**3. Psychological theories on pain and pain management**

Attempts to explain pain and human experience of pain dates back to the time of Descartes in the 17th century, with pain described and understood as a sensory

*Pain Management - Practices, Novel Therapies and Bioactives*

and Egypt [10, 17].

components.

**2.1 Arthritis pain experience**

and 0.30% among HIV-infected population in Burkina Faso.

*Gout*: This particular type of arthritis is considered to have significant genetic underlining as it is found to run in families [12]. Its symptoms include acute joint pain, swelling in the knees, foot and big toe. It is more prevalent in males than females. The prevalence of gout is reported as 0.70% among white South African

*Ankylosing Spondylitis*: It is a chronic, progressive arthritic condition that leads to severe disability. It occurs in early adulthood with symptoms like pain in the mid and lower back, heel, eyes, shoulder, ankle, and knee, reduced flexibility in the spine, sleep disorder, inflammatory bowel disease, and abnormal bone formation. Some occurrences of this type of arthritis are recorded in South Africa, Cameroun

Pain often contributes to dramatic reduction in a patient's quality of life. Like every other pain, arthritis pain is multidimensional [18]. It has physical, social, psychological and economic dimensions and how each person perceives these dimensions influences their treatment outcome. Despite the obvious, treatment of pain and arthritis pain in particular is usually and largely based on the biomedical procedures like medication, surgery and physical therapy. Traditionally, arthritis disease known as a musculoskeletal disorder is classified as a biological and physiological condition. As such, its epidemiology, pathogenesis as well as treatment efforts have been majorly focused on and drawn from the biomedical field. This has largely served to under-prioritize the potential contributions of other approaches especially psychological approaches to the treatment and care of arthritis patients. It has also indirectly suppressed the understanding of pain, in this context arthritic pain, as a psychological experience with cognitive, emotional and behavioral

Pain is described as an unpleasant experience signaled by behavioral expressions such as crying, screaming, withdrawal, change in posture, gait or facial expression [19] which limits, hinders or alters the bearer's behavior. Pain was defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage [14]. The relationship between the incidence of pain and possible cell damage or existence of disease provides clear evidence or support for the biomedical understanding of pain. Nevertheless, this connection is not able to explain why two individuals with the same level of cell damage or disease activity would have varying degrees of pain. The biomedical perspective is considered as being weak due to its inability to explain the differentials in pain responses of patients with similar disease activity [20], neither is it able to address psychological factors in the experience of pain. Again, the biomedical drug treatment approach to the management of arthritis in Africa with recourse to non-pharmacological or surgical treatments may have increased the likelihood for self-medication among sufferers. This is most likely because of the problems of inaccessible, unavailable or expensive healthcare services in Africa (especially among rural women dwellers). A situation that may explain the seemingly low prevalence rates arthritis disease reported by studies originating from Africa. Therefore, the argument that pain sensation is not merely a biological process but mostly a psychological experience forms the basis for this call to fully adapt psychological techniques in the management of arthritis pain among Africans and all people in general. The importance of this call for the use of psychological techniques in the treatment of arthritis pain, relates to the bio-psychosocial model of [21] which postulated that no particular factor can account for health outcome. Rather, that health outcome depends on the synergistic and reciprocal interactions

**72**

experience. Later theories like the pattern theory also derived from the biomedical models, till mid-20th century when Melzack and Wall in 1965 propounded the gate control theory of pain. Unlike the biomedical models before it, the gate control theory expanded the understanding of pain perception and experience to include psychological factors like stress, emotions, motivations, past experience, context and their impact on pain processing in the brain. This new understanding of pain opened doors for the use of psychological therapies in the control and management of pain. The understanding that not all kinds of pain can be explained by disease activity or tissue damage that are responded to by peripheral nerves gave room for a potentially better explanation of pain [26]. Consequently, the gate control theory proposed that higher neural mechanisms in the brain make meaning of a pain experience by incorporating other individualized factors including cognition, emotion, and motivation.

This theory contributed to a better understanding of pain so that it is scientifically understood and clinically practical that pain is dependent on a reciprocal relationship between ascending nociceptive input from peripheral nerves (pathophysiology) and feedback from higher brain activities (psychological factors) see **Figure 1**.

