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Faculty of Art

Department of Psychology

Proposal:

Comparing the effectiveness of psychological method (CBT) vs. physiotherapy for pain management

By: Abdolla Zare’

M.A in Psychology

Iran


Contents
Introduction
Statement of the problem
Necessity and Importance of the Problem
Research variable
Literature
Research goals
Research Methods
Research Hypothesis
Tools
Statistical Method

Introduction

Pain is the second commonest reason for visiting doctors and clinics. It can threaten the personal and familial health in society, regarding to its different aspects. Pain is not just a medical problem but there are other factors as well which affect it. One of the definite and important factors in relieving; increasing or controlling the pain is its psychological aspects which has roots in strong interaction between human physic and soul. So we must pay attention to the neuropsychological aspects of pain. Relieving pain not only has positive effects for mental health, but also saves the time and money by decreasing the visits one pay to doctors and clinics. This phenomenon can influence a society. For instance if a society lacks special institutions for pain relieving then the majority of disables and patients with chronic and acute pains would choose the use of narcotics and other addictive drugs which will result in a more important social problem called addiction (Zareh, 88).

There are also some theories that consider pain merely as a medical problem. In this approach, people have a passive role in relieving pain and each person should treat his pain like a physical illness which needs medical treatment and the patient is only receiving it (Weed and Halligan, 2004). An obvious consequence of pain permanence is a number of psychological and social problems like decline of physical fitness, depressed mood and decline of general activities which these can affect the level of personal interactions and result in hopelessness and depression. Believing in the passive nature of patient (meaning he/she is just the receiver of medical treatments) will cause him/her to search for an external cure and forget his/her role in rehabilitation. For instance using sedative drugs for pain relieving may result in dependence phenomenon which has negative consequences such as social and familial problems, addiction and losing one's job. So one can conclude that chronic pain is not just a physical symptom; it is not a pain with an old start. Chronic pain has biopsychosocial aspects (Treck, 1996; Treck and Monarch, 2002). Evaluation of pain should be based on the main cause of illness and then treating it. After curing the main cause, the symptoms – like pain – and its consequential problems – like depression, stress and such – must be removed (Treck, 1996).

The statement of the problem

Among all illnesses, pain is the second reason for visiting doctors and clinics. Among different pains, headache is the commonest one and lumbago has the highest costs for treatment. Statistics show that 10-15% of people always suffer from headache which has different reasons such as bad sleeping habits, bad eating habits, stress and as such (Zamani Rad, 1388).

Pain is divided to acute and chronic; in Iran, 18-20% of people suffer from chronic pains (Sharifi, 1379). Acute pains are those resulted from a tissue injury and after curing that injury will finish automatically. One should not ignore the role of patient in controlling and relieving the pain, especially in the case of chronic pains his/her cooperation with doctor is of valuable importance. Chronic pains are those lasting for more than 3 months and sometimes up to 6 months. These will create no tissue injury in the body.

The 20^th century medicine aimed at using all technical and para-clinical facilities for medical treatment of various illnesses. In the 21^st century medicine, the cooperative role of patient in controlling his/her chronic pain has been taken into consideration. Most of us have suffered a kind of pain in our life. The experience of pain is not pleasant for sure and it will cause each person to react differently. Some believe that there are different pains and each person may consider a different pain as worse, for example for someone toothache may be the worst and for another one headache.

Whether it is intense or not, it would be an unwelcomed factor which causes the patient to search for a way to stop it. Its importance lies in that although one can tolerate pain but his/her life will be affected and it is a symptom of illness so the infected person will search for an escape and follow the issue carefully.

Because the patient would search for a cure and follow the problem carefully, the role of motive becomes important in that it provides the power to start or put an end to a behavior. That is why when defining motive, it is mentioned that motive is the power that determinesthe direction of one's acts. As pain acts like a source of power in making someone to act in a special way for controlling or relieving the pain, it can be considered a sort of motive. There are pleasant stimuli as well, like one's hopes and dreams, or even a tasty cookie that motivates someone to gain it.

