ABSTRACT: Phantom limb pain (PLP) is a significant source of chronic pain in most persons with amputation at some time in their clinical course. Pharmacologic therapies for this condition are often only moderately effective and may produce unwanted adverse effects. There is growing empirical evidence of the therapeutic effectiveness of mind-body therapies for the relief of chronic pain; therefore, an exploration of their role in relieving amputation-related chronic pain iswarranted. We undertook a focused literature review on mind-body interventions for patients with amputation who experience PLP. Because of study heterogeneity, only descriptive presentations of the studies are presented. Only studies of hypnosis, imagery, and biofeedback, including visual mirror feedback, were found; studies on meditation, yoga, and tai chi/qigong were missing from the literature. Few studies of specific mind-body therapies were dedicated to management of PLP, with the exception of mirror visual therapy. Overall, studies were largely exploratory and reflect considerable variability in the application of mind-body techniques, making definitive conclusions inadvisable. Nevertheless, the weight of existing findings indicates that a mind-body approach to PLP pain management is promising and that specific methods may offer either temporary or long-term relief, either alone or in combination with conventional therapies. The authors discuss the potential for usefulness of specific mind-body therapies and the relevance of their mechanisms of action to those of PLP, including targeting cortical reorganization, autonomic nervous system deregulation, stress management, coping ability, and quality-of-life. The authors recommend more and better quality research exploring the efficacy and mechanisms of action.

Am J Phys Med Rehabil. 2012 Jan 26. Moura VL, Faurot KR, Gaylord SA, Mann JD, Sill M, Lynch C, Lee MY. From the Department of Physical Medicine and Rehabilitation (VLM, KRF, SAG, MS, CL, MYL), and Department of Neurology, University of North Carolina at ChapelHill (JDM).

Full Title: Complementary and alternative medicine in the treatment of pain in fibromyalgia: a systematic review of randomized controlled trials.

OBJECTIVE: The purpose of this study was to systematically review the literature for randomized trials of complementary and alternative medicine (CAM) interventions for fibromyalgia (FM). METHODS: A comprehensive literature search was conducted. Databases included the Cochrane library, PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health, Natural Medicines Comprehensive Database Manual, Alternative and Natural Therapy Index System (MANTIS), Index for Chiropractic Literature, and Allied and Complementary Medicine (AMED). Inclusion criteria were (a) subjects were diagnosed with fibromyalgia and (b) the study design was a randomized controlled trial that compared a CAM therapy vs a control group. Studies were subgrouped by CAM treatment into 11 categories. Evidence tables and forest plots were organized to display quality ratings and effect sizes of each study. RESULTS: The literature search yielded 1,722 results; 102 abstracts were selected as potential articles for inclusion. Sixty studies met criteria and were rated by 2 reviewers; 18 were rated as good quality; 20, moderate; 18, low; and 4, very low. Synthesis of information for CAM categories represented by more than 5 studies revealed that balneotherapy and mind-body therapies were effective in treating FM pain. This study analyzed recent studies and focused exclusively on randomized controlled trials. Despite common use of manual therapies such as massage and manipulation to treat patients with FM, there is a paucity of quality clinical trials investigating these particular CAM categories. CONCLUSION: Most of these studies identified were preliminary or pilot studies, thus had small sample sizes and were likely underpowered. Two CAM categories showed the most promising findings, balneotherapy and mind-body therapies. Most of the other CAM categories showed a trend favoring the treatment group. It appears that several CAM therapies show some preliminary treatment effect for FM pain, but larger trials that are more adequately powered are needed.

J Manipulative Physiol Ther. 2011 Sep;34(7):483-96. Terhorst L, Schneider MJ, Kim KH, Goozdich LM, Stilley CS. Assistant Professor, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA. lat15@pitt.edu

Chronic abdominal pain is a common pediatric condition affecting 20% of the pediatric population worldwide. Most children with this disorder are found to have no specific organic etiology and are given the diagnosis of functional abdominal pain. Well-designed clinical trials have found hypnotherapy and guided imagery to be the most efficacious treatments for this condition. Hypnotic techniques used for other somatic symptoms are easily adaptable for use with functional abdominal pain. The author discusses 2 contrasting hypnotic approaches to functional abdominal pain and provides implications for further research. These approaches may provide new insights into this common and complex disorder.

Am J Clin Hypn. 2011 Jul;54(1):56-69. Gottsegen D. Department of Pediatrics, Baystate Medical Center Tufts University, Springfield, Massachusetts, USA. daveygmd@charter.net

Although the evidence is clear that hypnosis has been an effective treatment for recurrent headaches in children, review of the literature revealed no previous reports of hypnosis for youth with the condition of chronic daily headache. Two adolescents with continuing chronic daily headaches were taught self-hypnosis through careful attention to individual strengths and finding the hypnotic elements within the clinical encounters. Self-reports of intensity, frequency, and duration of headaches described substantial benefit from learning and practicing self-hypnosis after little to no benefit from pharmacologic and other nonpharmacologic therapies. These results and analogous success with several other adolescents with chronic daily headache support the further use of self-hypnosis training for this condition. As a self-regulation technique that is quickly and easily learned by most young people, self-hypnosis training holds considerable promise for effectively treating and perhaps preventing chronic daily headaches in children and adolescents.

