of treatment, and better tolerability.
Allais G, De Lorenzo C, Quirico PE, Airola G, Tolardo G, Mana O, Benedetto C. Acupuncture in the prophylactic treatment of migraine without aura: a comparison with flunarizine. Headache 42 (9): 855-861, Oct 2002.

Issue 86

STRAUSS-BLASCHE and colleagues, Department of Physiology, University of Vienna, Austria, gerhard.strauss-blasche@univie.ac.at, investigate the seasonal variations in the effect of spa therapy on chronic pain.

Background: Conventional spa therapy research suggests that the effects are subject to seasonal variation.

Methods: 268 women and 119 men with noninflammatory chronic pain were studied. Patients stayed at an Austrian spa for 3 weeks and received 2-4 treatments per day. Treatments included mudpacks, massages, and exercise therapy. Pain, mood, and fatigue were measured pre-treatment, post treatment and 6 weeks post treatment. Data were analyzed by multivariate analysis of covariance controlling for possible group differences between seasons and cosinor analysis.

Results: The effect of spa therapy was found to be season dependent. Short-term decrease of pain was best between April and June, and medium-term pain relief was best between October and November, with a second minor peak in autumn and spring. The magnitude of the variation was greater for back pain (approximately 30%) than for joint pain (approximately 20%). Mood was also improved most between April and June. The observed seasonal variations do not correspond to the well-known annual changes in many physiological and psychological parameters.

Conclusions: The study suggests that the effects of spa therapy and possibly other complementary therapies and physical therapies are subject to seasonal variation.

Strauss-Blasche G, Ekmekcioglu C, Leibetseder V, Melchart H, Marktl W, et al. Seasonal variation in effect of spa therapy on chronic pain. Chronobiology International 19 (2): 483-495, Mar 2002.

Issue 83

FAUCETT et al., University of California, San Francisco 94143, USA, E: jaf@itsa.ucsf.edu, tested two training interventions to prevent work-related musculoskeletal disorders of the upper limb.

Background: Two types of worker training interventions were investigated, both designed to reduce unnecessary muscle tension and the symptoms of work-related musculoskeletal disorders. The first of these was Muscle Learning Therapy (MLT), using electromyographic feedback and operant conditioning to decrease muscle tension. The second used adult learning and cognitive behavioural techniques in small group discussions to enhance workers’ stress management skills.

Methods: Workers were randomly assigned to a control group or to either treatment. Interventions were conducted for 6 weeks with reinforcement training provided at 18 and 32 weeks post baseline. Symptom diaries and electromyographic readings of the trapezius and forearm muscles of both arms were taken at baseline, at the conclusion of the 6 weeks training period, and at 32 weeks, prior to the reinforcement training.

Results: Significant differences were found at 6 weeks in symptom severity, increasing for the control group and decreasing modestly for the education group, with little change for the MLT group. At 32 weeks follow-up, these differences were not maintained. The MLT group was consistently effective in reducing tension in the trapezius muscle both at 6 and at 32 weeks, and partially effective for the forearms.

Conclusions: Further testing of these training interventions is recommended, especially including periodic reinforcement of the workers’ learning.

Methods: Patients suffering from myofascial pain dysfunction were treated in this controlled study. The control group consisted of 20 waiting list patients. Inclusion criteria for the study were pain in the temporomandibular region for at least 3 months, no evidence of internal derangement or osteoarthritis, and symptoms of postural dysfunction. Treatment consisted of active and passive jaw movement exercises, correction of body posture and relaxation techniques. Pain at rest, pain at stress, impairment, and mouth-opening were measured at baseline and at 6 months follow-up.

Results: The waiting-list controls experienced no significant changes. After treatment 6 patients had no pain at all (p = 0.01) and 7 patients experienced no impairment (p = 0.005). Pain at stress, impairment and incisal edge clearance improved significantly (p = 0.001). At 6 months, 16 patients experienced no pain at all, 13 patients were not impaired, and only 3 patients had a restricted mouth opening, compared to 12 before treatment (p = 0.001).

Conclusions: Exercise therapy seems to be useful in the treatment of myofascial pain dysfunction syndrome.

Issue 82

ADAMS and FIELD, School of Health and Human Sciences, Liverpool John Moores University, Liverpool, UK, reviewed (52 references) psychological and social aspects of pain as relevant for pain management.

Background: Pain is at the same time a physical and emotional experience. Psychological and sociological factors can therefore not be meaningfully separated from neurophysiological factors.

