Authors
- Saravanan, Anitha PhD, RN
- Reagan, Louise PhD, APRN, ANP-BC, FAANP
Abstract
Objectives: Chronic pain frequently coexists with other distressing symptoms (depressive mood, sleep disturbance, fatigue, and stress) and maladaptive beliefs (fear avoidance and pain catastrophizing) that together are linked with increased pain severity and interference, poor function, and quality of life. Although a tremendous amount of research has been conducted to identify risk factors and treatment targets for managing pain, too often the strategies are not combined in a way to make them useful for daily multimodal application. The purpose of this narrative review is to examine the existing literature on the co-occurring symptoms and maladaptive beliefs, lifestyle, and socioenvironmental factors associated with chronic pain and the current nonpharmacological treatment strategies designed to help patients manage chronic pain.
Methods: Literature databases PubMed/Medline, CINAHL, and PsycINFO were searched to review the evidence on treatment strategies that have evidence of effectiveness in managing chronic pain and co-occurring symptoms. Conceptual models of chronic pain and nonpharmacological pain management strategies were reviewed.
Results: Evidence was found in support of cognitive-behavioral, lifestyle, and socioenvironmental factors and treatment strategies that are effective in managing chronic pain and co-occurring symptoms. The key factors identified and proposed include lifestyle factors (physical activity, diet, maintaining body weight, keeping a routine, and sleep habits), planned phases of activities (relaxing, pacing, and meditation at regular intervals), CBT strategies (stretching, breathing, meditation, and stress reduction), socioenvironmental factors (keeping a calm, peaceful, environment), and positive support system. On the basis of this evidence, a biobehavioral pain hygiene model is proposed that combines existing strategies in managing pain to make them useful for daily multimodal application and which may be used to integrate therapeutic interventions for chronic pain management.
Discussion: Given the dearth of research on integrative multimodal pain management, this review and the biobehavioral pain hygiene model could drive future research in the management of chronic pain. Identification of the key strategies and combining them to be a useful multimodal application will be a first step toward identifying innovative methods that could help improve pain and function in patients with chronic pain.
Article Content
Learning Objectives: After participating in this continuing professional development activity, the provider should be better able to:
1. Describe the symptoms that commonly co-occur with chronic pain.
2. Evaluate the lifestyle and socioenvironmental factors that influence chronic pain.
3. Apply the pain hygiene model in the context of a multimodal approach for management of chronic pain.
Globally, there is increasing concern on the financial and societal burden of chronic pain and its current management strategies, necessitating a need for reframing or creating new theoretical frameworks for treatment. Historically, chronic pain was viewed as an isolated symptom caused by damage to the central and/or peripheral nervous system. However, the biopsychosocial model shifted the paradigm of pain management by addressing critical contextual factors to consider in the individual's experience, including the psychological, social, and environmental state in which chronic pain occurs.1 This insight calls for an integrated approach to pain management that goes beyond pharmacological and/or invasive interventions and addresses the holistic well-being of the individual and their support unit, access to resources, and transdisciplinary coordination of care. Evidence regarding treatment strategies that should be considered across all pain conditions could provide an initial set of behaviors and strategies to help optimize pain outcomes.
One example of these treatment strategies is improving sleep hygiene. Sleep hygiene was originally introduced in the late 1970s as a set of behavioral and environmental characteristics to promote sleep for people with mild to moderate insomnia.2 Since the original introduction into the realm of sleep medicine, sleep hygiene education has been evaluated against sleep restriction, stimulus control, and cognitive-behavioral therapy for insomnia (CBT-I).3,4 Of importance, CBT-I is a multimodal approach that uses a combination of cognitive therapy, behavioral interventions (stimulus control and sleep restriction), and education (sleep hygiene), and is recommended as the initial treatment for chronic insomnia.5 A similar paradigm for the treatment of chronic pain may be a useful next step, specifically, by identifying topics for a universal educational component that could comprise pain hygiene. The purpose of this article was to conduct a narrative review of the current state of the science, based on current evidence pertaining to behavioral and environmental treatment strategies for chronic pain that may be integrated to develop a pain hygiene model.
Methodology
A literature review of research databases (CINAHL, PubMed/MEDLINE, and PsycINFO) was conducted to identify relevant research related to nonpharmacological strategies for chronic pain management. The review was conducted using the key terms: chronic pain, depressive mood, sleep disturbances, fatigue, stress, comprehensive pain management, diet, weight management, fear avoidance, pain catastrophizing, adults, support, and environmental factors. Publications from 2010 to the present that were written in English were included and grouped according to the strategies used. Because our goal was to conduct a narrative review, we did not analyze each study for methodological rigor and quality for assessing risk of bias, nor did we use a formal methodological evaluation tool.
