social role functioning and increasing positive cognitive coping and activity levels. This type of therapy also has a significant effect on reducing subjective pain experiences and overt pain behaviors (Knoerl, et al, 2016). More recent reviews have also supported the use of CBT for problems associated with chronic pain in adults with fibromyalgia (Dellwo, 2019). or cancer (Brown, 2020). . Additionally, with some modifications, CBT is also suitable for use with children and adolescents who suffer from chronic pain and for those who have emotional and behavioral problems which is pain-related (Bosmans, 2016). Small controlled clinical trials investigating the efficacy of CBT in temporomandibular disorders have shown promising and stable results with regard to pain intensity, coping skills, and satisfaction with the treatment (Institute for Chronic Pain, 2016; Ran et al., 2020). Ultimately CBT is a psychological intervention which blends cognitive restructuring and teaching behavioral techniques which emphasize learning, personal control, problem solving and expectations (Academy of Pain Medicine, 2019). It is unfortunate that CBT is an underutilized treatment modality for chronic pain Time constraints, patient resistance or lack of knowledge about CBT, low reimbursement rates and the convenience of prescribing medications individually or collectively can negate the use of (CBT) for the treatment of patients with chronic pain (Wolters Kluwer Health, 2017). Good evidence exists for small to moderate effects of a comprehensive CBT approach in treating chronic pain, but strictly behavioral approaches may not be as effective, and booster sessions (i.e., sessions scheduled after treatment completion) may be important to maintain gains over time. It also appears that both cognitive and behavioral components are necessary for effective CBT. Relaxation training For many years, it has been believed that stress and tension are both a cause and an effect of pain and that interventions that relax the body may also be beneficial for pain. Virtually all treatment programs for chronic pain now include some form of relaxation training. Here we will review three of the most commonly used relaxation approaches and describe (where available) the evidence for their effectiveness. Generally speaking, it is recommended that relaxation approaches be included as part of CBT or other treatment rather than as stand-alone interventions (Jeffrey, et al. 2016). Clinicians typically emphasize the importance of home practice of relaxation techniques, which have been associated with better outcomes in some as continuing use of relaxation techniques is more effective than short-term use (National Center for Complementary and Integrative Health, 2016; Harvard Health Publishing, 2020). Due to the paucity of randomized controlled clinical trials for temporomandibular disorders, headaches, and neuropathic pain, the information in this section is based on chronic pain in general. Diaphragmatic breathing Deep, slow breathing is perhaps the oldest intervention for pain and is widely integrated into a number of traditional, non-Western approaches – such as yoga, qigong, and tai chi – that are often used for pain management (Shah, et al., 2020; London Pain clinic, 2017). Physiologically, deep and slow breathing appears to decrease blood pressure, lower heart rate, and decrease subjective muscle tension (Harvard Health Publishing, 2020). There is indeed evidence that deep breathing can modulate the perception of painful stimuli and negative affect (Mirgain, et al., 2016). Most researchers and clinicians recommend instructing patients to slow their rate of breathing by about half (to about seven cycles per minute) and to breathe deeply from the diaphragm (rather than high up in the chest). Mindful meditation Mindfulness is a practice that has its roots in Buddhist meditation and is defined as intentionally paying attention to experiences in the present moment in a nonjudgmental way (Hilton, et al. 2017; Neckar, 2020). A person who is practicing mindfulness attempts
to become an outside and neutral observer to his or her own experiences and learns to avoid thinking of the past or future. Distracting thoughts and worries are not intentionally “ignored” but rather noticed without being engaged. This practice has shown good effects in conditions with mood components such as anxiety and depression (Hliton, et al, 2017). The mechanisms of mindfulness on pain are thought to be both psychological and neurological in nature. Magnetic resonance imaging studies of people engaging in mindful meditation have shown that it involves increased activation in the prefrontal brain regions associated with attentional control with less activation in the parts of the brain which manage pain impulses. The reduction of pain from meditation is due to the engagement of opioid receptors in the brain (Neckar, 2020; Zeidan and Vago, 2016; Hilton, et al., 2017). Only recently have these techniques been scientifically studied in people with chronic pain. Mindfulness techniques for pain are very different from those that are typically practiced in Western psychology, such as mental distraction or thought challenging in cognitive therapy. After brief training with the technique of mindfulness meditation both the sensory and affective pain- related responses are diminished the extent of which will vary among individuals (Zeidan and Vago, et al., 2016). In traditional CBT, thoughts around pain may be identified and challenged, whereas in mindfulness those thoughts would simply be nonjudgmentally observed: “My body is feeling overwhelmed by pain right now. My mind is having the thought that I can’t handle this amount of pain.” Evidence indicates that mindfulness medication can provide a significant reduction in pain and its accompanying problems such as opioid addiction, stress, depression, and anxiety (Zeidan and Vago, 2016). Mindfulness meditation involves several brain mechanisms which decrease the subjective perception of pain. Even a brief training of less than one week can produce a significant decrease in the intensity and perception of pain (Zeidan and Vago, 2016). However, reviews suggest that although the intervention is promising, there is not yet sufficient evidence to recommend it for large-scale use, and further studies are required (Pain Relief Foundation 2016; Hilton et al., 2017). Self-hypnosis training Self-hypnosis training is an approach in which individuals are taught to guide themselves into a deep state of relaxation, suggestibility, and altered perception. Although definitions of hypnosis vary, the general principle of hypnosis is the induction of a trance state that is used to encourage beneficial cognitive, emotional, or physical healing responses with the trance being a natural biological state of focus, inner absorption and concentration (Whole Health, 2020). Self-hypnosis for pain (also called hypnotic analgesia ) attempts to take advantage of this increased capacity for modifying perception by providing individuals with suggestions for decreased pain sensations and increased feelings of comfort. The goal of hypnotic analgesia is not to reduce pain intensity directly, but rather to alter an individual’s perceptions and experience of the pain. In general, a session of hypnotic analgesia has three stages: 1. Hypnotic induction : The hypnotic induction stage serves as a transition from a normal, waking state to a hypnotic state. This process typically involves engaging clients’ full attention and interest and encouraging them to focus all of their attention on one particular stimulus (e.g., the sound of the clinician’s voice or their breath). This part of the hypnotic induction is not unlike mindful meditation. Typically, once the client has focused his or her attention, what follows is a progressive relaxation (referred to as deepening ). Progressive hypnotic inductions can feature the hypnotherapist suggesting that the patient focuses upon various things such as breathing, muscle relaxation, visualization, and counting (Fulcher, 2019). Clients may be asked to use mental imagery to imagine themselves in a safe or comforting place.
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