Pain Management Through Creative Therapies
According to a 2002 report published by the Department of Health in the UK, specialized pain management are services for patients with chronic pain which may not always be available in local general hospitals and according to the Department of Health, these services specified are as follows: Source : Department of Health, 2002
specialised referral centre facility
advanced pain management techniques in adult palliative care
assessment and management of patients with complex intractable non malignant pain
neuromodulatory techniques
neurodestructive techniques
drug delivery systems
intensive inter-disciplinary cognitive behavioural therapy
The services for pain management require specialist clinical expertise located in hospitals and provide facilities for local hospitals and primary care trusts and there may be cases in which a hospital is capable of delivering only one particular specialized treatment or pain management services as part of a clinical network.
Advanced pain management techniques for palliative care specified by the Department of Health as in adult cancer pain include opioid infusion, drug delivery systems, drug weaning techniques, neuromodulatory techniques and neurodestructive procedures. Some of these techniques may be relatively ‘low technology’ but are performed fairly infrequently, and are therefore included as specialised services. Specialised services requires the right equipments and access to inpatient beds where an appropriate level of care can be provided to enable advanced pain management techniques to be undertaken such as spinal infusion of opioids. Appropriate supporting facilities and advanced imaging techniques such as computer tomography (CT) scanning for invasive procedures, and magnetic resonance imaging (MRI) are also required (DH, 2002).
For assessment and management of patients with intractable non-malignant pain, the DH suggests that for the assessment and management of specific conditions, including intractable angina, complex neurological disease, spinal cord injury, brachial plexus injury, urogenital pain syndromes and pain in drug dependency, patients need to be assessed in specified pain management clinics where they should be supported by multidisciplinary teams who have specific training and skills to deal with pain management. Techniques such as Quantitative Sensory Testing (QST) are used for describing sensory abnormalities and to monitor effects of pain investigation infusions and pain management interventions.
The Neuromodulatory techniques specified by the department of health may include various types of peripheral, central and brain stimulation techniques. Examples include:
peripheral nerve stimulation
paravertebral nerve stimulation
spinal cord stimulation
deep brain stimulation
thalamic stimulation
motor cortex stimulation
Sometimes trial neuromodulation techniques may be necessary before any permanent implantation. (Source: DH, 2002) Intensive Interdisciplinary Cognitive Behavioural therapy is often used in pain management programmes endorsed by the Department of Health. Cognitive Behavioural Therapy or CBT is a core service given by primary care trusts and is delivered on an outpatient basis as standard management technique within all pain clinics in the UK. However, a quite a few patients are considered inappropriate for an outpatient programme of CBT as they may be more severe cases and require more intensive therapy over a three or four week period in a residential or inpatient setting (DH 2002; Jensen, 2005). These patients are usually characterised by having high levels of pain-related depression and anxiety, high dependency on care providers and medicine, and a high level of disability (Department of Health, 2002). Within the Cognitive behavioural therapeutic approach, staff in specialist pain management multidisciplinary teams liaise and work in collaboration with other mental health professionals and some of the chronic pain patients require additional individual psychotherapy or referral to clinical psychology or psychiatry services.
Pain Management and Clinical Evidence
In this section we discuss ain management considering Art therapy, cognitive behavioural therapy, group therapy, exercise and other conventional and unconventional methods of pain management used in hospitals and clinics especially following an operation or injury. Miles et al (2005) describes the experiences of people with chronic ain giving a more psychological picture to pain management. They use the method of grounded theory and use 29 chronic pain sufferers for their study. All these pain sufferers were interviewed at an outpatient pain clinic and following this study, the researchers developed a model depicting basic social and psychological processes of maintaining a normal life through constraint. The people’s perception of constraints imposed by pain such as bodily and activity constraints and even identity constraints were studied and identified. Through an evaluation of the impact of pain, the degree to which pain challenges activities and states that are normal is highlighted in the study. An evaluation on how people coped with the constraints if pain and how they perceived their life, and their psychological states were studied emphasizing on their psychological reactions as to whether they assimilated, subverted, confronted or accommodated their constraints as a result of the pain. The limitations imposed by the pain determine the coping efforts and the desire to retain the normal lifestyle may form the basis of coping strategies. Factors identified by Miles et al in pain management were restrictions and constraints, role of body techniques, identity management as adjustment to pain and pain acceptance and assimilation.