Chronic Pain and Impact
Chronic pain (persistent or recurrent pain for more than 12 weeks) affects more Americans than heart disease, diabetes, and cancer combined and is one of the most common reasons for adults seeking medical care.6 As of 2016, prevalence rates among adults in the United States are anywhere from 11% to 40%.7
Epidemiologic studies suggest that most people with chronic pain have multiple pain sites. Common causes of chronic pain include headache (16.1%), low back pain (28.1%), neck pain (15.1%), knee pain (19.5%), shoulder pain (9.0%), and hip pain (7.1%).
In a survey, 59% reported that the pain impacts their overall enjoyment of life, 77% reported feeling depressed, 70% reported having trouble concentrating, 79% reported having low energy levels, and 86% reported inability to sleep well.8
Chronic pain is the most common reason for long-term disability and is often accompanied by depressive disorders, poor perceived health outcomes, or reduced quality of life.9-11 An estimated societal cost of $560 billion each year is attributed to chronic pain related to direct medical costs, lost productivity, and disability programs.12
According to the Global Burden of Disease Study 2016, pain and pain-related diseases are the leading causes of disability worldwide, and the burden of chronic pain is constantly escalating.13 Among chronic pain, recurrent tension-type headache, low back, and neck pains are leading causes of disability worldwide.13,14 If not appropriately managed, chronic pain can cause long-term suffering, disability, mental health issues, and poor quality of life.15 Disability caused by chronic pain adds to the economic and societal burden,16,17 and at an individual level can significantly affect quality of life.18,19 Patients with chronic pain who have higher pain intensity and higher disability scores report poor quality of life.15 Moreover, co-occurring symptoms and beliefs, including anxiety, depression, fear avoidance, and catastrophizing, cause impairment in health-related quality of life.20
Current Theoretical Models of Pain
In the field of psychology, several models of chronic pain have been posited,21-24 including operant conditioning that is the basis of cognitive-behavioral therapy (CBT). Although these models originated and focused on human experiences and behavior,25 more recent models such as the fear-avoidance model26 include CBT and interpretation and response to chronic pain.27 Yet another treatment process model, the psychological flexibility model, goes a step beyond to portray how pain is interpreted by patients and changed within the context of the psychological experiences.28,29 These models have also been shown to benefit co-occurring symptoms in chronic pain. For example, multidisciplinary programs that have incorporated CBT have been shown to improve pain and depressive mood, sleep disturbances, stress, and quality of life.30
Other theoretical models have posited the co-occurrence of symptoms such as depressive mood, sleep disturbances, stress, and fatigue in chronic pain. Based on these models, several recent investigations have demonstrated significant impact on pain outcomes from treating the co-occurring symptoms.31-34 These studies add to the evidence regarding the clinical importance of the assessment and treatment of co-occurring symptoms in patients with chronic pain and potential positive influence on mental, physical, and functional status and on quality of life.35-38 In addition, lifestyle factors that have been found to influence pain and co-occurring symptoms include physical inactivity, stress, poor sleep, unhealthy diet, and smoking.39
Impact of Co-Occurring Symptoms and Maladaptive Beliefs on Chronic Pain
Depression and Anxiety
In addition to direct impact on functional outcomes and quality of life, chronic pain is significantly associated with depression and anxiety.10,22,37,38 Studies have also demonstrated that depression is a consequence of chronic pain and not a predisposing factor, with pain severity predicting depressive symptoms.40,41 The coexistence causes additive adverse effects on patient outcomes, such as reduced response to treatment, and poorer functioning.42
Sleep Disturbance
Poor sleep is yet another challenge faced by patients with chronic pain. About 50% to 88% of patients with chronic pain also suffer from sleep disorders, and more than 40% patients with insomnia also have a diagnosis of chronic pain.43 Chronic musculoskeletal pain, including that due to arthritis, low back pain, and fibromyalgia, is often associated with insomnia.44 Epidemiologic studies highlight poor sleep quality as an independent risk factor for developing chronic pain, especially musculoskeletal pain.45 Recent meta-analysis to quantify the effect of sleep deprivation on pain perception in healthy human subjects revealed a medium effect size (standardized mean difference = 0.62).46
