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How self-awareness may help relieve chronic pain

Many years ago I was plagued with debilitating headaches associated with a number of seemingly unrelated activities that included cooking for company and sewing drapes for the house. I thought I might be allergic to natural gas or certain fabrics until one day I realized that I tensed my facial muscles when I concentrated intently on a project.

The cure was surprisingly simple: I became aware of how my body was reacting and changed it through self-induced behavior modification. I consciously relaxed my muscles when I focused on a task that could precipitate a tension-induced headache.

Fast forward about five decades: Now it was my back that ached when I hurriedly cooked even a simple meal. And once again I realized that I was transferring stress to the muscles of my back and had to learn to relax them and allow more time to complete a project to mitigate the stress. Happy to report, I recently prepared dinner for eight with nary a pain.

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I don't mean to suggest that every ache and pain can be cured by self-awareness and changing one's behavior. But recent research has demonstrated that the mind –along with other nonpharmacological remedies – can be powerful medicine to relieve many kinds of chronic or recurrent pains, especially low back pain.

As Dr. James Campbell, a neurosurgeon and pain specialist, put it, "The best treatment for pain is right under our noses." He suggests not "catastrophizing" – not assuming that the pain represents something disastrous.

Acute pain is nature's warning signal that something is wrong that should be attended to. Chronic pain, however, is no longer a useful warning signal, yet it can lead to perpetual suffering if people remain afraid of it, the doctor said.

"If the pain is not an indication that something is seriously wrong, you can learn to live with it," said Campbell, an emeritus professor at Johns Hopkins Medical Institutions. Too often, he explained, "people with pain get caught in a vicious cycle of inactivity that results in lost muscle strength and further pain problems."

Throwing powerful drugs at chronic pain problems may only add to the problem because ever higher doses are often needed. Knowing this, a growing cadre of specialists are exploring nondrug, noninvasive treatments, some of which have proved highly effective in relieving chronic pain.

The American College of Physicians recently issued new nondrug guidelines for treating chronic or recurrent back pain, a condition that afflicts about one-quarter of adults at a cost to the country in excess of $100-billion a year.

Noting that most patients with back pain improve with time "regardless of treatment," the college recommends such remedies as superficial heat, massage, acupuncture or, in some cases, spinal manipulation (chiropractic or osteopathic). For those with chronic back pain, the suggestions include exercise, rehabilitation, acupuncture, tai chi, yoga, progressive relaxation, cognitive behavioral therapy and mindfulness-based stress reduction.

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Drug-free pain management is now a top priority among researchers at the National Center for Complementary and Integrative Health, a division of the National Institutes of Health. A comprehensive summary of the effectiveness of nondrug treatments for common pain problems – back pain, fibromyalgia, severe headache, knee arthritis and neck pain – was published last year in Mayo Clinic Proceedings by Richard L. Nahin and colleagues at the center.

Based on evidence from well-designed clinical trials, the team reported that these complementary approaches "may help some patients manage their painful health conditions: acupuncture and yoga for back pain; acupuncture and tai chi for osteoarthritis of the knee; massage therapy for neck pain with adequate doses and for short-term benefit; and relaxation techniques for severe headaches and migraine."

Weaker evidence also suggested that massage therapy and spinal and osteopathic manipulation may be of some benefit to patients with back pain, and relaxation techniques and tai chi may help patients with fibromyalgia find relief.

Among the newest studies, conducted by Daniel C. Cherkin and colleagues at the Group Health Research Institute and the University of Washington in Seattle, both mindfulness-based stress reduction and cognitive behavioral therapy proved more effective than "usual care" in relieving chronic low back pain and improving patients' function.

Cognitive behavioral therapy, or CBT, in essence teaches people to restructure how they think about problems. "There was already evidence that CBT is effective for various pain conditions," Cherkin said. "Our study showed that cognitive behavioral therapy and mindfulness-based stress reduction were comparable in reducing dysfunction and pain severity."

A cost analysis showed that the mindfulness technique – basically, a form of meditation that helps patients "get in touch with their bodies and their lives," as Cherkin described it – proved more cost-effective than both CBT and usual care in reducing health care costs and lost productivity.

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The mindfulness technique, essentially a demystified form of Buddhist meditation, is taught and practiced in eight weekly two-hour sessions and combined with gentle yoga, Cherkin said. Patients learn to relax, become "nonreactive" to pain and not allow it to be the focus of their lives, he explained.

In a follow-up study done two years later, patients treated with mindfulness therapy or CBT remained more likely to be improved than those who received usual care, the team reported in February.

However, when it comes to accessing nondrug treatments for pain, there are two major problems. One is the failure of most health insurers to cover the cost of many if not all complementary methods and the practitioners who administer them. When forced to pay out of pocket, many patients are likely to choose a drug remedy – despite its potential pitfalls – that insurance will cover.

Another challenge is availability. People residing in nonurban areas may be hard put to find a nearby therapist trained in cognitive behavioral therapy or mindfulness-based stress reduction or even an expert massage therapist, tai chi teacher or acupuncturist.

However, there is another option too often overlooked that may be easier to find and is usually covered by insurance: physical therapy. Good physical therapy can often speed recovery and teach people how to avoid conditions – including inactivity – that can precipitate or exacerbate their pain.

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