Throughout the history of Western civilizations considerable changes have happened for beliefs about pain and its effects. In Middle Ages, in the army pain was considered as disobedience and a feminine behavior. The religious regarded it as a sign of heavenly punishments (related to gods of heaven). Up to the 13^th century, Jesus Christ's sufferings was the main issue but at that time, people started to think about pain as something that should be cured and relieved. Pain became an important part of daily life's problems and difficulties and became as significant as influenza and other grave illnesses.

Factors affecting the motive of pain

Pain is considered as a sentimental experience which may be accompanied with real physical suffering or not. This is a definition for pain in which it is regarded as a mental experience affected by physical or psychological factors, and its level differs from intense to weak.

Physical factors

Sufferings of physical problems mostly appear by different symptoms. Pain is a symptom indicating a physical problem in where it occurs, for example toothache may be a sign of putrefaction in its root, headache, eye ache and other pains have the same meaning.

Psychological factors

Some pains have no physical factors behind, but these have a message for us from psychological perspective. Their message has nothing to do with physical problems but a psychological notice for attracting others, seeking protection, protesting and such. One good example is the abdominal pains observed in schoolchildren who use them as an excuse for not attending school. Although this sort of pains is not real ones but they can let the real pain to start or stop. This theory shows that pain is a dual lane to and from brain and that brain is not only processing the information but directly affecting these mechanisms.

The necessity and importance of the problem

Pain clinics are centers for diagnosing, evaluating and curing chronic and acute pains in order to help patients suffering from pain. The main goal of these clinics is to analyze the patients suffering from chronic pains. Although the expenses of these clinics looks high at first sight but in long run and after complete treatment it would be more economical for both the patient and the society as well.

American Pain Society states that a pain clinic can provide the following effects in treatment period if offer proper services:

1. Decreasing drug use (consequently, drugs' side effects and expenses would lower down).

2. Increasing general activities of the patient (consequently, both patient and his/her family members would have a more peaceful life).

3. Decreasing the intensity of patient's pain (consequently, both patient and his/her family members would have a more peaceful life).

4. Increasing the chance of patient's return to work more than 35-45% (consequently, both the patient and medical system would suffer less damage).

5. Patient's general and spiritual condition would have a noticeable increase (consequently, his/her depression would lower down and his/her family's spirit would be reconstructed).

6. The patient's use of medical system would decrease (consequently, both patient and medical system would experience less financial costs).

7. Proper clinical and financial effects would be resulted for the patient and consequently for the society (Dr. Mohammad Sharifi, Iranian Pain Society).

Defining theoretical variable of the research

Although the nature of pain threshold mechanisms activities is not clear now and more research must be done in this field, preconditions of a chronic pain are as follow:

Preparing factors like pains with acute start, pains unrelated to impulses (an important note about pains related to impulses is that uncontrollability of tension-creators has a major role in chronic pain which is not responding to treatment). Patients with chronic pains are mostly self-efficient and feels weakness in control (Dolous, 1987; Asghari and Nicholas, 2001; et al, 2004).

The hypothesis is that long-term stress can result in intense activation of Opioids system. Although this activation decreases pain in short term but in long run it causes Opioids exhaustion. This phenomenon can determine great painlessness which is a sign of long-term stress and parellelly increase patient's vulnerability against pain and stress during time (Brohel and colleagues, 1999).

On the other hand, increasing self-efficacy will increase the effectivity of Opioids system (Bandura and colleagues, 1987). Healthy testees showed that learning the skills of handling pain will increase self-efficacy and this growth can determine the testee's pain tolerance in inductive pain test using cold water.

- Evocative responses: understanding general and physiological phenomena of body

- Pain memory: physical-sensational pain memories (recalls) against the pain

- Permanent phenomena: actor's learning – responsive's learning

Feeling pain is considered as the most important feelings in human. It informs us about the injuries in organs so that we will visit a doctor. For doctors the presence of pain also shows where injuries have been made.