Fatigue
Fatigue is prevalent and a problematic co-occurring condition for individuals with chronic pain.47-50 Some studies have shown that 64% of the individuals with chronic widespread pain reported co-occurring persistent fatigue whereas others have shown up to 70% prevalence.50 Fatigue, as a comorbid condition with chronic pain, can be an additional burden and cause disability if it is not treated.51,52 Further, fatigue has shown to reduce ability of patients to engage in treatments involving physical activity.53 A prospective cohort study of 120 patients with chronic widespread pain participating in multidisciplinary rehabilitation treatment (baseline, 6, and 18 months of follow-up) revealed that higher levels of pain, interference of pain, depression, and negative emotional cognitions were associated with a higher level of fatigue.54 A systematic review demonstrated high prevalence of fatigue in individuals with chronic pain that was predicted by pain severity and duration.55 Strategies such as planned physical activity and motivational interviewing have been used to manage fatigue in patients with chronic pain.56,57
Fear Avoidance
Based on key theoretical models of pain originating from the fear-avoidance model, many studies have underlined the critical role of fear of movement and related fear avoidance as co-occurring in chronic pain and significantly associated with increased pain, increased functional limitations, and poor quality of life.26,58,59 In particular, fear of movement (kinesophobia) is associated with greater levels of pain intensity, disability, and low quality of life.60 Further, fear-avoidance beliefs have been associated with poor treatment outcome in patients with low back pain of less than 6 months,61 indicating need for early interventions to address fear of movement. Although there is moderate evidence that multidisciplinary psychological cognitive-behavioral interventions are effective in reducing fear of movement,62 recent evidence indicates the potential benefit of conservative interventions such as manual therapy and electrotherapy to reduce fear-avoidance beliefs in individuals with chronic low back pain.63-65
Pain Catastrophizing
Pain catastrophizing has been most consistent with predicting adjustment to chronic pain and contributes to its duration and delayed recovery.66 In a systematic review of 6 prospective longitudinal studies with small- to mid-sized samples, pain catastrophizing was identified as a significant predictor of chronic pain persisting for 3 months or longer after total knee arthroplasty.67
In another review of 11 studies, involving 2269 patients with chronic low back pain, pain catastrophizing predicted degree of pain and disability and mediated treatment efficacy in most studies.68 Although a modifiable characteristic, interventions so far have only produced moderate benefits.69
To understand the possible mechanisms underlying pain catastrophizing in both chronic pain patients and healthy controls, 20 articles involving MRI studies were reviewed. The review demonstrated that changes in pain perception areas of the brain are more pronounced in chronic pain patients, indicating that structural and functional brain changes are related to pain catastrophizing.70
Among other factors, anxiety has been found to be closely associated with pain catastrophizing. Across 29 studies conducted in postoperative pain, anxiety and pain catastrophizing together were found to play a role in development of chronic postsurgical pain.71 As more studies continue to identify the mechanisms involved and the interventions that might benefit chronic pain patients with pain catastrophizing, there is yet another important aspect that is pain beliefs across cultures. In a recent review involving 10 studies and 6797 adults, 1365 articles from across the world, there was significant difference of 50% or more in mean scores of pain beliefs and pain catastrophizing between people from different countries.72
Lifestyle Factors
There is growing research on the extent to which lifestyle factors are important in the onset and continued experience of chronic pain. Current literature has shown lifestyle factors such as physical activity/exercise,73,74 diet,75 and stress76,77 can be associated with patient-reported pain, function, and quality of life in adults.
