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Pain Management
Niger Postgrad Med J. 2007 Sep;14(3):238-41.
Hypnosis and its place in modern pain management - review article.
Amadasun FE.
Department of Anaesthesiology, University of Benin Teaching Hospital, Benin City, Nigeria.
This is an evidence-based review of the efficacy of hypnosis in pain management. Hypnosis is as old as mankind. It is reported in the Ebers Papyrus in ancient Egyptian cures. It went into decline in the Middle Ages with the rise of Christianity, being erroneously associated with witchcraft. There was resurgence of interest in the 19th century. In the early 1950s, the British Medical Association endorsed the teaching of hypnosis in all medical schools. The literature is replete with anecdotal and controlled studies of the efficacy of hypnotherapy in pain management. Not much is found of the effectiveness in acute pain conditions. Nevertheless, in spite of some methodological flaws in many reports, there seems to be sufficient clinical evidence of sufficient quality, to conclude that hypnosis has demonstrable efficacy in the treatment of chronic pain.
Pain. 2007 Aug 3
Hypnosis in the management of persistent idiopathic orofacial pain - Clinical and psychosocial findings.
Abrahamsen R, Baad-Hansen L, Svensson P.
Department of Clinical Oral Physiology, School of Dentistry, University of Aarhus, Vennelyst Boulevard 9, DK-8000 Aarhus, Denmark.
This controlled and patient blinded study tested the effect of hypnosis on persistent idiopathic orofacial pain (PIOP) in terms of clinical and psychosocial findings. Forty-one PIOP were randomized to active hypnotic intervention or simple relaxation as control for five individual 1-h sessions. Primary outcome was average pain intensity scored three times daily in a pain diary using visual analogue scale (VAS). Secondary outcome measures were pain quality assessed by McGill pain questionnaire (MPQ), psychological symptoms assessed by symptom check list (SCL), quality of life assessed by SF36, sleep quality, and consumption of analgesic. Data were compared between groups before and after treatment using ANOVA models and paired t-tests. The change in VAS pain scores from baseline to the last treatment (t4) was (33.1+/-7.4%) in the hypnosis group and (3.2+/-5.4%) in the control group (P<0.03). In the hypnosis group, highly hypnotic susceptible patients had greater decreases in VAS pain scores (55.0+/-12.3%) when compared to less susceptible patients (17.9+/-6.7%) (P<0.02). After the last treatment there were also statistically significant differences between groups in perceived pain area (MPQ) and the use of weak analgesics (P<0.03). There were no statistically significant changes in SCL or SF36 scores from baseline to t4. In conclusion, hypnosis seems to offer clinically relevant pain relief in PIOP, particularly in highly susceptible patients. However, stress coping skills and unresolved psychological problems need to be included in a comprehensive management plan in order also to address psychological symptoms and quality of life.
Palliat Support Care. 2007 Jun;5(2):147-52.
An exploration of the utility of hypnosis in pain management among rural pain patients.
Thornberry T, Schaeffer J, Wright PD, Haley MC, Kirsh KL.
The Pain Treatment Center of the Bluegrass, Lexington, Kentucky, USA.
OBJECTIVE: Hypnosis is an adjunctive, noninvasive treatment with few side effects that can be useful in the management of chronic pain. However, it has fallen into disfavor in recent years and is often perceived by physicians as simple charlatanism. We evaluated the efficacy of this treatment as used clinically in a large, mostly rural, pain management center. METHODS: We conducted a chart review of 300 pain patients from the Pain Treatment Center of the Bluegrass who had undergone hypnosis for their pain concerns. A chart audit tool was developed consisting of basic demographics, pre- and posthypnosis pain ratings, a rating of relaxation achieved posthypnosis, and scores on the Beck Depression Inventory, Perceived Disability Scale, and the Pain Anxiety Symptom Scale. RESULTS: The sample consisted of 79 men (26.3%) and 221 women (73.7%) with a mean age of 46.3 years (SD = 9.9, range = 19-78). Pain levels recorded pre- and posthypnosis revealed significant improvement as a result of the intervention (mean difference = 2.5, t (1,298) = 25.9, p < .001). Patients reported an average of 49.8% improvement in relaxation level posthypnosis (SD = 24.2%) and had a mean score of 19.0 on the Beck Depression Inventory (SD = 9.9), indicating moderate levels of depression. Also, patients saw themselves as severely disabled regarding their ability to engage in physical (8.3/10) or job-related (7.7/10) activities. Attempts to identify predictors of hypnosis success were not fruitful with one exception. "Poor" responders to hypnosis reported greater levels of perceived dysfunction in their sexual functioning compared to the "good" responders, F(1,187) = 7.2, p < .01. SIGNIFICANCE OF RESULTS: Hypnosis appears to be a viable adjunct for pain management patients, including those from rural and relatively disadvantaged backgrounds. Prospective trials are needed to examine the utility of this modality in end-of-life and palliative care patients.