As mentioned in the abstract, pains are classified according to where they appear and their characteristics; this classification is represented below:

Pain

I) Physical (somatic)

a) External like the entrance of a sharp-point tool into body

1) Obvious (Primary)

2) Non-obvious (Secondary)

b) Deep like muscular tensions and headache

II) Visceral like peptic ulcer, duodenal ulcer vermiform appendix, lithotrity, nephritic pains and such.

The type of pain is divided into physical and visceral; in physical if the pain starts from surface of skin, it is called external like a needle's pain or a pinch. In external pain, when needle contacts the surface, pain is felt obviously and when the contact is stopped, pain will vanish. This pain is known as the first pain, when the intension is higher generally after 0.5-1 second a non-obvious pain is felt which will vanish when the tension is stopped; this is called the second pain (like pinch's pain).

If the pain is located in muscles, bones, tissues and joints, it is called deep pain. This type like the external one is regarded as a physical pain. Mostly it is accompanied with non-obvious nature and irritation.

There is an important difference between the first external pain with the second external and deep pain in that the latter ones are associated with disinclination and tiredness and patient fells illness and experiences unnatural reflections like vomiting, perspiring and decreasing of blood pressure.

The first external pain is usually accompanied with runaway reflections and in fact saves the living creature from danger. Visceral pain looks like deep pain in that it has a non-obvious nature and has an irritation with self-acting reflections (Lirvani and Khodapanahi, 1384).

Pain threshold

One can create pain using electrical, chemical, thermal stimulations. Also by mechanical stimulation (pressure) one can determine pain threshold. Experiments show that pain threshold on forehead is about 600 grams per cm². Pain threshold for thermal stimulations are normally between 43-47 C and mostly take place at 45 C.

Adaptability

Besides pains characteristics, adaptability is of high importance. The general belief is that patient will adapt him/herself to the pain after a while, but Hardy's experiment shows something different. In this experiment thermal stimulation is used for creating pain; infrared rays are flashed on the testee's forehead in a way that its level is controllable, besides temperature of forehead skin is computed and written down. The testee can set the rays level him/herself. He/she is asked to set the degree in a way he/she can feel the pain threshold. Skin temperature is considered the threshold. The results show that at first minutes pain threshold is a bit more than 45 C but after some minutes it decreases to a meaningful amount (Hardy, 1989).

Operational variable

Analyzing different aspects of pain with an emphasis on CBT method and by using cognitive-behavioral treatment methods for decreasing pain level.

Independent variable

Using cognitive-behavioral treatment methods which are intervened by the researcher as quasi-experimental forms.

Dependent variable

Pain aspects in this research are depended on treatment.

Controlled variable

Analyzing different aspects of pain with an emphasis on CBT method and by using cognitive-behavioral treatment methods for decreasing pain level which are randomly analyzed by the researcher.

Intruder variable

Age, sex, place of residence, educational background are controlled by the researcher.

Goals of research

General goal: Increasing the level of knowledge about different aspects of pain.

Specific goal: analyzing different aspects of pain with emphasis on CBT method and using cognitive-behavioral treatments for decreasing pain.

Research hypotheses

Can psychological aspects of pain with CBT method affect relieving pain?

Is there a relation between cognitive-behavioral treatments and pain?

Chapter II
Research Theories
Review of Literature

Introduction

In Current theories of pain, it is believed that there are different types of neurons involved in detection of pain. These neurons include large neurons (with strong myelin cover that have a galvanizing function), a beta cords that are dermal, and extremely weak myelin cords with slow performance. A dermal cord includes skinny a cords and soft C cords without myelin. Each of these cords responds differently to the pain experience. For example, there are pain receptors that detect heat or receptors that detect touching.