Am J Clin Hypn. 2011 Jul;54(1):32-46. Kohen DP. Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota 55414, USA. dpkohen@umn.edu

Abstract The purpose of this pilot project was to test the feasibility of hypnosis as a preoperative intervention. The unique features of this study were: (a) use of a standardized nurse-delivered hypnosis protocol, (b) intervention administration immediately prior to surgery in the preoperative holding area, and (c) provision of hypnosis to breast cancer surgery patients receiving general anesthesia. A mixed-method design was used. Data collected from the intervention group and historical control group included demographics, symptom assessments, medication administration, and surgical, anesthesia, and recovery minutes. A semi-structured interview was conducted with the intervention group. A reduction in anxiety, worry, nervousness, sadness, irritability, and distress was found from baseline to postintervention while pain and nausea increased. The results support further exploration of the use of nurse-led preoperative hypnosis.

Int J Clin Exp Hypn. 2011 Oct-Dec;59(4):406-23. Lew MW, Kravits K, Garberoglio C, Williams AC. a City of Hope , Duarte , California , USA.

Abstract Dopaminergic mechanisms have been theorized to influence hypnotizability and sensorimotor gating. In this study, the authors investigated an association between sensorimotor gating, as measured by prepulse inhibition (PPI), and hypnotizability, as assessed by the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C). They found an inverse correlation between the SSHS:C and PPI. This finding, which replicates an earlier study, provides further evidence for a dopaminergic basis for hypnotizability and suggests additional avenues for research, including a method for possibly enhancing hypnotizability through pharmacological interventions.

Int J Clin Exp Hypn. 2011 Oct-Dec;59(4):399-405. Levin R, Heresco-Levy U, Edelman S, Shapira H, Ebstein RP, Lichtenberg P. a Herzog Memorial Hospital and Hebrew University , Jerusalem , Israel.

Virtual reality (VR) has been used to manage pain and distress associated with a wide variety of known painful medical procedures. In clinical settings and experimental studies, participants immersed in VR experience reduced levels of pain, general distress/unpleasantness and report a desire to use VR again during painful medical procedures. Investigators hypothesize that VR acts as a nonpharmacologic form of analgesia by exerting an array of emotional affective, emotion-based cognitive and attentional processes on the body's intricate pain modulation system. While the exact neurobiological mechanisms behind VR's action remain unclear, investigations are currently underway to examine the complex interplay of cortical activity associated with immersive VR. Recently, new applications, including VR, have been developed to augment evidenced-based interventions, such as hypnosis and biofeedback, for the treatment of chronic pain. This article provides a comprehensive review of the literature, exploring clinical and experimental applications of VR for acute and chronic pain management, focusing specifically on current trends and recent developments. In addition, we propose mechanistic theories highlighting VR distraction and neurobiological explanations, and conclude with new directions in VR research, implications and clinical significance.

Pain Manag. 2011 Mar;1(2):147-157. Li A, Montaño Z, Chen VJ, Gold JI. Children's Hospital Los Angeles, Departments of Anesthesiology Critical Care Medicine & Radiology, 4650 West Sunset Boulevard, MS#12, Los Angeles, CA 90027, USA.

Osteoarthritis of the knee is a major cause of disability among adults worldwide. Important treatment options include nonpharmacologic therapies, and especially symptom management strategies in which patients take an active role. Among these, mind-body therapies may have particular promise for alleviating the distressful symptoms associated with osteoarthritis of the knee. However, systematic reviews are lacking. The objective of this paper is to review English-language articles describing clinical studies evaluating the effects of patient-driven mind-body therapies on symptoms of knee osteoarthritis. Eight studies, representing a total of 267 participants, met the inclusion criteria. Interventions included tai chi, qigong, and yoga. Collectively, these studies suggest that specific mind-body practices may help alleviate pain and enhance physical function in adults suffering from osteoarthritis of the knee. However, sample sizes are small, rigorous investigations are few, and the potential benefits of several mind-body therapies have not yet been systematically tested. Additional high-quality studies are needed to clarify the effects of specific mind-body therapies on standardized measures of pain, physical function, and related indices in persons with osteoarthritis of the knee, and to investigate possible underlying mechanisms.

Curr Rheumatol Rev. 2009 Nov 1;5(4):204-211. Selfe TK, Innes KE. Department of Community Health, West Virginia University School of Medicine, Morgantown, WV, USA.

This paper reviews the evidence for mind-body therapies (eg, relaxation, meditation, imagery, cognitive-behavioral therapy) in the treatment of pain-related medical conditions and suggests directions for future research in these areas. Based on evidence from randomized controlled trials and in many cases, systematic reviews of the literature, the following recommendations can be made: 1) multi-component mind-body approaches that include some combination of stress management, coping skills training, cognitive restructuring and relaxation therapy may be an appropriate adjunctive treatment for chronic low back pain; 2) multimodal mind-body approaches such as cognitive-behavioral therapy, particularly when combined with an educational/informational component, can be an effective adjunct in the management of rheumatoid and osteoarthritis; 3) relaxation and thermal biofeedback may be considered as a treatment for recurrent migraine while relaxation and muscle biofeedback can be an effective adjunct or stand alone therapy for recurrent tension headache; 4) an array of mind-body therapies (eg, imagery, hypnosis, relaxation) when employed pre-surgically, can improve recovery time and reduce pain following surgical procedures; 5) mind-body approaches may be considered as adjunctive therapies to help ameliorate pain during invasive medical procedures.

