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effective analgesia in clinical situations, for example, in burns patients (Hoffman et al, 2000
Level III‐2; Das et al, 2005 Level III‐2).
The use of certain music to divert attention from pain and to promote a sense of relaxation
and well‐being has long been a popular approach. A Cochrane review, which included studies
published up to and including 2004, concluded that listening to music reduced pain intensity
and opioid requirements after surgery, but that the magnitude of benefit was small (Cepeda et
al, 2006 Level I). Later systematic reviews of studies investigating the use of music found that
pain and anxiety in the perioperative period were reduced in half of the studies examined
(Nilsson, 2008 Level I) and that anxiety and pain were reduced in children undergoing medical
and dental procedures (Klassen et al, 2008 Level I).
There is some evidence that rather than shifting attention away from the pain, instructions
to focus attention on the pain site can alter pain perception, but possibly mainly among
sub‐groups of patients (Baron et al, 1993 Level II; Logan et al, 1995 Level II). The study by
Haythornthwaite et al (Haythornthwaite et al, 2001 Level II) provides further support for
this approach.
The use of mindfulness meditation is a type of attentional technique that includes noting pain
sensations. This approach encourages the patient to deliberately experience their pain as
calmly as possible, as just another sensation (ie without judging it as good or bad), often while
engaging in slowed breathing styles (Kabat‐Zinn, 2003). This approach derives from ancient
Buddhist methods and was initially described as a stress‐reduction technique by Kabat‐Zinn.
While this technique has been used in people experiencing chronic pain (McCracken et al, 2007
Level IV), and has been shown to increase experimental pain tolerance (Kingston et al, 2007
Level II), there are no reports on its use in the management of acute pain.

8.1.4 Cognitive-behavioural interventions
Typically, cognitive‐behavioural interventions involve the application of a range of behaviour‐
change principles, such as differential positive reinforcement of desired behaviours,
CHAPTER 8 change in targeted behaviours. In the context of acute pain this could include encouraging the
identification and modification of unhelpful thoughts, and goal setting, in order to achieve
appropriate use of the techniques outlined above.
Cognitive‐behavioural methods focus on both overt behaviours and cognitions (thought
processes) in patients, but interactions with environmental factors are often also addressed.
This means that interactions between patients and others, especially medical and nursing staff
as well as families, may need to be specifically changed to support the desired responses in
the patient. The latter may entail displaying a calm and reassuring manner, and
encouragement to persevere with a given task or procedure. Specific training in skills
(eg relaxation and other coping strategies), other behavioural techniques (eg modelling and
systematic desensitisation), information provision and reconceptualisation of the experiences
of the patient may also be provided as part of this approach.
Cognitive‐behavioural interventions are usually aimed at reducing the distressing or threat
value of pain and enhancing a patient’s sense of his or her ability to cope with pain. In this
context, coping usually refers to acceptance of pain rather than pain control or relief. Effective
coping with pain may be reflected in minimal pain‐related distress or disability. If patients are
able to perceive their pain as less threatening, they might also evaluate their pain as less
severe. But in this context reduced severity would be seen more as a by‐product rather than
the primary goal.

224 Acute Pain Management: Scientific Evidence