Page 36 Guide to Pain Management in Low-Resource Settings

24 Harald C. Traue et al.

Th e most commonly known relaxation tech- on the basis of physiological abnormalities—on the basis
niques are progressive muscle relaxation as per Jacob- of muscle activity on the surface EMG or physical diag-
son (PMR), autogenic training (AT), and other imagi- nostic parameters such as active myogeloses (localized
nation, breathing, and meditation techniques. All these muscle tension that is painful to the touch). One specifi c
techniques must be practiced for quite some time be- application is a portable biofeedback device that can be
fore they can be mastered. Sustainable success can only used under normal day-to-day conditions.
be achieved through prolonged eff ort. Relaxation tech-
niques are less successful in acute pain situations, which Multimodal processes
is why they are more usually used to treat chronic pain.
Multimodal pain psychotherapy is based on two as-
Biofeedback sumptions:
1) Chronic pain does not have individually identifi -
Biofeedback therapy involves physiological learning by able causes, but is the result of various causes and infl u-
measuring physiological pain components such as mus- ential factors.
cle activity, vascular responses, or arousal of the auto- 2) A combination of various therapeutic interven-
nomic nervous system and providing visual or acoustic tions has proven successful in the treatment of chronic
feedback to the patient. Biofeedback therapy is helpful pain (usually independent of the specifi c pain disorder).
for migraines, tension headaches, and back pain. Several In a modern pain therapy, therapeutic pro-
diff erent methods are used for migraines, such as hand- cesses are usually not isolated, but are used within the
warming techniques and vascular constriction training context of an umbrella concept. Th e process is centered
(targeting the temporalis artery). on a reduction of the (subjectively perceived) handicap
In the hand-warming or thermal biofeedback by changing the patient’s general situational conditions
technique, the patient receives information on the and cognitive processes. Th ese kinds of programs can
blood supply to one fi nger, usually by measuring the be applied according to the shotgun principle, e.g., all
skin temperature with a temperature sensor. Th e pa- modules are used with the view that we will defi nitely
tient is asked to increase the blood supply to the hand hit upon the most important areas, or the therapist can
(and thereby reduce vasodilatation in the arteries of use the diagnosis to put together a specifi c modular
the head). In autogenic feedback training, the hand treatment plan. Th e latter method should be used if an
warming is supported by the development of formu- individual diagnosis is possible. In a group setting, the
la-type intentions from autogenic training (heat exer- standardized process works better due to the expected
cises). Th e processes are demonstrated and used only diff erences between the patients.
during pain-free periods. First, the patient practices
with feedback and heat imagery. Th en, the conditions Functional restoration programs
of the exercise are made harder, and the patient, sup-
ported by the temperature feedback, is asked to re- Th ese programs are characterized by their clear focus
main relaxed while imagining a stressful situation. And on sports medicine and underlying behavioral therapy
fi nally, the patient is asked to increase the temperature principles. Pain reduction as a treatment goal plays a
of the hand without any direct feedback, and is told minor role. Due to learning theory considerations per-
subsequently if he or she was successful. taining to the “enhancement character” of pain behavior,
In electromyography (EMG) biofeedback for the pain itself is basically pushed out of the therapeu-
tension headaches or back pain, the feedback usual- tic focus. Th ese programs try to help patients function
ly consists of the level of tension in the forehead, neck again in their private and professional lives (functional
muscles or lumbar muscles and is used to teach patients restoration). Th e primary goal of therapy is to reduce
how to reduce tension. Patients with pain in the loco- the subjective adverse eff ect and the consequent fear
motor apparatus might also, however, practice certain and anxiety.
movement patterns. Th ese patterns are then practiced Th e treatment integrates sport, work therapy,
not only in a reclined position or while resting, but also physical exercises, and psychotherapeutic interven-
in other body positions and during dynamic physical ac- tions into one standardized overall concept. Th e physi-
tivity. It is important that the muscle groups are selected cal therapy components usually include an increase in