Clin J Pain. 2004 Jan-Feb;20(1):27-32. Astin JA. California Pacific Medical Center Research Institute, San Francisco, CA, USA. john@integrativearts.com

Virtual reality (VR) has been used to manage pain and distress associated with a wide variety of known painful medical procedures. In clinical settings and experimental studies, participants immersed in VR experience reduced levels of pain, general distress/unpleasantness and report a desire to use VR again during painful medical procedures. Investigators hypothesize that VR acts as a onpharmacologic form of analgesia by exerting an array of emotional affective, emotion-based cognitive and attentional processes on the body's intricate pain modulation system. While the exact neurobiological mechanisms behind VR's action remain unclear, investigations are currently underway to examine the complex interplay of cortical activity associated with immersive VR. Recently, new applications, including VR, have been developed to augment evidenced-based interventions, such as hypnosis and biofeedback, for the treatment of chronic pain. This article provides a comprehensive review of the literature, exploring clinical and experimental applications of VR for acute and chronic pain management, focusing specifically on current trends and recent developments. In addition, we propose mechanistic theories highlighting VR distraction and neurobiological explanations, and conclude with new directions in VR research, implications and clinical significance.

Pain Manag. 2011 Mar;1(2):147-157. Li A, Montaño Z, Chen VJ, Gold JI. Children's Hospital Los Angeles, Departments of Anesthesiology Critical Care Medicine & Radiology, 4650 West Sunset Boulevard, MS#12, Los Angeles, CA 90027, USA.

Full title: Hypnotherapeutic treatment approaches in children and adolescents suffering from functional abdominal pain.

Functional abdominal pain significantly impairs day-to-day function. It is one of the most frequent somatic complaints among children and adolescents. For most of those affected, despite some indication of their possible presence, physiological factors fail to explain the symptoms adequately. The increased level of psychological symptoms suggests that the focus should be on behavioural and psychological aspects. Brief hypnotherapeutic treatment methods show encouraging results. A review of the current literature; potential mechanisms of effective intervention and their practical applicability are discussed.

Prax Kinderpsychol Kinderpsychiatr. 2011;60(5):386-400. Gulewitsch MD, Schlarb AA. Universität Tübingen, Fachbereich Psychologie.

BACKGROUND: Recent systematic reviews on psychological therapies of fibromyalgia syndrome (FMS) did not consider hypnosis/guided imagery (H/GI). Therefore we performed a systematic review with meta-analysis of the efficacy of H/GI in FMS. METHODS: We screened ttp://ClinicalTrials.gov, Cochrane Library, MEDLINE, PsycINFO and SCOPUS (through December 2010). (Quasi-) randomized controlled trials (CTs) comparing H/GI with controls were analyzed. Outcomes were pain, sleep, fatigue, depressed mood and health-related quality of life (HRQOL). Effects were summarized using standardized mean differences (SMD). RESULTS: Six CTs with 239 subjects with a median of 9 (range 7-12) H/GI-sessions were analysed. The median number of patients in the H/GI groups was 20 (range 8-26). Three studies performed follow-ups. H/GI reduced pain compared to controls at final treatment (SMD -1.17 [95% CI -2.21, -0.13]; p = 0.03). H/GI did not reduce limitations of HRQOL at final treatment (SMD -0.90 [95% CI -2.55, 0.76]; p = 0.29) compared to controls. Effect sizes on fatigue, sleep and depressed mood at final treatment and follow-up and on pain and HRQOL at follow-up were not calculated because of limited data available. The significant effect on pain at final treatment was associated with low methodological and low treatment quality. CONCLUSION: Further studies with better treatment quality and adequate methodological quality assessing all key domains of FMS are necessary to clarify the efficacy of H/GI in FMS.

BMC Musculoskelet Disord. 2011 Jun 15;12:133. Bernardy K, Füber N, Klose P, Häuser W. Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital, Kirrberger Straße 100, D-66421 Homburg/Saar, Germany.

Full Title: Efficacy of hypnosis/guided imagery in fibromyalgia syndrome - a systematic review and meta-analysis of controlled trials.