Among these factors, physical activity/exercise has been extensively studied in various chronic pain conditions, including in fibromyalgia, rheumatoid arthritis, osteoarthritis, low back pain, and neck pain and across various modalities of activity types such as aerobic, strength, and aquatic exercises. However, favorable effects in improving pain experiences and function have shown only small to moderate effect.78
For example, in knee and hip osteoarthritis, there is moderate quality of evidence on effects of aquatic exercise on pain, disability, and quality of life.79 In fibromyalgia, aerobic exercises showed moderate effect size improvement in pain, depressive mood, and quality of life.80
In another systematic review, there was low quality of evidence on benefit of high-intensity compared with low-intensity exercise in short-term pain and physical function outcomes.81 Although one study demonstrated a significant association between exercise duration and exercise-induced hypoalgesia in neck pain,82 there is still no clear evidence on the type, dose, and intensity of physical activity that can be beneficial for patients with different types of chronic pain. Nevertheless, physical activity has been shown to be effective as a nonpharmacological intervention.83
Obesity has been found to be highly prevalent in chronic pain, and together, these 2 factors worsen health-related quality of life.84-87 In one study, 40% of obese individuals reported chronic pain and 90% of them reported moderate to severe pain.85 In another study, overweight individuals had about 20% more pain compared with normal-weight people; and as body mass index increased, the intensity of pain increased.86
Although current literature suggests an association between obesity and chronic pain, a direct cause-effect relationship remains enigmatic.88 However, obesity has been linked to mechanical impact on joints and muscles and systemic inflammation.89,90 Some studies also show the influence of pain contributing to weight gain due to fear avoidance91,92 and eating behaviors.93,94 Moreover, some studies report improvement in quality of life as a benefit of weight loss.95,96
Chronic pain can lead to physical, emotional, social, and financial stress that can affect all domains of life.97 Many types of chronic pain conditions such as fibromyalgia, migraine, and headache are affected by stress76 and have been found to be related to changes in the hypothalamic-pituitary-adrenocortical axis. Studies have provided evidence on exposure to experimental stress and the relationship of cortisol levels to changes in pain sensitivity.98,99 Further, cellular aging has been identified to be more marked in older adults who experience high levels of perceived stress and chronic pain.100
In summary, although lifestyle factors such as diet,75 stress,76,77 and physical activity73,74 are associated with pain, function, and quality of life across chronic pain conditions, very few programs have integrated these approaches into a multimodal strategy. The few integrative interventions that have been examined, however, have shown medium effect sizes for pain severity, interference, and disability.30,97
Socioenvironmental Factors
The positive effects of social support in patients with chronic pain on function, pain, and disability continue to be studied. Some studies are showing that social support is linked with improved coping, resilience, overall well-being, and the maintenance of optimal physiologic function.101-106 For example, in chronic low back pain, patients who reported strong social support had lower disability, and social support moderated the relationship between pain and function.107,108 Low social support can possibly relate to higher risk for low back pain109 and increased risk for low back pain chronicity.110 In rheumatoid arthritis patients, early social support was associated with positive long-term effects on pain and function.111 Similarly, in individuals with osteoarthritis, increased social support helped decrease the effects of pain on physical function.101
Current Treatment Strategies
Research has shown that multidisciplinary pain rehabilitation programs (PRPs) improve daily functioning in patients with chronic pain. Systematic review studies of 10 randomized controlled trials (RCTs) reporting on 10 multidisciplinary PRPs concluded that PRPs that offer more than 100 hours are superior to monodisciplinary treatment and PRPs offering 30 hours of rehabilitation.112 Furthermore, studies have shown that integrative approaches for chronic pain improve physical, social, work-related activities and reduce pain, emotional distress, disability, and medication use.113
Meta-analysis of 25 CBT RCTs concluded that CBT provides greater change in cognitive coping, pain experience domains, and reduced behavioral expression of pain.114 In addition, studies have shown that multimodal interventions are more beneficial than single-modal interventions in adults with osteoarthritis,115,116 back pain,116,117 neck pain,118 and headache.119
Physiotherapy along with pain neuroscience education has been shown to provide greater pain relief and function.120-123 When taken together, there is a growing body of literature that has examined the linkages among chronic pain, co-occurring symptoms, and maladaptive beliefs (depressive mood, anxiety, sleep disturbances, fear avoidance, and pain catastrophizing) and the effects of various treatment strategies (CBT and mindfulness-based interventions) on managing pain and psychobehavioral symptoms. However, optimal implementation and evaluation of integrated chronic pain management are critical. Clinical trials, such as the Whole Health Options and Pain Education (wHOPE trial), which compares multidisciplinary team management to primary care group education to promote nonpharmacological strategies to improve pain, functioning, and quality of life in military veterans123 will begin to provide evidence on how integrative strategies can be feasibly employed.
Proposed Conceptual Framework
Based on the literature review, a pain hygiene conceptual model was constructed to depict key co-occurring symptoms, lifestyle, and socioenvironmental factors that influence chronic pain. Figure 1 illustrates the core of the framework as the bidirectional interplay with various co-occurring symptoms and maladaptive beliefs, including depressive mood, anxiety, sleep disturbances, fear avoidance, and pain catastrophizing. These associations are framed most immediately by the impact on quality of life and function in patients with chronic pain.
Given the critical role of lifestyle and socioenvironmental factors on chronic pain, these are shown in the model to be influenced by strategies such as lifestyle modifications, planned daily activities, CBT, and socioenvironmental strategies that likely interact with pain, co-occurring symptoms, and maladaptive beliefs to shape the temporal experience of chronic pain. The proposed pain hygiene model expands upon the biopsychosocial framework of chronic pain, which primarily depicts the relationships among these domains to influence the experience of pain and functional outcomes. Specifically, after providing pain neuroscience education, the pain hygiene model could be used to guide education on a multimodal approach to chronic pain, as it incorporates key areas for improving pain, function, and quality of life, including health promotion strategies.