Patients’ own psychological barriers to recovery from pain have been studied by Jerant et al (2005) who identify barriers to patient self management due to chronic conditions. The study was conducted on 10 focus groups involving 54 chronically ill patients and 85% of them had multiple chronic conditions. The aim of the study was to elicit the perceived barriers in active self management to access self management support resources. Jerant et al stated that depression, weight problems, exercising difficulty, fatigue, poor communication with physician, low family support, continuous pain and financial problems were the most frequently noted barriers to active self-management. The most common barriers, in accessing self-mangement support resources as found by the authors were lack of awareness on pain symptoms and management, physical symptoms, transportation problems, and cost/lack of insurance coverage. The authors suggest that many home based interventions may be more effective any centralised facility-based program to overcome the barriers of pain management.
The cognitive behavioural model is most effective for chronic stress management and Dysvik et al (2005) claim that many models of pain give coping an important role in understanding adaptation to chronic pain. The Lazarus and Folkman’s cognitive-phenomenological model of stress and coping provides a theoretical framework with which to conceptualise stress and coping strategies related to chronic pain symptoms (Dysvik et al , 2005). Dysvik et al reiterates that an understanding of the concept of coping, the coping strategies used are crucial for the success of any pain management and rehabilitation program. In this study 88 people were recruited for a multidisciplinary pain management programme and the dominant stressors were found to be family life and social activities. Pain was identified as bringing forth issues of pain as problem focused coping as well as well emotion focused coping along with depression, threat and reduced self esteem. The psychological dimensions of pain bring into play method of behavioural, cognitive, client centred and group therapy.
Vivian et al (2004) evaluated the feasibility of a cognitive behavioural training program in adolescents suffering from chronic pain. The study also aimed to focus on the effect of a CBT pain management program and quality of life. For the study 8 adolescents from 14-18 years and their parents were chosen and they had five group meetings and four telephone contacts over 9 weeks. This was more of group therapy cognitive behavioural intervention program and the training involved changing ain behaviour through pain education, cognitive restructuring problem-solving techniques, relaxation strategies, assertiveness training, and stimulating the adolescent’s physical activity level. The social context of pain was also addressed and adolescents were taught to be more in control of their pain to help improve their quality of life. Pain as a psychological and social perception has been found to be effectively tackled through group therapy as found in this study.
Apart form cognitive behavioural and group therapy discussed, person centred approaches when the patient is given full control of his condition and allowed to cope with his physical condition independently is an important aspect of therapy. In client centred approaches to pain therapy, the person overcomes his condition b focusing on moving towards more meaningful goals. Music and art as well as Yoga (Williams, 2005) are also newly developed forms of therapy and their effectiveness on pain has been recently studied by several researchers (Stoll, 2005; Aldridge, 1994). Aldridge (1994) suggests that group creative music therapy in psychiatric hospitals reflects the acceptance of the creative art therapies in such settings. For art therapy, receptive taped music used as anxiolytic for individual patients, are being used in coronary care units and also in cancer pain care. Aldridge writes further that music therapy with adults and children is seen as part of a necessary creative arts environment that is developed within hospital settings for the management of the mentally handicapped people of varying ages. Music therapy is also accepted as a valid therapeutic treatment for children (Aldridge, 1994).
Conclusion
In this essay we discussed the mechanism of pain as well as clinical evidence of pain management discussing several approaches to pain management including art therapy, cognitive behavioural and group therapeutic approaches. We also discussed the National service Framework for Chronic Pain management given by the Department of Health and identified its agenda and objectives as well the services available in clinics and primary care trusts.
Tags: art therapy, behavioural therapy, CBT, music, pain, pain management, QST, UK, yoga