ABSTRACT:BACKGROUND: Recent systematic reviews on psychological therapies of fibromyalgia syndrome (FMS) did not consider hypnosis/guided imagery (H/GI). Therefore we performed a systematic review with meta-analysis of the efficacy of H/GI in FMS. METHODS: We screened http://ClinicalTrials.gov, Cochrane Library, MEDLINE, PsycINFO and SCOPUS (through December 2010). (Quasi-) randomized controlled trials (CTs) comparing H/GI with controls were analyzed. Outcomes were pain, sleep, fatigue, depressed mood and health-related quality of life (HRQOL). Effects were summarized using standardized mean differences (SMD). RESULTS: Six CTs with 239 subjects with a median of 9 (range 7-12) H/GI-sessions were analysed. The median number of patients in the H/GI groups was 20 (range 8-26). Three studies performed follow-ups. H/GI reduced pain compared to controls at final treatment (SMD -1.17 [95% CI -2.21, -0.13]; p = 0.03). H/GI did not reduce limitations of HRQOL at final treatment (SMD -0.90 [95% CI -2.55, 0.76]; p = 0.29) compared to controls. Effect sizes on fatigue, sleep and depressed mood at final treatment and follow-up and on pain and HRQOL at follow-up were not calculated because of limited data available. The significant effect on pain at final treatment was associated with low methodological and low treatment quality. CONCLUSION: Further studies with better treatment quality and adequate methodological quality assessing all key domains of FMS are necessary to clarify the efficacy of H/GI in FMS.

BMC Musculoskelet Disord. 2011 Jun 15;12:133. Bernardy K, Füber N, Klose P, Häuser W. Department of Internal Medicine I, Klinikum Saarbrücken, Winterberg 1, D-66119 Saarbrücken, Germany. whaeuser@klinikum-saarbruecken.de.

ABSTRACT:BACKGROUND: Recent systematic reviews on psychological therapies of fibromyalgia syndrome (FMS) did not consider hypnosis/guided imagery (H/GI). Therefore we performed a systematic review with meta-analysis of the efficacy of H/GI in FMS. METHODS: We screened http://ClinicalTrials.gov, Cochrane Library, MEDLINE, PsycINFO and SCOPUS (through December 2010). (Quasi-) randomized controlled trials (CTs) comparing H/GI with controls were analyzed. Outcomes were pain, sleep, fatigue, depressed mood and health-related quality of life (HRQOL). Effects were summarized using standardized mean differences (SMD). RESULTS: Six CTs with 239 subjects with a median of 9 (range 7-12) H/GI-sessions were analysed. The median number of patients in the H/GI groups was 20 (range 8-26). Three studies performed follow-ups. H/GI reduced pain compared to controls at final treatment (SMD -1.17 [95% CI -2.21, -0.13]; p = 0.03). H/GI did not reduce limitations of HRQOL at final treatment (SMD -0.90 [95% CI -2.55, 0.76]; p = 0.29) compared to controls. Effect sizes on fatigue, sleep and depressed mood at final treatment and follow-up and on pain and HRQOL at follow-up were not calculated because of limited data available. The significant effect on pain at final treatment was associated with low methodological and low treatment quality. CONCLUSION: Further studies with better treatment quality and adequate methodological quality assessing all key domains of FMS are necessary to clarify the efficacy of H/GI in FMS.

BMC Musculoskelet Disord. 2011 Jun 15;12:133. Bernardy K, Füber N, Klose P, Häuser W. Department of Internal Medicine I, Klinikum Saarbrücken, Winterberg 1, D-66119 Saarbrücken, Germany. whaeuser@klinikum-saarbruecken.de.

Full title: EEG Biofeedback Treatment Improves Certain Attention and Somatic Symptoms in Fibromyalgia: A Pilot Study.

Fibromyalgia (FMS) is a chronic, painful disorder often associated with measurable deficiencies in attention. Since EEG biofeedback (EEG-BF) has been used successfully to treat attention problems, we reasoned that this modality might be helpful in the treatment of attention problems in FMS. We also speculated that improvement in central nervous system (CNS) function might be accompanied by improvement in FMS somatic symptoms. We studied fifteen FMS patients with attention problems, demonstrated by visual and auditory continuous performance testing (CPT), while completing 40 or more EEG-BF sessions. Training consisted of a "SMR protocol" that augmented 12-15 Hz brainwaves (sensory motor rhythm; SMR), while simultaneously inhibiting 4-7 Hz brainwaves (theta) and 22-30 Hz brainwaves (high beta). Serial measurements of pain, fatigue, psychological distress, morning stiffness, and tenderness were also obtained. Sixty-three FMS patients who received standard medical care, but who did not receive EEG-BF, served as controls. Visual, but not auditory, attention improved significantly (P < 0.008). EEG-BF treated subjects also showed improvement in tenderness, pain and fatigue. Somatic symptoms did not change significantly in controls. Visual attention parameters and certain somatic features of FMS appear to improve with an EEG-BF SMR protocol. EEG-BF training in FMS deserves further study.

Appl Psychophysiol Biofeedback. 2011 Jun 9. Caro XJ, Winter EF. David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA, xjcaro@earthlink.net.

Fibromyalgia (FM) is a chronic pain condition which is difficult to diagnose and to treat. Most individuals suffering from FM use a variety of complementary or alternative medicine (CAM) interventions to treat and manage their symptoms. The aim of this overview was to critically evaluate all systematic reviews of single CAM interventions for the treatment of FM. Five systematic reviews met the inclusion criteria, evaluating the effectiveness of homoeopathy, chiropractic, acupuncture, hydrotherapy and massage. The reviews found some evidence of beneficial effects arising from acupuncture, homoeopathy, hydrotherapy and massage, whilst no evidence for therapeutic effects from chiropractic interventions for the treatment of FM symptoms was found. The implications of these findings and future directions for the application of CAM in chronic pain conditions, as well as for CAM research, are discussed.