The term "pain hygiene" refers to an integrated approach to educating and working with patients and families to help manage chronic pain. The clinician first assesses the patient's breadth of knowledge about the neurophysiology of chronic pain and provides additional information to augment understanding. Then, using reliable and valid instruments, the clinician should assess the severity, frequency, and impact of co-occurring symptoms and maladaptive beliefs.
Screening instruments for depression and anxiety may be helpful to inform the need for referral to psychiatry for evaluation and treatment, whereas assessment of sleep disturbance may indicate a necessary referral to a psychologist who specializes in CBT-I.
Explaining how these co-occurring symptoms and maladaptive beliefs impact the experience of pain and outcomes can provide patients with insight on their own experiences and encourage monitoring and follow-up. Physical and occupational therapists can be helpful in addressing fear avoidance, whereas CBT techniques can target pain catastrophizing through awareness, using positive self-statements and practicing other adaptive coping strategies.124
The clinician should review other psychological, behavioral, lifestyle, and socioenvironmental factors that affect the pain experience, and existing strategies available to help manage chronic pain. It is also important to seek education on how to incorporate pain hygiene into daily life as a routine practice.
CBT strategies have served to help patients learn how to live well with pain. However, integration of lifestyle factors, planned activities, and modifications of the individual's socioenvironmental factors may help to optimize the impact on pain outcomes (pain severity, interference, and quality of life). Motivational interviewing may be used to assist the patient to engage in general health promotion strategies with follow-up for goal modifications and problem-solving.
Implications and Future Directions
Although some research has examined the implications of lifestyle factors such as diet, physical activity, weight management, and sleep on chronic pain outcomes, there remains a significant need for research to identify effective integrative treatment paradigms.
Areas of pain education and treatment that are not routinely addressed in current chronic pain interventions include diet and weight management, planned phases of activities (relaxing, pacing, and meditation at regular intervals), and socioenvironmental factors (keeping a calm, peaceful, environment), and positive support system.
In addition, because chronic pain is often a comorbid condition along with other chronic health conditions, development of novel ways to integrate self-management strategies tailored to the chronic comorbid conditions of the individual could help to provide a more pragmatic approach for patients and families. Skills of self-management, such as monitoring symptoms and goals, problem-solving, and strengthening emotional regulation in response to daily challenges, are applicable to all chronic conditions and should be purposefully tailored to the unique context in which self-management takes place.
The pain hygiene model proposes an integrative approach to educating patients with chronic pain. Highlighted in this review and the pain hygiene model are the relationships among co-occurring symptoms and strategies that can be effectively implemented to improve chronic pain outcomes.
Most of the research studies in chronic pain have examined lifestyle factors or socioenvironmental factors either independently or as risk factors contributing to the transition from acute to chronic pain.
More research is needed to continue to identify the associations between lifestyle, socioenvironmental factors, and chronic pain. The pain hygiene model can be used as a framework. There is also a need to clarify, within the context of current conceptual models, the mechanisms that underlie each of these factors and their implications in maintenance of chronic pain and other comorbid symptoms associated with chronic pain.
Although cross-sectional studies have significantly improved the understanding of chronic pain along with comorbid symptoms, there is limitation of temporality. Yet another avenue for future research is collaborative interdisciplinary research among various health care providers who work with patients in using the pain hygiene model for education to improve function and pain. Currently, in clinical practice, pain education is provided by physicians, nurses, and physical therapists during their interaction with patients. The use of multimodal, digital education templates to deliver personalized treatment strategies is needed to further drive this area of research.
Conclusion
Integrative chronic pain treatment strategies that address co-occurring symptoms and maladaptive beliefs, lifestyle, and socioenvironmental factors may provide an avenue to deliver holistic care for patients and families. Identifying tailored multimodal treatments for patients with chronic pain is a critical area for future research. We advocate for a renewed focus on the factors that attribute to occurrence and maintenance of chronic pain, and novel treatment targets. Chronic pain management is incomplete without addressing psychobehavioral symptoms and lifestyle modifications. Our pain hygiene model depicts the intricate and complex interactions among multiple domains of chronic pain and treatment strategies to improve health outcomes. There is a need for better means to capture all lifestyle factors and psychobehavioral symptoms, and to create chronic pain management guidelines to help patients with chronic pain to improve their health outcomes.
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Biobehavioral pain management; Multimodal, Pain hygiene