General Treatments of Chronic Pain

The cause of the chronic pain syndrome should be determined from a medical and psychosocial point of view and the location of pain generators should be noted. Attempts to decrease or eliminate the pain generators are important and should be carried our first, followed by consideration of other treatment options.

The Fordyce model of behavioral modification is useful in patients with chronic pain syndrome. The goal in these patients is not to cure the pain but to interrupt the pain behavioral reinforcement cycle by rewarding healthy behavior and setting appropriate goals that the patient must achieve.

These goals are to reduce medication use, modulate pain response, increase activity, and modify pain behaviors.

Behavior treatment

Behavioral treatments of chronic pain are based on operant model of pain. Fordyce's operant model emphasizes the behavioral expression of pain. So-called pain behaviors are those overt expressions of pain that a person who is suffering might exhibit like limping, grimancing, moaning, lying down.

This model focuses on the environmental rein forcers, which perpetuate pain behaviors. For example, family members can reinforce pain behaviors by providing attention or allowing the patient to avoid physical activity. Likewise, the Worker's Compensation system can reinforce pain behaviors by providing financial rewards for pain behaviors and continued disability.

Physicians and therapists can reinforce pain behavior as well, and the old adage that "the squeaky wheel gets the grease" certainly hold true for these patients.

The performance of pain behaviors during the acute phase of illness may be appropriate and adaptive. However, if these behaviors persist for an extended period, they become detrimental to long-term recovery.

This is particularly true for decreased activity, which can lead to generalize deconditioning and decreased flexibility.

In the behavioral model, the treatment approach emphasizes the manipulation of environmental factors. The goal is to extinguish pain behaviors and reinforce "wellness" behaviors.

Under the behavioral model of pain management, the use of pain medications on an as-needed basis is seen as inappropriate. Exercising up to the point of increased pain is also viewed as reinforcing pain behavior.

In contrast, scheduling medications on a time-contingent basis and exercising on a quota system are viewed as reinforcing wellness behavior. By changing the medication regime to a time-contingent schedule, the reinforcement value of pain medications is reduced.

This method maximizes medicinal pain coverage while minimizing the risk of the patient developing tolerance and dependence (physical and psychological) on drug.

Similarly, when exercise quotas are established, pain no longer serves as a signal to stop the activity. Termination of the exercise occurs only after the quota is reached and completion of the activity becomes the reward.

This model can be utilized in treatment settings to modify behaviors that serve to perpetuate a cycle of continued behavioral dysfunction.