Clin Rheumatol. 2011 May 26. Terry R, Perry R, Ernst E. Complementary Medicine, Peninsula Medical School, University of Exeter, Exeter,UK, rohini.terry@pms.ac.uk.

Headache is the most common pain problem in children and adolescents and, in a considerable proportion, a source of suffering and disability. Medical intervention mainly relies on abortive pharmacological agents (analgesics and antimigraine drugs). Psychological therapies aim at the prevention of headache episodes and the modifications of cognitive-emotional and cognitive-behavioral processes influencing pain. Three main forms of therapy have been evaluated in randomized controlled trials and reviewed in meta-analyses: relaxation training,biofeedback and multimodal cognitive-behavioral therapy. So far there is only scarce evidence on hypnosis and acceptance and commitment therapy, although they seem to be promising. Evidence demonstrates that psychological therapies are efficacious, and that clinically relevant improvement is found in approximately 70% of the treated children at follow-up examination. Future research needs to focus on mechanisms of change, and to extend its view of effects induced by therapy beyond headache improvement to indicators of quality of life.

Expert Rev Neurother. 2011 Mar;11(3):403-10. Kröner-Herwig B. Department of Clinical Psychology and Psychotherapy, Georg-Elias-Müller Institute of Psychology, Georg-August-University of Göttingen, Gosslerstr. 1437073 Göttingen, Germany. bkroene@uni-goettingen.de.

FULL TITLE: Effect of hypnotic pain modulation on brain activity in patients with temporomandibular disorder pain.

Hypnosis modulates pain perception but the associated brain mechanisms in chronic pain conditions are poorly understood. Brain activity evoked by painful repetitive pin-prick stimulation of the left mental nerve region was investigated with use of fMRI in 19 patients with painful temporomandibular disorders (TMD) during hypnotic hypoalgesia and hyperalgesia and a control condition. Pain intensity and unpleasantness of the painful stimulation was scored on a 0-10 Numerical Rating Scale (NRS). NRS pain and unpleasantness scores during hypnotic hypoalgesia were significantly lower than in the control condition and significantly higher in the hypnotic hyperalgesia condition. In the control condition, painful stimulation caused significant activation of right posterior insula, primary somatosensory cortex (SI), BA21, and BA6, and left BA40 and BA4. Painful stimulation during hypnotic hyperalgesia was associated with increased activity in right posterior insula and BA6 and left BA40 whereas hypnotic hypoalgesia only was associated with activity in right posterior insula. Unexpectedly, direct contrasts between control and hypnotic hyperalgesia conditions revealed significant decreases in S1 during hyperalgesia. Direct contrasts between control and hypnotic hypoalgesia conditions demonstrated significant decreases in right posterior insula and BA21, as well as left BA40 during hypoalgesia. These findings are the first to describe hypnotic modulation of brain activity associated with nociceptive processing in chronic TMD pain patients and demonstrate that hypnotic hypoalgesia is associated with a pronounced suppression of cortical activity and a disconnection between patient-based scores and cortical activity in S1 during hypnotic hyperalgesia.

Pain. 2010 Dec;151(3):825-33. Abrahamsen R, Dietz M, Lodahl S, Roepstorff A, Zachariae R, Østergaard L, Svensson P. Department of Clinical Oral Physiology, School of Dentistry, Aarhus University, Aarhus, Denmark.

FULL TITLE: Chronic low-back pain modulation is enhanced by hypnotic analgesic suggestion by recruiting an emotional network: a PET imaging study.

This study aimed to characterize the neural networks involved in patients with chronic low-back pain during hypnoanalgesia. PET was performed in 2 states of consciousness, normal alertness and hypnosis. Two groups of patients received direct or indirect analgesic suggestion. The normal alertness state showed activations in a cognitive-sensory pain modulation network, including frontotemporal cortex, insula, somatosensory cortex, and cerebellum. The hypnotic state activated an emotional pain modulation network, including frontotemporal cortex, insula, caudate, accumbens, lenticular nuclei, and anterior cingulate cortex (ACC). Direct suggestion activated cognitive processes via frontal, prefrontal, and orbitofrontal cortices, while indirect suggestion activated a widespread and more emotional network including frontal cortex, anterior insula, inferior parietal lobule, lenticular nucleus, and ACC. Confirmed by visual analog scale data, these results suggest that chronic pain modulation is greater with hypnosis, which enhances both activated networks.

Int J Clin Exp Hypn. 2011 Jan;59(1):27-44. Nusbaum F, Redouté J, Le Bars D, Volckmann P, Simon F, Hannoun S, Ribes G, Gaucher J, Laurent B, Sappey-Marinier D. University of Lyon II, Laboratoire Santé-Individu-Société, 5 avenue Pierre Mendès France – Bâtiment K – 69500 Bron, France. f.nusbaum@wanadoo.fr

FULL TITLE: Effects of self-hypnosis training and cognitive restructuring on daily pain intensity and catastrophizing in individuals with multiple sclerosis and chronic pain.

