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19 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

A review of the evidence of psychological techniques, from auto-suggestion to yoga, for managing pain and improving quality of life.
Pages 15-18

The relevance of psychotherapy in chronic pain management is questioned far less than it used to be, due in large part to investigations into the social and psychological components of pain. In 2007, a classification of psychological techniques was developed by Kreitler & Kreitler, and was based on which component of pain is the focus of treatment, including sensory, affective, cognitive, and behavioral approaches.1 Treatments that focus on the sensory component primarily target attaining a change in the sensation of pain by modifying its emotional and cognitive meaning.2 Several psychological techniques fall under this category, including guided imagery, hypnosis, auto-suggestion, relaxation, biofeedback, distraction, music therapy, and meditation. A review of each psychotherapy follows, along with a broad overview of its effectiveness in the realm of pain.

Guided imagery involves using one’s imagination to create sensory images that decrease pain. This technique often involves several or all the senses in the mind of the listener, including vision, smell, sounds, touch, and taste. (Image: iStock)

Guided Imagery

Guided imagery is a therapeutic technique in which a facilitator uses descriptive language intended to psychologically benefit mental imagery. Guided imagery involves using one’s imagination to create sensory images that decrease pain. This technique often involves several or all the senses in the mind of the listener, including vision, smell, sounds, touch, and taste. The length is tailored to the patient’s preference and energy level. Often, guided imagery sessions may use an audiotaped script or a live guide. Note that caution should be taken when using this technique in patients with dissociative disorders.3

Target Patients: Research has shown a positive effect on arthritis and rheumatic diseases, and potential positive effects on the secondary outcomes of anxiety, mobility, and quality of life.4 However, patients with fibromyalgia

experienced no effect on pain with guided imagery, but potential positive effects on secondary outcomes including psychological distress and coping with pain.5

Hypnosis / Auto-Suggestion

Hypnosis is a procedure involving cognitive processes, such as imagination, in which a patient is guided by a health professional to respond to suggestions for changes in perceptions, sensations, thoughts, feelings, and behaviors.6 According to the Society of Psychological Hypnosis (Division 30) of the American Psychological Association, hypnosis involves learning how to use the mind and thoughts to manage emotional distress, unpleasant physical symptoms, and certain habits or behaviors.

Hypnosis has been found to be generally more effective than non-pharmacological interventions, such as physical therapy and pain education, for a range of pain conditions (dental, low back, post-operative, and Multiple Sclerosis).7-10 There is growing evidence to suggest that hypnosis may have a greater influence on the effects of pain rather than the sensation of pain.11,12 Hypnosis may be able to reduce stress, relieve anxiety, improve sleep, improve mood, and/or reduce the need for opioids.

Some patients living with chronic pain conditions may have trained themselves in self-hypnosis, or auto-suggestion, in which they have learned to guide themselves through a hypnotic procedure. The suggestive interpretation is provided in soothing, repetitive, fixed phrases that are pronounced for extended periods of time (eg, 10 to 20 minutes) by the patient. The suggestions refer mostly to the beneficial outcomes rather than to the means in which these outcomes can supposedly be attained.1

For example, one may say silently to oneself “I am becoming calm and relaxed. My back is beginning to feel wonderful.” Past research has shown that hypnosis interventions that included an auto-suggestion component to improve disease management evidenced significant improvement.13

Target Patients: Findings from a systematic review suggest that hypnosis may potentially provide symptom relief and improve overall gastrointestinal functioning in patients with IBS, but no effect on secondary outcomes including pain related to IBS.14 Further, hypnosis may enhance the efficacy of other well-established psychological treatments for pain.8


Several relaxation techniques may be used in pain care, including diaphragmatic breathing, progressive muscle relaxation (PMR), and autogenic training. Diaphragmatic breathing is the act of breathing deep into the lungs by flexing the diaphragm rather than breathing shallowly by flexing the rib cage. PMR involves the tensing and relaxing of different muscle groups of the body, and a mental component, which focuses on the difference between the feelings of tension and relaxation.15 Autogenic training involves a daily practice of 15-minute sessions in which the patient is encouraged to repeat a set of visualizations to induce muscle relaxation.1

Target Patients: The most recent research review indicated some evidence that relaxation may reduce pain outcomes for both acute and chronic pain; however, there is also evidence that these improvements are not maintained over time.16


The term “biofeedback” alludes to the function of this modality with “bio” meaning body and “feedback” meaning that information is fed back to the patient. Biofeedback uses instrumentation to mirror psychophysiological processes that an individual may not normally be aware of and works to bring those processes back under voluntary control. Instruments used in biofeedback training may include a thermistor (for temperature), photoplethysmograph (for heart rate variability), pnuemograph (for respiration), electrodermograph (for sweat gland activity), electromyograph (for muscle tension), and the electroencephalograph (for electrical activity in the brain).17 These instruments do not change or influence bodily processes; they merely monitor or measure bodily functions. The implementation of mental exercises by the patient after being trained by a practitioner is key to successful biofeedback outcomes and may range from listening to pre-recorded audio to mindfulness and relaxation techniques to self-hypnosis practice.

