**3. Psychological interventions**

#### **3.1. Cognitive behavioral therapy**

Incorporating the biopsychosocial (BPS) model to pain management by targeting cognitive responses to pain and maladaptive behavioral in addition to social and environmental factors that may play an important role in modifying reactions to pain [23]. Such therapy has shown efficacy for many physical disorders and psychiatric illnesses, as well as pain [24]. Cognitive behavioral therapy (CBT) helps to develop important set of coping skills intended to improve psychological functioning, including behavioral activation, structured relaxation exercises, recalling and scheduling of pleasurable events, dogmatic assertive communication, and behavior pacing aiming to avoid prolongation and/or exacerbation of flares of pain. CBT for pain also addresses maladaptive thoughts about pain and pain catastrophizing through formal use of cognitive restructuring.

In a meta-analysis by Sielski, he found that biofeedback led to a small to medium effect when it comes to pain intensity reduction in patients with chronic back pain, also it led to reducing depression, disability, muscle tension, and improved cognitive coping in the same patients' groups [34]. Biofeedback was also used successfully in patients with juvenile rheumatoid arthritis, in a randomized clinical trial for children aged 8–13, the use of electromyography biofeedback was associated with reduced pain intensity and improved quadriceps strength [35].

Non-Pharmacological Pain Management http://dx.doi.org/10.5772/intechopen.79689 7

It is a technique in which an experienced practitioner helps a patient provoke a state of mind or mental images in the absence of that stimuli, defined by Bresler and Rossman as a range of techniques from simple visualization and direct imagery-based suggestions through metaphor and storytelling [36]. Recently, it has been increasingly explored in different medical settings, like for managing post-operative pain, fibromyalgia, low back pain or musculoskel-

Those images if they are vivid enough, this may elicit a physiological response, through modulations at the level of the autonomic nervous system, such effects would result in changes of the cardiovascular, respiratory, nervous, endocrine and even immune system [37]. Many randomized clinical trials have shown significant reduction in pain scores using guided imagery or hypnosis, but there is a lack of rigors high-quality studies, in a systematic review by Posadzki, he found only nine RCT with quality ranged between 1 and 3 on Jadad scale, eight of them suggested significant reduction of musculoskeletal-related pain, while one showed

In another systematic review of randomized clinical trial by Posadzki, he found that 11 trails of the 15 included in his analysis showed significant reduction of non-musculoskeletal pain, while 4 trails showed no significant change from standard of care. Although the evidence remains inconclusive but simply looking at the risk to benefit ratio, we can simply conclude

Many trials have looked into the efficacy of guided imagery and hypnosis in fibromyalgia cases, were they have shown a clinically significant benefit, moreover, a meta-analysis by Zechhave showed that combined therapy of cognitive behavioral therapy and hypnosis is superior to the use of cognitive behavioral therapy alone in patients with fibromyalgia [40].

In the middle ages, pain was considered a religious matter. Pain was seen as God's punishment for sins, or as evidence that an individual was possessed by demons. Spiritual counseling in such situation can be more of a priority than medical treatment [41]. Major parts of Hindu believers consider pain as a God punishment or as a result of personal actions. In Islam, it can be vindictive or Allah's willingness. A common Buddhist belief is that suffering is the price of attachment [42]. Spiritual and religious beliefs are important in many individuals' lives.

no significant change from the usual standard of care [38].

that benefits significantly outweigh the risk [39].

**3.5. Guided imagery**

etal-related pain.

**4. Others**

**4.1. Spirituality and religion**

According to recent meta-analytic studies [25], CBT for pain demonstrates small-to-medium effect sizes in a variety of domains and shows effects on pain and functioning compared to standard medical care for pain.

#### **3.2. Mindfulness-based stress reduction**

This approach aims to disconnect the link between the sensory elements of pain from the emotional and evaluative elements and enhances uncoupled awareness of both somatic and psychological sensations [26]. Because the signal of pain usually cannot be distinguished, such detachment may alter the response to pain [27].

Using mindfulness-based stress reduction strategies such as awareness and meditation, different ideas and beliefs about pain may be perceived as an unattached event rather than a sign of an underlying matter that requires lineal and possibly maladaptive reactions.