Fifteen adults with multiple sclerosis were given 16 sessions of treatment for chronic pain that included 4 sessions each of 4 different treatment modules: (a) an education control intervention; (b) self-hypnosis training (HYP); (c) cognitive restructuring (CR); and (d) a combined hypnosis-cognitive restructuring intervention (CR-HYP). The findings supported the greater beneficial effects of HYP, relative to CR, on average pain intensity. The CR-HYP treatment appeared to have beneficial effects greater than the effects of CR and HYP alone. Future research examining the efficacy of an intervention that combines CR and HYP is warranted.

Int J Clin Exp Hypn. 2011 Jan;59(1):45-63. Jensen MP, Ehde DM, Gertz KJ, Stoelb BL, Dillworth TM, Hirsh AT, Molton IR, Kraft GH. University of Washington, Seattle, USA. mjensen@u.washington.edu

FULL TITLE: Effect of Hypnosis on Pain and Blink Reflexes in Patients With Painful Temporomandibular Disorders.

OBJECTIVE: This study contrasted the effect of hypnosis on self-reported pain and changes in a nociceptive brainstem reflex, the blink reflex (BR), in 39 women with temporomandibular disorder. METHODS: The patients were randomized to hypnosis or control (nonhypnotic relaxation). Pain intensity was assessed 3 times daily on a 0 to 10 numerical rating scale. BRs were elicited by electrical stimulation with a nociceptive-specific electrode and recorded before and after treatment at pain threshold (Ip) and supra threshold (2×Ip). RESULTS: Significant reduction of pain intensity was observed in the hypnosis group from 4.5±2.1 at baseline to 2.9±2.4 after treatment (P<0.001). The pain reduction was generally unrelated to changes in the BR, with the exception being a lowered ipsilateral R2 BR component at the right side supra threshold (P=0.034). CONCLUSIONS: Hypnosis thus seems to reduce complex temporomandibular disorder pain, most likely because of cortical changes with little, if any, involvement of brainstem reflex pathways.

Clin J Pain. 2010 Dec 20. Abrahamsen R, Baad-Hansen L, Zachariae R, Svensson P. *Department of Clinical Oral Physiology, School of Dentistry, Aarhus University †Psychooncology Research Unit ‡Department of Oral Maxillofacial Surgery §MindLab, Center for Functionally Integrative Neuroscience (CFIN), Aarhus University Hospital, Aarhus, Denmark.

Full Title Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: a national survey.

OBJECTIVES: Chronic pain is a serious public health problem and is treated by diverse health care providers. In order to enhance policies and programs to improve pain care, we collected information about the distribution of pain patients among four major groups of pain management providers: primary care physicians (PCPs), pain physicians, chiropractors, and acupuncturists, and the variation in the attitudes and practices of these providers with respect to some common strategies used for pain.

METHODS: National mail survey of PCPs, pain physicians, chiropractors, and acupuncturists (ntotal = 3,000).

RESULTS: Eight hundred seventeen responses were usable (response rate, 29%). Analyses weighted to obtain nationally representative data showed that PCPs treat approximately 52% of chronic pain patients, pain physicians treat 2%, chiropractors treat 40%, and acupuncturists treat 7%. Of the chronic pain patients seen for evaluation, the percentages subsequently treated on an ongoing basis range from 51% (PCPs) to 63% (pain physicians). Pain physicians prescribe long-acting opioids such as methadone, antidepressants or anti-convulsants, and other nontraditional analgesics approximately 50-100% more often than PCPs. Twenty-nine percent of PCPs and 16% of pain physicians reported prescribing opioids less often than they deem appropriate because of regulatory oversight concerns. Of the four groups, PCPs are least likely to feel confident in their ability to manage musculoskeletal pain and neuropathic pain, and are least likely to favor mandatory pain education for all PCPs.

CONCLUSIONS: There is substantial variation in attitudes and practices of the various disciplines that treat chronic pain. This information may be useful in interpreting differences in patient access to pain care, planning studies to clarify patient outcomes in relation to different providers and treatment strategies, and designing a system that matches chronic pain patients to appropriate practitioners and treatments.

Breuer B, Cruciani R, Portenoy RK. South Med J. 2010 Aug;103(8):738-47. Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY 10003, USA. bbreuer@chpnet.org

Complementary and alternative medicine has become immensely popular. This review summarizes the recent literature on complementary and alternative medicine for rheumatic conditions. Research has emerged in the following areas: acupuncture, herbal remedies, homeopathy, magnetic fields, massage therapy, spiritual healing, and supplements. Positive evidence was found in relation to glucosamine, chondroitin, some herbal remedies, and acupuncture. Generally speaking, complementary and alternative medicine is grossly underresearched. Because of the popularity of complementary and alternative medicine, adequately defining risk-benefit relationships is an urgent matter.

Curr Opin Rheumatol. 2002 Jan;14(1):58-62. Ernst E. Department of Complementary Medicine, School of Sport and Health Sciences, University of Exeter, Exeter, United Kingdom. E.Ernst@exeter.ac.uk

This intensive case study used an A-B time-series analysis design to examine whether 5 adult patients with various AIDS-related pain symptoms benefited from a hypnosis-based pain management approach. The 3 dependent variables in this study were: (a) self-ratings of the severity of pain, (b) self-ratings of the percentage of time spent in pain, and (c) amount of p.r.n. pain medication taken. Data were collected over a period of 12 weeks, including a 1-week baseline period and an 11-week treatment period. Autoregressive integrated moving-average (ARIMA) models were used to determine the effects of the hypnotic intervention over and above autoregressive components in the data. All 5 patients showed significant improvement on at least 1 of the 3 dependent variables as a result of the hypnotic intervention. Four of the 5 patients reported using significantly less pain medication during the treatment phase.