Psychological theories that form the bases for pain management psychotherapies include the behavioral, cognitive and humanistic models and modern models like the psychological flexibility model. Behavioral theories like operant conditioning of BF Skinner and classical conditioning of IvanPavlov explain behavior as an outcome of learning and as such a learned behavior can also be unlearned [27]. Therapies that generate from these theories like behavior modification techniques (e.g., token economy) cause behavioral change, either by decreasing unwanted behavior or increasing wanted behavior [28]. In the instance of chronic pain, these patients are taught new coping skills that would help them reduce or eliminate aversive or problematic pain behaviors. On the other hand, cognitive theories of psychology like Albert Ellis rational emotive behavior and Beck's cognitive theory would address a patient's thoughts, feelings and actions in relation to their pain experience [28]. These theories and therapies generating from them would explain problems like depression, pain catastrophizing, pain avoidance behaviors, feelings of helplessness, etc., that commonly accompany chronic pain conditions. The humanistic theories of psychology would explain pain experience in its social, economic, cultural, etc., contexts. How these factors could be contributing to the experience and sustenance of pain or how they can help alleviate the problem. Therapies developed from this

**75**

*Review of Psychological Interventions in the Management of Arthritic Pain: The Case of Africa*

theoretical background would focus on providing emotional support while encouraging social support and selfcare strategies with a goal of reducing the psychological distress experienced by the patient. Finally, the *psychological flexibility model for chronic pain management* is a recently developed understanding that is attracting the attention of researchers and practitioners in recent times. The model refers to "the capacity to persist or to change behaviour in a way that (a) includes conscious and open contact with thoughts and feelings, (b) appreciates what the situation affords and (c) is guided by one's goals and values". This model integrates both cognitive and environmental influences in describing and understanding behavior [29]. It focuses on such processes like acceptance, cognitive defusion, flexible present-focused attention, self-as-observer, values, and committed action; of these, acceptance has risen in popularity among psychotherapist and in treatment of

Effective pain management protocols are therefore expected to also cover the psychological (cognition, emotional, behavioral) aspect of pain experience. Pain management especially management of chronic pain (like arthritis pain) that is based on biomedical approach is apparently deficient of the psychological intervention protocol and would most likely result in poor health outcome. This is true and supports or explains the extensive acceptance and inclusion of psychological interventions in comprehensive wholistic pain management approaches used in

Across the globe but especially in Africa, the use of psychological interventions in the management of pain is quite minimal. Psychological interventions are mostly present in the management of cancer patients, hence, the development of Psycho-Oncology; but lacking in the management of other chronic conditions particularly arthritis. This is despite the established knowledge that arthritis disease onset, progression, severity and treatment outcome affects and can be affected by a person's life style, psychological and social circumstances [24]. It has therefore become imperative to reawaken psychologists and other health care professionals in Africa to the need to provide better healthcare service to arthritis patients by incorporating psychological interventions that could improve treatment outcome, quality of life, and adjustment skill for the patient. This can be done by referring arthritis patients presenting in the hospitals and clinics to psychologists for pain management psychological therapies. Such referral can be made when chronic arthritis pain results

5.Inadequate social support (informational, behavioral and emotional)

*DOI: http://dx.doi.org/10.5772/intechopen.93633*

chronic conditions.

developed nations like France.

in or is as a result of the following:

4.Pain catastrophizing

7.Insomnia (Sleep disorder)

8.Emotional distress

9.Anxiety [24].

3.Low self-efficacy for pain control

1.Depression

2.Disability

6.Stress

#### **Figure 1.**

*An illustration of how activities in the higher brain areas and inputs from nociceptive neurons influence gate opening or closing in the dorsal horn to elicit a pain experience. Pain is experienced when the combined activities results in the opening of the gate.*

#### *Review of Psychological Interventions in the Management of Arthritic Pain: The Case of Africa DOI: http://dx.doi.org/10.5772/intechopen.93633*

theoretical background would focus on providing emotional support while encouraging social support and selfcare strategies with a goal of reducing the psychological distress experienced by the patient. Finally, the *psychological flexibility model for chronic pain management* is a recently developed understanding that is attracting the attention of researchers and practitioners in recent times. The model refers to "the capacity to persist or to change behaviour in a way that (a) includes conscious and open contact with thoughts and feelings, (b) appreciates what the situation affords and (c) is guided by one's goals and values". This model integrates both cognitive and environmental influences in describing and understanding behavior [29]. It focuses on such processes like acceptance, cognitive defusion, flexible present-focused attention, self-as-observer, values, and committed action; of these, acceptance has risen in popularity among psychotherapist and in treatment of chronic conditions.