Target Patients: There is strong evidence that biofeedback may be effective in reducing the frequency, duration, and intensity of headaches.18 The approach has also been found to have a potential benefit for pain when using the electromyograph among patients with fibromyalgia.19

Distraction / Displacement of Attention

Distraction is the process of diverting the attention of an individual or group from a desired area of focus and thereby blocking or diminishing the reception of undesired information, in this case pain signals. Distraction requires the mental capacity to concentrate and the physical ability and energy to engage in distracting activities.

Activities used for distraction may include humor, crafts, tapping, gaming, reading, writing, or drawing. The distraction is typically more successful when the patient chooses something they are interested in and when the activity stimulates the major senses in order to keep the patient engaged. Note that the patient’s awareness of pain may return once the distraction ends. Therefore, it is often beneficial to select a distraction activity that has the potential to increase its stimulating effect when pain increases.20 For example, beating a drum at different intensities based on the pain level.

Target Patients: There has been little examination of the use of distraction in chronic pain management but some ancillary evidence suggests that it should be used with caution as it may be unhelpful and even counterproductive at times.21 More recent studies have shown that virtual reality as a distraction activity may be effective in reducing pain when fully immersing the individual in a virtual environment.22

Music therapists primarily help patients improve their health by using music experiences such as free improvisation and singing. (Image: iStock)

Music Therapy

Music therapists primarily help patients improve their health by using music experiences such as free improvisation and singing. Research suggests that drumming, for example, serves as a distraction from pain and promotes the production of endorphins and endogenous opiates.23 Past studies have suggested that active singing may have some benefits in terms of active coping, but further research is required to fully explore such effects.24 Research has also shown that music may increase the effectiveness of medical therapies and may be used as an adjuvant with other pain-management programs.25 (More on music therapy for fibromyalgia.)

Target Patients: Music therapy is most often used in medical hospitals and cancer centers. It is now accepted as a discipline alongside other paramedical professions such as physiotherapy, occupational therapy, speech therapy, psychology, and special education services provided by health and education authorities.26

Meditation / Mindfulness

Meditation is a devotional exercise of or leading to observation and serves as an umbrella term that encompasses the practice of reaching ultimate consciousness and concentration to acknowledge the mind and regulate the individual’s attention. Meditation involves several techniques, including compassion, love, patience, tantra, sexuality, silence, breathing, emptiness, mindfulness, and yoga.

Mindfulness is one type of meditation commonly used in pain management. Mindfulness is an exercise in just noticing, or awareness; it is not some special mystical state nor is it a form of relaxation. There are several types of mindfulness-based interventions available, including Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-
Based Cognitive Therapy (MBCT). MBSR uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful. MBCT uses traditional cognitive-behavioral therapy methods and adds in mindfulness meditation.15

Target Patients: Research has shown that practicing short meditation exercises can help patients break away from pain; it may also reduce anxiety, depression, and sleep trouble.27 There is evidence of improved pain associated with mindfulness interventions.28 One systematic review addressed somatization disorders, including fibromyalgia, which suggested that mindfulness-based therapies may be effective in treating at least some aspects of the disorder.29


Yoga is an ancient Indian philosophical practice that pairs physical postures with breath awareness and meditation to bring a sense of contentment to the existential human condition. Yoga is thought to work by increasing embodiment through exposure to bodily sensations as practitioners are often reminded to pay attention to their bodies and focus attention on certain body parts. Moreover, yoga practice emphasizes attention to the breath and encourages steady and even inhalations and exhalations, resulting in vagal nerve suppression.30

A 2012 national US health survey, the most recent and extensive, found that more than 13% of the US population practiced yoga, and musculoskeletal conditions and stress were the top health reasons cited for starting yoga.31 Clinicians, however, should consider the fit of yoga for their patient before prescribing its practice. Patients who are low on trait mindfulness might first benefit from practices to improve mindfulness.32 Also, patients whose attitude toward yoga effectiveness is pessimistic may benefit from learning about the effectiveness of yoga before trying the practice.33

Target Patients: Yoga practice has been found to decrease low back pain, neck pain, knee osteoarthritis pain, migraine, and pain in patients with fibromyalgia. Further, yoga may be more effective than traditional exercise at decreasing nonspecific, chronic low back pain.34-40


The treatments that focus on the sensory component of pain are often referred to as “mind-body” medicine, or modalities that make the connection between the mental and physical aspects of the pain. They are unique in that once patients are trained in these approaches, they can often carry out most of these practices at home. 

Last updated on: August 3, 2020
Continue Reading:
The Perseverance Loop: The Psychology of Pain and Factors in Pain Perception
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