Int J Clin Exp Hypn. 2002 Apr;50(2):170-88. Langenfeld MC, Cipani E, Borckardt JJ. California School of Professional Psychology-Fresno, 93727-2014, USA.

OBJECTIVE: To survey the use of complementary and alternative medical therapies by pediatric pain management services affiliated with major universities. DESIGN: A telephone survey was conducted of pediatric anesthesia training programs accredited by the Accreditation Council for Graduate Medical Education in the United States. The survey instrument included questions on the provision of complementary and alternative medical therapies in their pediatric pain programs. RESULTS: Forty-three pediatric anesthesia fellowship programs (100%) responded to the survey. Thirty-eight institutions (86%) offered one or more complementary and alternative medical therapies for their patients. Those therapies included biofeedback (65%), guided imagery (49%), relaxation therapy (33%), massage (35%), hypnosis (44%), acupuncture (33%), art therapy (21%), and meditation (21%). CONCLUSIONS: This report documents trends in complementary and alternative medical therapies usage in the tertiary pediatric pain management service. There is a high prevalence in the integration of complementary and alternative medical therapies in pediatric pain management programs. Additional clinical research in the safety and efficacy in complementary and alternative medical therapies for pediatric pain management is urgently needed.

Pain Med. 2005 Nov-Dec;6(6):452-8. Lin YC, Lee AC, Kemper KJ, Berde CB. Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston; Harvard Medical School, Boston, Massachusetts 02115, USA. yuan-chi@tch.harvard.edu

Full Title: Complementary and alternative medicine for pain management in U.S.- and foreign-born Chinese women with breast cancer

This study explores beliefs about complementary and alternative medicine (CAM) use for pain management among 15 U.S.-born and 15 foreign-born Chinese women with breast cancer. For this investigation, trilingual interviewers conducted individual, face-to-face, qualitative interviews in Cantonese, Mandarin, or English. All study participants lived in San Francisco, and the foreign-born women had resided in the U.S. for 15 years or fewer. Findings indicate that many participants consider CAM a viable method of pain management. However, concerns about affordability and quality of treatment prevent some women from using CAM on a regular basis. Many participants indicated that Western health care providers are poorly equipped to provide CAM to manage the pain resulting from breast cancer treatment. Future research should explore how access to CAM can be improved for poor and uninsured patients with cancer and how alternative approaches to pain management can be integrated more broadly in the U.S. health care system.

J Health Care Poor Underserved. 2007 Nov;18(4 Suppl):118-29. Wong-Kim E, Merighi JR. Department of Social Work, California State University, Hayward 94542, USA. evaon@csueastbay.edu

Full Title: The effect of cultural background on the usage of complementary and alternative medicine for chronic pain management

BACKGROUND: Chronic pain is a debilitating problem with significant impact on healthcare utilization in the US. Many chronic pain patients use complementary or alternative medicine (CAM) in addition to standard pharmacologic therapy. OBJECTIVE: The aim of our study was to identify differences in the characteristics of usage of CAM for chronic pain control among several ethnic groups. DESIGN: We recruited 92 consecutive patients seeking treatment at the pain clinic and interviewed them using a questionnaire. RESULTS: The most common pain complaint was back pain (55.4%) and the mean pain duration for all chronic pain problems was 9.8 years. Approximately 81% of respondents were using or have used CAM before. The commonest CAM used by patients in our study included massage therapy, spiritual healing as well as the consumption of mineral and vitamin supplements. Sixty-three percent of them were satisfied with CAM treatment compared to 56% of patients who were satisfied with prescription therapy. However, there was no difference in the use of CAM among the different ethnic groups (P > 0.05). CONCLUSION: Our study demonstrates that CAM is used very frequently in patients with chronic pain. However, it did not show any ethnic or racial differences in CAM utilization.

Pain Physician. 2009 May-Jun;12(3):685-8. Ho KY, Jones L, Gan TJ. Pain Management Centre, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore. ho.kok.yuen@sgh.com.sg

Pain following traumatic injuries is common, can impair injury recovery and is often inadequately treated. In particular, the role of adjunctive nonpharmacologic analgesic techniques is unclear. The authors report a randomized, controlled study of 21 hospitalized trauma patients to assess the analgesic efficacy of virtual reality hypnosis (VRH)-hypnotic induction and analgesic suggestion delivered by customized virtual reality (VR) hardware/software. Subjective pain ratings were obtained immediately and 8 hours after VRH (used as an adjunct to standard analgesic care) and compared to both adjunctive VR without hypnosis and standard care alone. VRH patients reported less pain intensity and less pain unpleasantness compared to control groups. These preliminary findings suggest that VRH analgesia is a novel technology worthy of further study, both to improve pain management and to increase availability of hypnotic analgesia to populations without access to therapist-provided hypnosis and suggestion.