For a better understanding of pain, some points should be noted:

* Pain measurement - Psychological aspects
* Pain motivation - Psychological aspects
* Various types of pain - Methods for measuring and assessing pain in children and aging people

- Pain Treatment - The role of training and counseling in pain management
- Nervous system – Pain and the quality of life
- Nervegraphy- Complementary Medicine and Pain Treatment
- Pain management - Pain from the perspective ofmedicine sociology
- Pain management and its economical role – pain in different cultures
- The morals of pain control - pain and its management in religions

Research Theories
Pain and its different aspects

One of the oldest attempts to describe the mechanism of pain was presented by Descartes in his paper, On Man, in 1664. He believed that the pain path extended from the top of the head to fingertips. The strike of a painful stimulus, such as a needle hitting the body or a strident unbearable sound is exclusive to a reflection mechanism and acts like a tense rope joined to a bell. The sound of the bell is a sign and a symptom of pain (the best function of pain is that it acts as an alarm signaling an unpleasant event or lesion, such as infection or cancer, is taking place in a part of the body). Nevertheless, with the advancement of science, it was logically proved that pain is transferred to brain through pain nerves.

Exclusive theory about pain:

This approach, taken from Descartes theory, suggests that there are many receptors in human skin that detect pain exclusively and send it to some centers of the brain. Now the important point is that there is an interaction between neural structures and psychological experiences, i.e. unpleasant psychological situation can enhance pain reception as the physical state of a person can enhance or diminish the pain and its psychological perception.

The Pain Gate Control theory was first proposed by (Mlzak&Vdvgal, 1965) in their now famous article “Mechanisms of pain: a new theory in science?" This theory merged the medical approach of the previous theories with the recent models of biological, psychological and social aspect of health.

Not only does this approach limit itself to the medical factors, but also it takes into consideration the interaction between biological, psychological and social factors. It maintains that there is a nerve system gate that tends to open and close in face of pain stimuli. On opening, it allows the neural messages to be sent to the brain nerve and on closing, it interrupts this transmission. The activities in cords cause the pain transmitter cells send symptoms of pain to the brain and thus open the gate. Activity in sensory nerves that is not directly associated with the pain causes the nerves with a greater diameter to bear the harmful and detrimental aspects (sticking, contact, rubbing and scratching). These activities close pain gate and provide an experience of pain relief.

One of the drawbacks of the bio-medical model concerns people suffering from imaginary limb syndrome (an amputated part of the body). Research gradually evinced the inevitable role of psychological factors in pain experience and responses to it and scholars like Hardy et al. (1952) strived to develop the issue at the heart of the "Exclusiveness" theory of pain and psychological factors influencing it. As such, they divided pain into two general categories of pain perception and pain reaction. Pain perception is primarily proposed as “a neurophysiologic process”, that is a simple receptor neuron and the mechanisms that lead it to the center. On the contrary, its reaction is regarded as a complex physiological – psychological process that includes cognitive behavior, such as previous experiences and the culture that influences what Hardy et al. call the threshold of pain reaction. This model was later criticized for maintaining a perfect relationship between stimulus intensity and chronic pain perception and regarding reaction to it as a secondary response to pain perception. (Bonika&Luzher, 1990)

In input control theory of pain (Mlzk and Wall, 1965) attempts were made to demonstrate the unifying role, neurophysiologic activities and psychological processes, particularly knowledge and emotions in pain experience and reaction to it. In this theory, the pain is not an inevitable consequence of the stimulated peripheral receptors sensitive to pain. It is the final result of a group of interactive process in which the central nervous system and the higher processes such as attention and seeking meaning of the phenomena, play an important role in determining the intensity of pain.

(Angell, 1997) was the first to introduce the biological, psychological and social pattern of the diseases. According to this model, the symptoms should be viewed as the result of the dynamic interactions of psychological, social and pathological variables. The essence of this model is as follows:

Biological factors can cause physiological changes or influence such changes. The psychological factors are reflected in people’s assessment of their disease and their perception of internal physiological phenomena. The assessment and reaction of the individuals to internal physiological changes are in turn affected by social and environmental factors. Also, this pattern is rooted in the idea that psychological, social and environmental factors can affect biological factors such as hormone release, the function of automatic nervous system and reduced physical fitness (Flora and Hrmnn 2004).

For example, the behavioral responses such as avoidance of activities due to the fear of re injuries or fear of pain may decrease physical fitness over time. This phenomenon can decrease the intensity of physical disability (Bartz, 1984). Thus, the biopsychosocial pattern of a disease brings into consideration not only the physical basis of the patient's symptoms, but also a range of psychological and social factors that can influence the patient's symptoms.