#### **3.3. Acceptance and commitment therapy**

This approach implies that thoughts do not basically have to be changed or targeted but the responses to these thoughts may be altered in a way that the resulting negative consequences are ameliorated [28]. ACT approaches can augment the sense of well-being via purposeful and nonjudgmental acknowledgment of mental events like emotions and thoughts, facilitating acceptance of such events, and enhancing the capability of the patients to sustain present and be aware of personally relevant environmental and psychological factors. Keeping this in mind, patients might be able to modify their behavior in a way that is in line with their goals and values, instead of keep focusing on immediate relief from their emotions and thoughts [27]. While conducting pain management, ACT can boost purposeful awareness and pain acceptance, hence diverting the focus on decreasing pain and its thought content and redirecting efforts trying to achieve favorable fulfilling behavior.

#### **3.4. Biofeedback**

Applied psychophysiology or better known as biofeedback is a technique in which the patient receives extra "extrinsic" information that is not based on what the patient feels, and the information should be in real time and biological in nature, that is, the use of real-time ultrasound biofeedback for patient with pelvic floor muscle dysfunction or low back pain, or the use of electromyography (EMG) in real time for patients with musculoskeletal disorders [29]. In simple words by Schawarts and Olsen, "psychophysiology involves the scientific study of the interrelation of physiological and cognitive processes" [30–32].

In a randomized clinical trial, it looked into the difference between hypnosis for chronic low back pain and hypnosis with biofeedback techniques, it showed that biofeedback with hypnosis is significantly more effective than hypnosis alone [33].

In a meta-analysis by Sielski, he found that biofeedback led to a small to medium effect when it comes to pain intensity reduction in patients with chronic back pain, also it led to reducing depression, disability, muscle tension, and improved cognitive coping in the same patients' groups [34]. Biofeedback was also used successfully in patients with juvenile rheumatoid arthritis, in a randomized clinical trial for children aged 8–13, the use of electromyography biofeedback was associated with reduced pain intensity and improved quadriceps strength [35].

#### **3.5. Guided imagery**

to improve psychological functioning, including behavioral activation, structured relaxation exercises, recalling and scheduling of pleasurable events, dogmatic assertive communication, and behavior pacing aiming to avoid prolongation and/or exacerbation of flares of pain. CBT for pain also addresses maladaptive thoughts about pain and pain catastrophizing through

According to recent meta-analytic studies [25], CBT for pain demonstrates small-to-medium effect sizes in a variety of domains and shows effects on pain and functioning compared to

This approach aims to disconnect the link between the sensory elements of pain from the emotional and evaluative elements and enhances uncoupled awareness of both somatic and psychological sensations [26]. Because the signal of pain usually cannot be distinguished,

Using mindfulness-based stress reduction strategies such as awareness and meditation, different ideas and beliefs about pain may be perceived as an unattached event rather than a sign

This approach implies that thoughts do not basically have to be changed or targeted but the responses to these thoughts may be altered in a way that the resulting negative consequences are ameliorated [28]. ACT approaches can augment the sense of well-being via purposeful and nonjudgmental acknowledgment of mental events like emotions and thoughts, facilitating acceptance of such events, and enhancing the capability of the patients to sustain present and be aware of personally relevant environmental and psychological factors. Keeping this in mind, patients might be able to modify their behavior in a way that is in line with their goals and values, instead of keep focusing on immediate relief from their emotions and thoughts [27]. While conducting pain management, ACT can boost purposeful awareness and pain acceptance, hence diverting the focus on decreasing pain and its thought content and re-

Applied psychophysiology or better known as biofeedback is a technique in which the patient receives extra "extrinsic" information that is not based on what the patient feels, and the information should be in real time and biological in nature, that is, the use of real-time ultrasound biofeedback for patient with pelvic floor muscle dysfunction or low back pain, or the use of electromyography (EMG) in real time for patients with musculoskeletal disorders [29]. In simple words by Schawarts and Olsen, "psychophysiology involves the scientific study of the

In a randomized clinical trial, it looked into the difference between hypnosis for chronic low back pain and hypnosis with biofeedback techniques, it showed that biofeedback with hyp-

of an underlying matter that requires lineal and possibly maladaptive reactions.

formal use of cognitive restructuring.

