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Attention Please! Attention management for chronic pain

Posted Jan 12 2010 10:04pm
A debate that’s been going on for some time is the role of ‘distraction’ in pain management.
So many of the people I see have told me they ‘just ignore’ the pain, or ‘I try to distract myself’, or similar, that there isn’t much doubt to me that people habitually use attention management as a coping strategy – yet the research findings have been quite mixed, especially with respect to ‘distraction’ and ‘ignoring’ pain.

Pain is naturally an attention-grabber. That’s one of the main purposes of acute pain, IMHO, to attract attention and direct the person to DO something in response. Of course in chronic pain, there is little to DO, so the person needs to redirect attention away from pain and back into the task at hand.

As I posted late last year, this process of redirecting attention detracts from the cognitive reservoir, so there is more effort needed to carry out tasks, it is more fatiguing, and it requires effective self regulation which also becomes depleted over time. (As an aside, I wonder whether one of the features of resilient people is that they have more effective self regulation skills, so they achieve more despite chronic pain – just a thought!).

The results from attention management are mixed, but despite this, many if not most CBT programmes include something on attention management such as attention diversion, imagery, and more recently, mindfulness.  The theory behind these interventions is derived from several models: Fear-avoidance model suggests that by avoiding activities, the negative thoughts about the pain become dominant and the individual becomes hypervigilant.  An information processing model suggests that there is only a certain amount of ‘brain space’ available to actively process information (a little like a torch shining into a dark room illuminates only what is within the beam of light), so whatever is salient, novel, intense and so on will ‘grab’ the attention, leaving the rest of what is going on to be ‘in the dark’ so to speak.

Mindfulness brings another style to attention management.  In mindfulness, the possibility that sensations can be recognised as simply that: sensations without emotive labelling (‘that is prickly’ rather than ‘I hate that prickly feeling’); leaves the individual able to engage with the sensations (ie feel them) but not buy into the emotional burden of judging those feelings.

A well-written but not empirically-tested manual for attention management was used in this study by Elomaa, Williams and Kalso (2009), to specifically look at the effects of attention management provided in a structured way, and within the context of a group programme.  The authors indicate that there were no other cognitive coping strategies provided as part of this programme, and that the facilitator followed the manual and allowed group discussion using CBT principles to help develop the skills.   The participants did, however, receive treatments aimed at reducing pain during the programme.

As usual, a battery of questionnaires was given to participants and these included the Pain Anxiety Symptoms Scale, the Fear Avoidance Behaviour Questionnaire, the Pain Vigilance and Awareness Questionnaire, and a Depression Scale.  Measures were taken at five time points (initial assessment, pre-treatment, post-treatment, 3- and 6-month follow-up). Information about pain location, duration of pain and work status was collected at every time point.

The treatment consisted of modules, which share a common CBT structure, from orientation, assessment, and reformulation/re-conceptualisation of the main issue to skills teaching, rehearsal, generalization and homework exercises.  If you’re interested, I’ve given the link to the manual above, and this paper also outlines the content of each of the six sessions provided.

57 participants were recruited to the programme, 41 started treatment, and five either  didn’t complete all the sessions, or didn’t complete the questionnaires.  Reasons for not participating were due to work issues, or ‘physical health’ (the details of physical health problems aren’t discussed).   27 of the 31 participants included in the analyses were women, most were married or in a relationship, half were not working or retired, and mean pain severity during the programme was 7.0 (SD = 1.5), 21 were concurrently receiving medical treatment for their pain.

Over the study period, pain intensity dropped, interference from pain dropped, and anxiety measures for experiencing pain also dropped.  There was no change in mood scores.  In the follow-up period (to 6 months postprogramme), pain intensity and pain interference continued to drop (although not as much as in the first time period); pain-related anxiety and fear-avoidance beliefs also dropped, but vigilance to pain didn’t continue to drop.  An interesting finding was that the people who attended the six month follow-up had lower FABQ scores and better self-rated working ability than those who only attended the three month follow-up.  Interference from pain was also lower in this group.

A further aspect of this study is that the use of techniques after the programme was also examined.  This is important, because some studies have shown that people typically don’t use any of the coping strategies 12 months after completing a pain management programme (see my post about this here).

Cutting to the chase for clinicians: What can we make of this?

The first thing is that there are some limitations to this study, apart from sample size – people were also receiving medical pain reduction treatment which could influence pain intensity (well, it’s meant to!!), and may also influence distress, catastrophising and function.  The measures used were all self-report, and most of the respondents were women who were not particularly depressed, although their pain intensity was quite similar to the people attending Burwood Pain Management Centre.

A couple of interesting things for me: it’s good to know there is a manual that can be used to deliver a systematic set of attention management strategies. This is one way at least to ensure that people who receive pain management have some consistent content (although there is no obligation for anyone anywhere to include this!).  Would that more programmes had some standardised components, although I’m one of the first to roar if I HAD to deliver a standard programme!  Despite this, it’s a start to learning more about the individual content of pain management that might be effective, rather than seeing it as one big black box.

Another interesting thing is that these psychologists consistently recognised the need to integrate the coping strategies into daily life. What a groundbreaking thing!  Perhaps that could be something that people delivering exercise programmes could consider too?!  Or instead, suggest that an occupational therapist be involved in delivering and helping people generalise and personalise their skill repertoire.  Just a thought.

Elomaa, M., de C. Williams, A., & Kalso, E. (2009). Attention management as a treatment for chronic pain European Journal of Pain, 13 (10), 1062-1067 DOI: 10.1016/j.ejpain.2008.12.002

McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale
(PASS-20) preliminary development and validity. Pain Res Manage

Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs
Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low-back
pain and disability. Pain 1993;52:157–68.

McCracken LM. Attention to pain in persons with chronic pain: a behavioral
approach. Behav Ther 1997;28:271–84.

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