Effective pain management protocols are therefore expected to also cover the psychological (cognition, emotional, behavioral) aspect of pain experience. Pain management especially management of chronic pain (like arthritis pain) that is based on biomedical approach is apparently deficient of the psychological intervention protocol and would most likely result in poor health outcome. This is true and supports or explains the extensive acceptance and inclusion of psychological interventions in comprehensive wholistic pain management approaches used in developed nations like France.

Across the globe but especially in Africa, the use of psychological interventions in the management of pain is quite minimal. Psychological interventions are mostly present in the management of cancer patients, hence, the development of Psycho-Oncology; but lacking in the management of other chronic conditions particularly arthritis. This is despite the established knowledge that arthritis disease onset, progression, severity and treatment outcome affects and can be affected by a person's life style, psychological and social circumstances [24]. It has therefore become imperative to reawaken psychologists and other health care professionals in Africa to the need to provide better healthcare service to arthritis patients by incorporating psychological interventions that could improve treatment outcome, quality of life, and adjustment skill for the patient. This can be done by referring arthritis patients presenting in the hospitals and clinics to psychologists for pain management psychological therapies. Such referral can be made when chronic arthritis pain results in or is as a result of the following:

1.Depression

*Pain Management - Practices, Novel Therapies and Bioactives*

factors) see **Figure 1**.

experience. Later theories like the pattern theory also derived from the biomedical models, till mid-20th century when Melzack and Wall in 1965 propounded the gate control theory of pain. Unlike the biomedical models before it, the gate control theory expanded the understanding of pain perception and experience to include psychological factors like stress, emotions, motivations, past experience, context and their impact on pain processing in the brain. This new understanding of pain opened doors for the use of psychological therapies in the control and management of pain. The understanding that not all kinds of pain can be explained by disease activity or tissue damage that are responded to by peripheral nerves gave room for a potentially better explanation of pain [26]. Consequently, the gate control theory proposed that higher neural mechanisms in the brain make meaning of a pain experience by incorporating other individualized factors including cognition, emotion, and motivation. This theory contributed to a better understanding of pain so that it is scientifically understood and clinically practical that pain is dependent on a reciprocal relationship between ascending nociceptive input from peripheral nerves (pathophysiology) and feedback from higher brain activities (psychological

Psychological theories that form the bases for pain management psychotherapies include the behavioral, cognitive and humanistic models and modern models like the psychological flexibility model. Behavioral theories like operant conditioning of BF Skinner and classical conditioning of IvanPavlov explain behavior as an outcome of learning and as such a learned behavior can also be unlearned [27]. Therapies that generate from these theories like behavior modification techniques (e.g., token economy) cause behavioral change, either by decreasing unwanted behavior or increasing wanted behavior [28]. In the instance of chronic pain, these patients are taught new coping skills that would help them reduce or eliminate aversive or problematic pain behaviors. On the other hand, cognitive theories of psychology like Albert Ellis rational emotive behavior and Beck's cognitive theory would address a patient's thoughts, feelings and actions in relation to their pain experience [28]. These theories and therapies generating from them would explain problems like depression, pain catastrophizing, pain avoidance behaviors, feelings of helplessness, etc., that commonly accompany chronic pain conditions. The humanistic theories of psychology would explain pain experience in its social, economic, cultural, etc., contexts. How these factors could be contributing to the experience and sustenance of pain or how they can help alleviate the problem. Therapies developed from this

*An illustration of how activities in the higher brain areas and inputs from nociceptive neurons influence gate opening or closing in the dorsal horn to elicit a pain experience. Pain is experienced when the combined* 

**74**

**Figure 1.**

*activities results in the opening of the gate.*