Psychosom Med. 2007 Mar-Apr;69(2):191-9. Epub 2007 Feb 8.
Effects of age on responsiveness to adjunct hypnotic analgesia during invasive medical procedures.
Lutgendorf SK, Lang EV, Berbaum KS, Russell D, Berbaum ML, Logan H, Benotsch EG, Schulz-Stubner S, Turesky D, Spiegel D.
Department of Psychology, University of Iowa, Iowa City, IA 52242, USA. susan-lutgendorf@uiowa.edu
OBJECTIVES: To assess the effects of age on responsiveness to self-hypnotic relaxation as an analgesic adjunct in patients undergoing invasive medical procedures. MATERIAL AND METHODS: Secondary data analysis from a prospective trial with 241 patients randomized to receive hypnosis, attention, and standard care treatment during interventional radiological procedures. Growth curve analyses, hierarchical linear regressions, and logistic regressions using orthogonal contrasts were used for analysis. Outcome measures were Hypnotic Induction Profile scores, self-reported pain and anxiety, medication use, oxygen desaturation < or =89%, and procedure time. RESULTS: Hypnotizability did not vary with age (p = .19). Patients receiving attention and hypnosis had greater pain reduction during the procedure (p = .02), with trends toward lower pain with hypnosis (p = .07); this did not differ by age. As age increased, patients experienced more rapid pain control with hypnosis (p = .03). There was more rapid anxiety reduction with attention and hypnosis (p = .03). Trends toward lower final anxiety were also observed with attention and hypnosis versus standard care (p = .08), and with hypnosis versus attention (p = .059); these relationships did not differ by age. Patients requested and received less medication and had less oxygen desaturation < or =89% with attention and hypnosis (p < .001); this did not differ by age. However, as age increased, oxygen desaturation was greater in standard care (p = .03). Procedure time was reduced in the attention and hypnosis groups (p = .007); this did not vary by age. CONCLUSIONS: Older patients are hypnotizable and increasing age does not appear to mitigate the usefulness of hypnotic analgesia during invasive medical procedures.
Pain. 1990 Aug;42(2):243-51
Quantitative evaluation of hypnotically suggested hyperaesthesia and analgesia by painful laser stimulation.
Arendt-Nielsen L, Zachariae R, Bjerring P.
Department of Medical Informatics, University of Aalborg, Denmark.
The ability to reduce both clinically and experimentally induced pain by hypnotic suggestion of analgesia is well known. However, the nature of hypnotic analgesia still remains uncertain. Attempts to demonstrate and identify specific psycho physiological mechanisms have, so far, been unsatisfactory. Methodological problems in inducing pain and monitoring physiological responses may be the reason for this lack of success. In the present study, we have attempted to eliminate some of these methodological problems. The sensory and pain thresholds to laser stimulation were determined, and the laser-evoked brain potentials were measured for 8 highly hypnotically susceptible subjects in 3 conditions: (1) waking state, (2) suggestion of hyperesthesia, (3) suggestion of analgesia.
J Behav Med. 2006 Jan 11;:1-30
Hypnotic Treatment of Chronic Pain.
Jensen M, Patterson DR.
Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
This article reviews controlled trials of hypnotic treatment for chronic pain in terms of: (1) analyses comparing the effects of hypnotic treatment to six types of control conditions; (2) component analyses; and (3) predictor analyses. The findings indicate that hypnotic analgesia produces significantly greater decreases in pain relative to no-treatment and to some non-hypnotic interventions such as medication management, physical therapy, and education/advice. However, the effects of self-hypnosis training on chronic pain tend to be similar, on average, to progressive muscle relaxation and autogenic training, both of which often include hypnotic-like suggestions. None of the published studies have compared hypnosis to an equally credible placebo or minimally effective pain treatment, therefore conclusions cannot yet be made about whether hypnotic analgesia treatment is specifically effective over and above its effects on patient expectancy. Component analyses indicate that labeling versus not labeling hypnosis treatment as hypnosis, or including versus not including hand-warming suggestions, have relatively little short-term impact on outcome, although the hypnosis label may have a long-term benefit. Predictor analyses suggest that global hypnotic responsivity and ability to experience vivid images are associated with treatment outcome in hypnosis, progressive relaxation, and autogenic training treatments. The paper concludes with a discussion of the implications of the findings for future hypnosis research and for the clinical applications of hypnotic analgesia.
J Vasc Interv Radiol. 2005 Dec;16(12):1585-92
Pain and anxiety during interventional radiologic procedures: effect of patients' state anxiety at baseline and modulation by nonpharmacologic analgesia adjuncts.
Schupp CJ, Berbaum K, Berbaum M, Lang EV.
Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, WCC 308, Boston, Massachusetts 02215, USA.
PURPOSE: To assess how patients' underlying anxiety affects their experience of distress, use of resources, and responsiveness toward nonpharmacologic analgesia adjunct therapies during invasive procedures. MATERIALS AND METHODS: Two hundred thirty-six patients undergoing vascular and renal interventions, who had been randomized to receive during standard care treatment, structured empathic attention, or self-hypnotic relaxation, were divided into two groups: those with low state anxiety scores on the State-Trait Anxiety Inventory (STAI, scores < 43; n = 116) and those with high state anxiety scores (> or = 43; n = 120). All had access to patient-controlled analgesia with fentanyl and midazolam. Every 15 minutes during the procedure, patients rated their anxiety and pain on a scale of 0-10 (0, no pain/anxiety at all; 10, worst possible pain/anxiety). Effects were assessed by analysis of variance and repeated-measures analysis. RESULTS: Patients with high state anxiety levels required significantly greater procedure time and medication. Empathic attention as well as hypnosis treatment reduced procedure time and medication use for all patients. These nonpharmacologic analgesia adjunct treatments also provided significantly better pain control than standard care for patients with low anxiety levels. Anxiety decreased over the time of the procedure; patients with high state anxiety levels experienced the most significant decreases in anxiety with nonpharmacologic adjuncts whereas patients with low state anxiety levels coped relatively well under all conditions. CONCLUSION: Patients' state anxiety level is a predictor of trends in procedural pain and anxiety, need for medication, and procedure duration. Low and high state anxiety groups profit from the use of nonpharmacologic analgesia adjuncts but those with high state anxiety levels have the most to gain.
Pain Manag Nurs. 2005 Sep;6(3):105-11
Hypnosis for pain management in the older adult.
Cuellar NG.
University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania 19002, USA. ncuellar@nursing.upenn.edu
Pain is a physical, emotional and psychologic phenomenon that is often ignored in older adults causing depression and poor quality of life. Older adults report the use of complementary and alternative medicine in some form with 80% of these users reporting improvement in their health conditions. Although physical pain in the older adult is usually managed with pharmacologic interventions, methods that may reduce the use of prescription drugs may decrease adverse effects that can compromise the physiologic state of the older adult. Hypnosis has continued to gain acceptance within mainstream medicine as an appropriate treatment and can be integrated safely with conventional medicine as an effective treatment for a variety of conditions in the older adult. It is an intervention that can be used for relaxation and pain control, especially when conventional pharmacologic regimens have failed. The purpose of this article is to review the concepts related to pain in older adults; the use of complementary and alternative medicine in the older adult; hypnosis and the older adult (i.e., background, definition, benefits, research, mechanism of action, hypnotizability, and the process); and the implications of using hypnosis for pain management in the older adult.
J Rheumatol. 1991 Jan;18(1):72-5
Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia.
Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC, Mallee C, Terwiel JP, Hekster GB.
Department of Rheumatology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands.
In a controlled study, 40 patients with refractory fibromyalgia were randomly allocated to treatment with either hypnotherapy or physical therapy for 12 weeks with followup at 24 weeks. Compared with the patients in the physical therapy group, the patients in the hypnotherapy group showed a significantly better outcome with respect to their pain experience, fatigue on awakening, sleep pattern and global assessment at 12 and 24 weeks, but this was not reflected in an improvement of the total myalgic score measured by a dolorimeter. At baseline most patients in both groups had strong feelings of somatic and psychic discomfort as measured by the Hopkins Symptom Checklist. These feelings showed a significant decrease in patients treated by hypnotherapy compared with physical therapy, but they remained abnormally strong in many cases. We conclude hypnotherapy may be useful in relieving symptoms in patients with refractory fibromyalgia.
Psychol Bull. 2003 Jul;129(4):495-521
Hypnosis and clinical pain.
Patterson DR, Jensen MP.
Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle 98104, USA. davepatt@u.washington.edu
Hypnosis has been demonstrated to reduce analogue pain, and studies on the mechanisms of laboratory pain reduction have provided useful applications to clinical populations. Studies showing central nervous system activity during hypnotic procedures offer preliminary information concerning possible physiological mechanisms of hypnotic analgesia. Randomized controlled studies with clinical populations indicate that hypnosis has a reliable and significant impact on acute procedural pain and chronic pain conditions. Methodological issues of this body of research are discussed, as are methods to better integrate hypnosis into comprehensive pain treatment.
Proc Natl Acad Sci U S A. 2005 Sep 6;102(36):12950-5
Koyama T, McHaffie JG, Laurienti PJ, Coghill RC.
Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1010, USA.