**3.2. Mindfulness-based stress reduction**

**3.3. Acceptance and commitment therapy**

**3.4. Biofeedback**

such detachment may alter the response to pain [27].

directing efforts trying to achieve favorable fulfilling behavior.

interrelation of physiological and cognitive processes" [30–32].

nosis is significantly more effective than hypnosis alone [33].

standard medical care for pain.

6 Pain Management in Special Circumstances

It is a technique in which an experienced practitioner helps a patient provoke a state of mind or mental images in the absence of that stimuli, defined by Bresler and Rossman as a range of techniques from simple visualization and direct imagery-based suggestions through metaphor and storytelling [36]. Recently, it has been increasingly explored in different medical settings, like for managing post-operative pain, fibromyalgia, low back pain or musculoskeletal-related pain.

Those images if they are vivid enough, this may elicit a physiological response, through modulations at the level of the autonomic nervous system, such effects would result in changes of the cardiovascular, respiratory, nervous, endocrine and even immune system [37]. Many randomized clinical trials have shown significant reduction in pain scores using guided imagery or hypnosis, but there is a lack of rigors high-quality studies, in a systematic review by Posadzki, he found only nine RCT with quality ranged between 1 and 3 on Jadad scale, eight of them suggested significant reduction of musculoskeletal-related pain, while one showed no significant change from the usual standard of care [38].

In another systematic review of randomized clinical trial by Posadzki, he found that 11 trails of the 15 included in his analysis showed significant reduction of non-musculoskeletal pain, while 4 trails showed no significant change from standard of care. Although the evidence remains inconclusive but simply looking at the risk to benefit ratio, we can simply conclude that benefits significantly outweigh the risk [39].

Many trials have looked into the efficacy of guided imagery and hypnosis in fibromyalgia cases, were they have shown a clinically significant benefit, moreover, a meta-analysis by Zechhave showed that combined therapy of cognitive behavioral therapy and hypnosis is superior to the use of cognitive behavioral therapy alone in patients with fibromyalgia [40].

## **4. Others**

#### **4.1. Spirituality and religion**

In the middle ages, pain was considered a religious matter. Pain was seen as God's punishment for sins, or as evidence that an individual was possessed by demons. Spiritual counseling in such situation can be more of a priority than medical treatment [41]. Major parts of Hindu believers consider pain as a God punishment or as a result of personal actions. In Islam, it can be vindictive or Allah's willingness. A common Buddhist belief is that suffering is the price of attachment [42]. Spiritual and religious beliefs are important in many individuals' lives. However, religious and spirituality are not the same. These beliefs can influence lifestyle, attitudes, and feelings about life, pain, and death. Spiritual and religious beliefs are important in many individuals' lives. However, religious and spirituality are not the same. These beliefs can influence lifestyle, attitudes, and feelings about life, pain, and death. Spiritual beliefs often place a greater significance at the time of illness than any other time in a person's life.

During labor, music has been shown to reduce women perceptions of and responses to pain. The same findings have been reported in premature infants as well as other categories of individuals living with chronic pain [53, 54]. Women during labor who enjoyed listening to slow soft music experienced less distress attributed to pain and repotted music as a helpful and effective tool in pain control [54]. Elderly patients with chronic osteoarthritis who listened to music daily for twenty minutes for couple of weeks reported decreased pain levels as compared to a control group [55]. Cancer survivors reported moderate pain relief upon listening to music, and in many cancer centers, music is offered as an adjunctive therapy [56, 57].

Non-Pharmacological Pain Management http://dx.doi.org/10.5772/intechopen.79689 9

One study has been designed to evaluate the effects of including music therapy on pain report, nausea, in addition to the time to engraftment for patients undergoing bone marrow transplant. Among such extremely ill individuals, those who received music therapy alongside with relaxation imagery experienced lower pain scales and less nausea. Moreover, they

The role of non-pharmacological approaches to pain management is evolving, and some nonpharmacological and complementary therapies have an increasingly important contribution

Generally, these approaches are relatively inexpensive with high safety profile and low

There is evidence to support the use of patient education, cognitive behavioral therapy (CBT), relaxation, music, and other modalities. These therapies should be taken into consideration to help and support the standard pharmacological treatment in pain management. While medical drugs are essentially being used for treating the somatic (physiological and emotional) dimension of the pain, non-pharmacological therapies aim to treat the cognitive, affective,

These therapies can treat the pain as adjuvant or complementary at middle level and severe

• Decrease the dosage of analgesic drugs, subsequently decreasing the well-known side

had faster engraftment [58].

to make to holistic patient care alongside analgesics.

behavioral and socio-cultural dimensions of the pain.

