Case-Based Review

Nonpharmacologic Treatment of Chronic Pain—A Critical Domains Approach

Journal of Clinical Outcomes Management. 2016 February;23(2)

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What simple strategies can be used to improve patients’ emotional well-being?

Emotional Well-Being

Psychological distress and emotional well-being occur along a continuum. Eliminating psychological distress only returns one to a state of being without distress. That is not the same as experiencing emotional well-being or happiness. People with chronic pain who also have higher levels of emotional well-being (or happiness) have decreased pain severity, fewer symptoms, better levels of functioning, and greater life satisfaction [47–49].

Recent studies provide preliminary evidence suggesting that resilience-based interventions such as keeping a gratitude journal or scheduling time to engage in pleasant activities boast equivalence or even superiority to CBT for the treatment of mood with effects that persist over time [50,51]. Two recent meta-analyses have shown that resilience-based interventions have been used to treat healthy individuals and a range of clinical conditions with a mean effect size for improving well-being ranging between 0.34 to 0.61 (ie, moderate-large effects [Cohen’s d]) [52,53]. Positive activities interventions are thought to function by increasing positive affect, which in turn, enables creativity, problem-solving, perspective-taking, and other beneficial states [54]. Such states are conducive to better mood [55,56], behavioral activation/increased physical activity [57–60], better sleep [61–63], increased social support [54,64] and physiological changes (eg, improved vagal tone, lower blood pressure, more adaptive immune responses) [57,65–69]. Recent studies have successfully adapted resilience-based interventions and shown them to be effective for individuals with pain [70–72]. Resilience-based interventions may be particularly helpful for chronic pain patients given that depression and sleep disturbances are frequent comorbidities [5,21–26,28,73,74].

Lisa stated, “I have zero joy in my life…” and later burst into tears. It is easy to surmise that her emotional well-being is quite poor. She also noted that she saves all of her energy for her job and has “nothing left in the tank” for her children or herself. This is a common picture for individuals with chronic pain. Valued life activities like spending quality time with loved ones, going to sporting events or doing a hobby are put aside in favor of obligatory (eg, activities of daily living) and committed (eg, work, school) activities. While this strategy might help one survive, it certainly is not conducive to thriving. To help Lisa improve her emotional well-being, there are good data supporting pleasant activity scheduling amongst other strategies. For pleasant activity scheduling Lisa would be directed to set aside time a few days a week (at least an hour) to do things that she enjoys. This time should be placed on her calendar and treated with the same level of commitment as going to work or to an appointment with her physician.

What nonpharmacologic options are available to help improve patients’ sleep?

Sleep

Lisa indicated that she has trouble falling asleep and then when she does sleep, she usually wakes up feeling unrefreshed and irritable. This is a common complaint amongst individuals with chronic pain who often report difficulty falling asleep, being awakened by pain or discomfort and awakening feeling unrefreshed and unrestored [75]. Sleep, pain and mood form a symptomatic triad such that when one aspect is affected the others are impacted. For example, when Lisa does not sleep well, her pain and mood worsen, as well. Conversely, when her pain is better, she likely sleeps better and wakes up feeling less irritable and experiences less pain.