Integration of Behavioral and Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia

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Abstract

Objective. To provide physicians with a responsible assessment of the integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia.

Participants. A non-Federal, nonadvocate, 12-member panel representing the fields of family medicine, social medicine, psychiatry, psychology, public health, nursing, and epidemiology. In addition, 23 experts in behavioral medicine, pain medicine, sleep medicine, psychiatry, nursing, psychology, neurology, and behavioral and neurosciences presented data to the panel and a conference audience of 528.

Evidence. The literature was searched through Medline and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience.

Assessment Process. The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference.

Conclusions. A number of well-defined behavioral and relaxation interventions now exist and are effective in the treatment of chronic pain and insomnia. The panel found strong evidence for the use of relaxation techniques in reducing chronic pain in a variety of medical conditions as well as strong evidence for the use of hypnosis in alleviating pain associated with cancer. The evidence was moderate for the effectiveness of cognitive-behavioral techniques and biofeedback in relieving chronic pain. Regarding insomnia, behavioral techniques, particularly relaxation and biofeedback, produce improvements in some aspects of sleep, but it is questionable whether the magnitude of the improvement in sleep onset and total sleep time is clinically significant.

Introduction

Chronic pain and insomnia afflict millions of Americans. Despite the acknowledged importance of psychosocial and behavioral factors in these disorders, treatment strategies have tended to focus on biomedical interventions such as drugs and surgery. The purpose of this conference was to examine the usefulness of integrating behavioral and relaxation approaches with biomedical interventions in clinical and research settings to improve the care of patients with chronic pain and insomnia.

Assessments of more consistent and effective integration of these approaches required the development of precise definitions of the most frequently used techniques, which include relaxation, meditation, hypnosis, biofeedback (BF), and cognitive-behavioral therapy (CBT). It was also necessary to examine how these approaches have been previously used with medical therapies in the treatment of chronic pain and insomnia and to evaluate the efficacy of such integration to date.

To address these issues, the Office of Alternative Medicine and the Office of Medical Applications of Research, National Institutes of Health, convened a Technology Assessment Conference on Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. The conference was cosponsored by the National Institute of Mental Health, the National Institute of Dental Research, the National Heart, Lung, and Blood Institute, the National Institute on Aging, the National Cancer Institute, the National Institute of Nursing Research, the National Institute of Neurological Disorders and Stroke, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

This technology assessment conference (1) reviewed data on the relative merits of specific behavioral and relaxation interventions and identified biophysical and psychological factors that might predict the outcome of applying these techniques and (2) examined the mechanisms by which behavioral and relaxation approaches could lead to greater clinical efficacy.

The conference brought together experts in behavioral medicine, pain medicine, sleep medicine, psychiatry, nursing, psychology, neurology, behavioral science, and neuroscience as well as representatives from the public. After 1-1/2 days of presentations and audience discussion, an independent, non- Federal panel weighed the scientific evidence and developed a draft statement that addressed the following five questions:

• What behavioral and relaxation approaches are used for conditions such as chronic pain and insomnia?
• How successful are these approaches?
• How do these approaches work?
• Are there barriers to the appropriate integration of these approaches into health care?
• What are the significant issues for future research and applications?

The suffering and disability from these disorders result in a heavy burden for individual patients, their families, and their communities. There is also a burden to the Nation in terms of billions of dollars lost as a consequence of functional impairment. To date, conventional medical and surgical approaches have failed&emdash;at considerable expense&emdash;to adequately address these problems. It is hoped that this Consensus Statement, which is based on rigorous examination of current knowledge and practice and makes recommendations for research and application, will help reduce suffering and improve the functional capacity of affected individuals.

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