Since 1977, the biopsychosocial model of disease has gradually entered the field of pain. Luzher (1982), borrowing ideas from Angell (1977), tried to determine the various factors that might play a role in one’s complaints of the pain.

Similar to Angell model, the key feature of Luzher’s pattern is that to achieve a correct understanding of the pain, we should consider several aspects and analyze them. Luzher’s model to assess pain in humans has provided a broad framework that has been utilized in description of biological, psychosocial and social model of pain. For example, Vadel (1987) believes that specialists in treatment of spine pain should analyze and treat the patients rather that their spine cords. They need to regard disability resulting from back pain (including biopsychosocial components) as a disease not merely a physical disorder.

The most recent schemes from biopsychosocial perspective of chronic pain has been proposed by Oggy Fuji (2002), Feler and Hrmann (2004) and Gachel (2004). Each of these patterns is distinctive in terms of its emphasis on a particular group of variables. For example, the main difference between the views of Feler and HrmannGachel is the way variables are interacted in the model (in terms of mechanisms, e.g. the social role of conditioning processes). Furthermore, in Terek and Oki’s (2002) description of pain and in biological, psychological and social model of pain, more emphasis has been placed on cognitive processes rather than variables (Nichols, 2006).

Hermann and Flor consider pain as physiological responses including physiological, behavioral, mental and verbal components. These responses may or may not have pathological basis (i.e. structural changes) but they always have physiological outcomes.
Physiological components of pain consist of ascending and descending neuron communication mechanism, spine and ultra spine cords mechanism and biochemical processes.

Behavioral-motor components include pain behavior (drug consumption,frowning, limping, and visiting medical centers).Mental-verbal components include thoughts, feelings and fantasies that can be verbalized. In the above model, reflection is a continual activity that leads to learning of physiological mechanisms that undergo change due to mental and behavioral changes (Flor, 2000).

The discussed model claims that cognitive and learning parameters as a dynamic process are an integral part of pain experience. Thus, any pain assessment and treatment should be according to these parameters. Although all individuals experience acute pain, but, according to Flor and Hermann’s model (2004),only in a small percent of them, the acute pain turns into a chronic pain.

Review of literature

Pain managementby application of psychological methods became the focus of attention about 25 years ago and it ever since it has advanced considerably. A number of psychological techniques have been applied more successfully than before. Some of these techniques are to reduce anxiety in patients who are suffering from chronic pain.
The relationship between pain and its perception and managementby reducing anxiety is still unknown to most people.

Two important approaches in treating chronic pain are mental therapy with a cognitive-behavioral approach (CBT) and behavioral therapy. The researches have shown that both approaches have been effective in this regard.

Thus, appropriate psychological interventions can be effectively reducing chronic pain Matisyohuweisenberg), (RAMAT.GVN, 2002).

Another study conducted at the University of Birmingham, Alabama, indicated that nine CBT treatment methods used in controlling and reducing chronic pain in patients suffering from two types of knee chronic pain, arthritis and rheumatism, were far more effective than pharmaceutical treatment. According to pre-tests, intervention (with medication and CBT) and post-test results, the CBT therapy method is more effective than the pharmaceutical method.

Another study, which expressly refers to the role of psychological interventions in reducing pain, introduces it as a very low risk and low cost sustainable method. In this article, it has been stated that pain, as a physical and mental factor, cripples individuals in a manner that impede them from doing their daily errands and leave a negative effect on their health. Thus, the research report of non-pharmaceutical interventions, particularly psychotherapy with cognitive-behavioral approach (CBT) can greatly help to reduce pain.

A host of researches have been conducted with regard to other non-pharmacological methods of pain relief by application of music. In recent decades, the idea that music can help reduce pain has gained popularity to the extent that it was prescribed in hospitals and patients with acute or chronic pain were exposed to different kinds of music. Obviously, prior to the play of the music, pre-test and after that post-test were conducted using self- report questionnaire of pain. Then, the difference of the pain method was compared to students’ Tاستیودنتtthat showed a significant difference in the rate of the scores and pain relief (Joana briygs, 2002).