Our subjective sensory experiences are thought to be heavily shaped by interactions between expectations and incoming sensory information. However, the neural mechanisms supporting these interactions remain poorly understood. By using combined psychophysical and functional MRI techniques, brain activation related to the intensity of expected pain and experienced pain was characterized. As the magnitude of expected pain increased, activation increased in the thalamus, insula, prefrontal cortex, anterior cingulate cortex (ACC) and other brain regions. Pain-intensity-related brain activation was identified in a widely distributed set of brain regions but overlapped partially with expectation-related activation in regions, including the anterior insula and ACC. When expected pain was manipulated, expectations of decreased pain powerfully reduced both the subjective experience of pain and activation of pain-related brain regions, such as the primary somatosensory cortex, insular cortex, and ACC. These results confirm that a mental representation of an impending sensory event can significantly shape neural processes that underlie the formulation of the actual sensory experience and provide insight as to how positive expectations diminish the severity of chronic disease states.
Clin J Pain. 2004 Jan-Feb;20(1):27-32
Mind-body therapies for the management of pain.
Astin JA.
California Pacific Medical Center Research Institute, San Francisco, CA, USA. john@integrativearts.com
This paper reviews the evidence for mind-body therapies (eg, relaxation, meditation, imagery, cognitive-behavioral therapy) in the treatment of pain-related medical conditions and suggests directions for future research in these areas. Based on evidence from randomized controlled trials and in many cases, systematic reviews of the literature, the following recommendations can be made: 1) multi-component mind-body approaches that include some combination of stress management, coping skills training, cognitive restructuring and relaxation therapy may be an appropriate adjunctive treatment for chronic low back pain; 2) multimodal mind-body approaches such as cognitive-behavioral therapy, particularly when combined with an educational/informational component, can be an effective adjunct in the management of rheumatoid and osteoarthritis; 3) relaxation and thermal biofeedback may be considered as a treatment for recurrent migraine while relaxation and muscle biofeedback can be an effective adjunct or stand alone therapy for recurrent tension headache; 4) an array of mind-body therapies (eg, imagery, hypnosis, relaxation) when employed pre-surgically, can improve recovery time and reduce pain following surgical procedures; 5) mind-body approaches may be considered as adjunctive therapies to help ameliorate pain during invasive medical procedures.
Pain. 2005 Dec 5;118(3):306-18. Epub 2005 Nov 14
Pain-related emotions modulate experimental pain perception and autonomic responses.
Rainville P, Bao QV, Chretien P.
Departement de Stomatologie, Faculte de medecine dentaire, Universite de Montreal, CP. 6128, Succ. Centre-ville, Montreal, Que., Canada H3C 1J7. pierre.rainville@umontreal.ca
The effect of emotions on pain perception is generally recognized but the underlying mechanisms remain unclear. Here, emotions related to pain were induced in healthy volunteers using hypnosis, during 1-min immersions of the hand in painfully hot water. In Experiment 1, hypnotic suggestions were designed to induce various positive or negative emotions. Compared to a control condition with hypnotic-relaxation, negative emotions produced robust increases in pain. In Experiment 2, induction of pain-related anger and sadness were found to increase pain. Pain increases were associated with increases in self-rated desire for relief and decreases in expectation of relief, and with increases in arousal, negative affective valence and decreases in perceived control. In Experiment 3, hypnotic suggestions specifically designed to increase and decrease the desire for relief produced increases and decreases in pain, respectively. In all three experiments, emotion-induced changes in pain were most consistently found on ratings of pain unpleasantness compared to pain intensity. Changes in pain-evoked cardiac responses (R-R interval decrease), measured in experiments 2 and 3, were consistent with changes in pain unpleasantness. Correlation and multiple regression analyses suggest that negative emotions and desire for relief influence primarily pain affect and that pain-evoked autonomic responses are strongly associated with pain affect. These results confirm the hypothesized influence of the desire for relief on pain perception, and particularly on pain affect, and support the functional relation between pain affect and autonomic nociceptive responses. This study provides further experimental
South Med J. 1999 May;92(5):521-3
What if your patient prefers an alternative pain control method? Self-hypnosis in the control of pain.
Nickelson C, Brende JO, Gonzalez J.
Department of Psychiatry and Behavioral Sciences, Mercer University School of Medicine, Macon, GA 31207, USA.
Despite the availability of specialized treatments for chronic pain, including biofeedback training, relaxation training, and hypnotic treatment, most physicians rely on the traditional approaches of surgery or pharmacotherapy. The patient in this case study had severe and chronic pain but found little relief from pain medications that also caused side effects. She then took the initiative to learn and practice self-hypnosis with good results. Her physician in the resident's internal medicine clinic supported her endeavor and encouraged her to continue self-hypnosis. This patient's success shows that self-hypnosis can be a safe and beneficial approach to control or diminish the pain from chronic pain syndrome and can become a useful part of a physician's therapeutic armamentarium.