Discussion: This two-part article presents the complex interactions between neurophysiological and psychological factors in pain perception and response, and ways in which pain experience can be modulated are presented. The role of attitudes, beliefs and expectations of both patient and practitioner are discussed, as well as pain behaviour and ability to cope. These are then further elaborated with particular reference to the nurse-patient interaction. The use of psychological approaches to augment clinical practice, such as education, reduction of anxiety and improving coping ability, are suggested. The importance of communication skills in pain management practice is addressed.

STOLLER and colleagues, Department of Sociology, Case Western Reserve University, Cleveland, Ohio 44106-7124, USA, eps3@po.cwru.edu, analysed the pain management strategies of patients presenting at a dental clinic with tooth pain.

Background: The primary objective was to identify the strategies patients use to manage their pain, and to elucidate the decision-making process leading to a clinic visit.

Methods: In this qualitative study, semi-structured interviews were conducted with patients presenting with tooth pain at a dental clinic in rural North Florida.

Results: Although respondents understood that their condition was not self-limiting, only about half of them contacted the clinic within several days of the onset of their pain.

Conclusion: Most dental patients tried one or more ‘lay’ management strategies to cope with their tooth pain.

Issue 81

SCHARFF and colleagues, Pain Treatment Service, Children’s Hospital, Boston, MA 02115, USA, lisa.scharff@tch.harvard.edu, evaluated the effectiveness of thermal biofeedback in comparison with attention control in improving migraine symptoms in children.
Background: Many studies have shown that thermal biofeedback can effectively reduce symptoms in children with migraine. However, there have been no reports of how this treatment compares with biofeedback-assisted attention control.
Methods: This randomized controlled study enrolled 36 children and adolescents (mean age 12.8 years) who experienced migraines and their parents. The children were assigned to one of three groups: 1) hand-warming biofeedback (HWB); 2) credible attention control using biofeedback technology (hand-cooling; HCB); or 3) waiting list (control). The treatment groups (HWB and HCB) received four sessions of biofeedback training and were given a portable biofeedback device for home practice. Children were assessed for anxiety and depression using questionnaires provided to the children and to both their parents. The children were also provided with instruments for rating their credibility of the two biofeedback treatments.
Results: 34 children completed the treatment programme(s). The two biofeedback treatments (HWB and HCB) were rated as equally credible by the children who experienced them. More subjects in the HWB group achieved clinical improvement of their migraine symptoms than in the HCB group. Benefits of treatment were still apparent up to 6 months after treatment. HWB resulted in a general increase in [body] temperature, while HCB caused a decrease in temperature.
Conclusion: The results confirm the findings of earlier studies of thermal biofeedback in children suffering from migraine. They also indicate that the benefits of treatments are specific to the HWB and stress management techniques used. HCB may be useful as a control treatment in future such studies in this area, but data from a larger number of subjects are needed to confirm this.
Scharff L et al. A controlled study of minimal-contact thermal biofeedback treatment in children with migraine. Journal of Pediatric Psychology 27 (2): 109-19. Mar 2002.

CHANG and colleagues, National Tainan Institute of Nursing, Tainan, Taiwan, evaluated the effects of massage on anxiety and reaction to pain during labour.
Background: Massage has been used since ancient times during labour, but its effects on women during labour have received little formal study. It may represent a useful adjunctive intervention to other forms of pain relief.
Methods: This controlled study was conducted between September 1999 and January 2000 at a regional hospital in southern Taiwan. Subjects were 60 primiparous (first-time pregnant) women expected to have a normal childbirth. During labour, the women received either massage or no massage in a randomized manner. Labour pain was assessed using the nurse-rated Present Behavioural Intensity (PBI) scale. Anxiety was measured on the Visual Analogue Scale for Anxiety (VASA). Intensities of pain and anxiety were measured in the latent phase (cervix dilated 3-4 cm), the active phase (5-7 cm) and the transitional phase (8-10 cm) of labour.
Results: Pain intensity and anxiety levels increased fairly steadily in both groups as labour progressed. The massage group had significantly lower pain reactions in the latent, active and transitional phases than the no-massage group. Only during the latent phase did anxiety levels differ significantly between the two groups. 87% of women in the massage group (26 out of 30) reported massage to have been helpful in providing pain relief and psychological support during labour.
Conclusion: The results indicate that massage is a cost-effective nursing intervention that can reduce pain and anxiety during labour. In addition, the partner’s participation in massage can have a positive effect on the quality of a woman’s birth experience.
Chang MY et al. Effects of massage on pain and anxiety during labour: a randomized controlled trial in Taiwan. Journal of Advanced Nursing 38 (1): 68-73.

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