Besides pain, other variables such as mood and anxiety were measured using the same method and the results were highly significant. Sometimes we come across with pains that cannot be attributed to any physical sources, though from a psychological stance, they contain messages, too. However, their message is not associated with any physical cause and it mainly includes a psychological message such as attention, support, protest, etc. These messages are similar to the abdominal pains that are often seen in the early years of primary school in pupils to avoid going to school. Although you do not feel any real pain in this category of pains, there is a category of psychological pain in which person really feels the pain, while examination and experiments do not register the existence of any problems whatsoever.

Researches show that the concept and experience of pain and its motivational factors will be different in societies in terms of cultural and environment. Even the type of pain is associated with social and environmental conditions as the reaction of people towards pain is different. That is, in specific regions, a special type of pain might be more prevalent. A similar pain invokes varied reactions in two different societies. Also, there are other important factors such as hunger, too, i.e. in different societies and cultures, people manifest different reactions to the hunger stimulus and resort to various methods to reduce the effect of this stimulus. This discrepancy can also be observed among different people in the same community (Mohajer, 1386).

In another research, it was shown that some people had learned to manifest severe discomfort in front of pain while other had more tolerance against pain and hardly expressed complaints or sought any support.

In different situations, one person may reveal different behaviors in face of pain. Definitely, his behavior among a supporting family would be different from his behavior in a formal meeting. From a psychological stance, there are pains without any physical causes. Though, from a psychological point of view, these pains contain message, too, but their message is not associated with any physical and it mainly includes a psychological message such as attention, support, protest, etc

The factors that are assumed to stimulate pain as a sensory and emotional experience might or might not be accompanied by a real physical discomfort. This definition of the pain introduces it as a subjective experience that could have been caused by physical or even psychological factors that other factors might affect its intensity as well (Sharifi, 1386).

Chapter III

Methodology

Statistical universe

Sampling methods

Tools and methodology of research

Introduction

Science began when human started to think about solving his life's problems. In other words, science birthday coincides with mankind's. Primitive people started with primitive steps to solve his problems and succeeded in understanding of his environment through some experimental relations. This chapter analyzes human methods for solving life's problems.

Methodology

In experimental method, researcher would use different control methods, observation and computing experiments' results to evaluate the effect of independent variable and find out the effect. Controlling different factors in an experimental research would let the researcher to distinguish the effect of other factors from the one under research, and he can attribute the observed effect to the variable under study. But in research, effect is being studied and the hypothetical causes would be studied. In this research, we will follow a quasi-experimental method based on comparison.

Statistical universe

Our statistical universe consists of all those patients visiting an orthopedist or rehabilitation specialist for the first time because of chronic pains. Doctors prescribed physiotherapy for them. These patients suffered from skeletal and muscular pains. In this research patients with Arthrith Romathoid pain were studied.

Sampling method

Our research sample was 30 male patients between 45-55 years old who went to physiotherapy clinics and the method for choosing them was random access.

Tools and methodology of research

Non-drug treatment method with CBT approach would be used instead of prescribing pain relieving drugs or surgery and other medical methods. In the first session a brief description of this research was given to the patient to decrease their stress, depression and pain, and then a medical interview would be done to start cooperation with pre-test patients.

Statistical method used for this research is independent T-test for determining mean level or else for group and group.

For determining relations between variables, Pearson coefficient correlation will be used. After sampling and discussing data and drawing tables and average, variance, standard violation and finally t-student, we will change qualitative data to quantitative one.

Faculty of Art

Department of Psychology

Proposal:

Comparing the effectiveness of psychological method (CBT) vs. physiotherapy for pain management

By: Abdolla Zare’

M.A in Psychology

Iran


Contents
Introduction
Statement of the problem
Necessity and Importance of the Problem
Research variable
Literature
Research goals
Research Methods
Research Hypothesis
Tools
Statistical Method