• Increase the individual ability to control feeling.

• Enhance the functional capacity and activity level.

• Decrease the pain behavior and focused pain level.

Non-pharmacological approaches help to

• Reduce the feeling of weakness.

• Reduces anxiety and stress.

effects of these drugs.

**5. Conclusion**

side effects.

pain experiences.

Both religious and spiritual beliefs help some people accept their own illness and help explain illness for others. Religion can supply the client, the family, and health professionals with a sense of strength, security, and faith during a time of need [41, 43].

Pain is an extremely complex phenomenon that involves multiple cascades of behavioral responses, thoughts, and emotions. A lot of non-physiologic factors such as psychological, familial and societal attitudes, life stressors, and cultural, spiritual and religious beliefs contribute significantly how the individuals experience and respond to pain. Emotional distress specifically depression and anxiety plays a vital role in pain experience. Numerous studies have demonstrated that individuals having pain perhaps report more severe pain and disability, if they have anxiety, depression or both. Interestingly, it has been found that fear of pain can cause more disability than that has been already caused by pain itself. There is a cyclical pattern of chronic pain leading to depression and depression causing an increase in chronic pain, creating a mutually reinforcing relationship [44, 45].

Since pain experienced in the context of biopsychosocial-spiritual system model (BPSSM), it should be understood that individuals' capacities to cope, tolerate, and accept disease and pain entail multiple levels of experience and thought. BPSSM suggests that illness disrupts the biological, interpersonal, and spiritual relationships unique to the individual. The BPSSM recognizes the potential impact of spiritual and religious variables that may increase or decrease experience of illness.

Spiritual interventions may differ depending on culture background. Generally, prayer is one of the most common daily spiritual activities, which can take variety of forms including gratitude, admission and confession, intercessory prayer or silent communion. The ultimate goal is to become more close to and loved one for God. Pain is often referenced in the context of people's relationships with God. God is responsible for wellbeing and health; therefore, spiritual beliefs are considered one of the most effective ways that influence healing. Individuals suffering pain may practice varieties of spiritual and religious activities including prayer and seeking specialized spiritual support, to cope more effectively with their pain [46]. Patients with chronic pain with a variety of conditions (e.g., musculoskeletal pain, cancer, or sickle cell) usually report that religiousness and spirituality are important in their lives [47].

#### **4.2. Music therapy**

Music has been used since ancient times to enhance wellbeing and reduce pain and suffering. Playing music for patients during or after surgery helps reduce pain and use of morphine and other sedatives, anxiolytics, and analgesics [48, 49].

Many randomized controlled studies adopting music therapy for subjects undergoing colonoscopy or sigmoidoscopy have found in comparison with the control group, those who listened to music reported a significant lower pain scores, less sedation and shorter examination times [50–52].

During labor, music has been shown to reduce women perceptions of and responses to pain. The same findings have been reported in premature infants as well as other categories of individuals living with chronic pain [53, 54]. Women during labor who enjoyed listening to slow soft music experienced less distress attributed to pain and repotted music as a helpful and effective tool in pain control [54]. Elderly patients with chronic osteoarthritis who listened to music daily for twenty minutes for couple of weeks reported decreased pain levels as compared to a control group [55]. Cancer survivors reported moderate pain relief upon listening to music, and in many cancer centers, music is offered as an adjunctive therapy [56, 57].

One study has been designed to evaluate the effects of including music therapy on pain report, nausea, in addition to the time to engraftment for patients undergoing bone marrow transplant. Among such extremely ill individuals, those who received music therapy alongside with relaxation imagery experienced lower pain scales and less nausea. Moreover, they had faster engraftment [58].