Int J Clin Exp Hypn. 2010 Jul;58(3):288-300. Patterson DR, Jensen MP, Wiechman SA, Sharar SR. Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98104, USA. davepatt@u.washington.edu

Full Title: Pain-reduction strategies in hypnotic context and hypnosis: ERPs and SCRs during a secondary auditory task

Pain-rating scores were obtained from 10 high, 10 medium, and 10 low hypnotizable subjects who were holding a painful cold bottle in their left hands and were exposed to pain reduction treatments while they were performing a secondary oddball task. All subjects received suggestions of dissociative imagery and focused analgesia as cognitive strategies for pain reduction. The following measures were obtained for tone targets of the auditory oddball task: (a) reaction time; (b) P300 peak amplitude of the event-related potentials; (c) skin conductance levels and skin conductance responses. Focused analgesia produced the most pain reduction in high, but not medium or low, hypnotizable subjects who showed shorter reaction times, higher central and parietal P300 peaks, and higher skin conductance responses. These findings were discussed vis-a-vis the dissociated-control model assuming that capacity demands of hypnotic suggestion are low.

Int J Clin Exp Hypn. 2004 Oct;52(4):343-63. De Pascalis V, Bellusci A, Gallo C, Magurano MR, Chen AC. Department of Psychology, University of Rome, La Sapienza, Rome, Italy. v.depascalis@caspur.it

Full Title: Clinical hypnosis versus cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations

A randomized controlled trial was conducted to compare the efficacy of clinical hypnosis versus cognitive behavioral (CB) coping skills training in alleviating the pain and distress of 30 pediatric cancer patients (age 5 to 15 years) undergoing bone marrow aspirations. Patients were randomized to one of three groups: hypnosis, a package of CB coping skills, and no intervention. Patients who received either hypnosis or CB reported less pain and pain-related anxiety than did control patients and less pain and anxiety than at their own baseline. Hypnosis and CB were similarly effective in the relief of pain. Results also indicated that children reported more anxiety and exhibited more behavioral distress in the CB group than in the hypnosis group. It is concluded that hypnosis and CB coping skills are effective in preparing pediatric oncology patients for bone marrow aspiration.

Int J Clin Exp Hypn. 1999 Apr;47(2):104-16. Liossi C, Hatira P. University of Sunderland, United Kingdom.

Hypnosis is a modified state of consciousness linking the conscious and the unconscious of a person. In the context of chronic pain, hypnosis enables to help controlling the intensity of the pain, managing the pain and the emotions accompanying it and to help the patient finding his own resources allowing him getting involved in his treatment.

Rev Med Suisse. 2009 Jun 17;5(208):1380-2, 1384-5. Grünenwald M. Centre multidisciplinaire de la douleur, Service de pharmacologie et toxicologie cliniques, HUG, Genève. grunenwaldmichele@hotmail.com

Full Title: Women's views regarding hypnosis for the control of surgical pain in the context of a randomized clinical trial

OBJECTIVE: The aim of this study was to assess women's satisfaction with a hypnotic intervention for anxiety and pain management during a pregnancy-terminating procedure. METHODS: Women (N = 350) scheduled for first-trimester surgical abortion were randomly assigned to standard care or to a short, standardized hypno-analgesia intervention before and during the procedure. We assessed their individual use of the various hypnotic strategies proposed during the intervention and their views (likes/dislikes) about the hypnotic intervention, the pregnancy termination experience, and their participation in this randomized study. RESULTS: Mental imagery of a secure place was the strategy used by most women (71%) in the hypnosis group, but a significant proportion of them also used dissociation (42%) and focal analgesia (39%). Advantages of hypnosis over standard care were found in the patients' report that they could resume their normal activities right after being discharged from the hospital (72% in hypnosis vs. 56% in control group) and in their appreciation of the accompaniment (hypnotherapist vs. nurse) provided during the procedure (97% in hypnosis vs. 56% in control group). Among those who received hypnosis, 97% affirmed that they would recommend hypnosis to a friend for a similar procedure. More than 98% in both groups indicated they would again volunteer to participate in a study evaluating hypnosis for pain management. CONCLUSIONS: Women in the hypnosis group generally reported higher levels of satisfaction with various aspects of the procedure. This is consistent with the growing literature in favor of hypnotic interventions to improve pain management and care.

J Womens Health (Larchmt). 2009 Sep;18(9):1441-7. Marc I, Rainville P, Masse B, Dufresne A, Verreault R, Vaillancourt L, Dodin S. Department of Pediatrics, Centre Hospitalier Universitaire de l'Universite Laval, Université Laval, Quebec, Canada. Isabelle.Marc@crsfa.ulaval.ca

Full Title: Qualitative systemic review of randomized controlled trials on complementary and alternative medicine treatments in fibromyalgia

The objectives of the study were identification, quality evaluation and summary of RCTs on complementary and alternative medicine as defined by the National Institute of Health with the exception of dietary and nutritional supplements. A computerized search of databases from 1990 (year of publication of the ACR criteria for fibromyalgia) to July 2007 was performed. The RCTs were assessed by a methodological quality score. A total of 23 RCTs issued from 1992 to 2007 on acupuncture, balneotherapy, thermotherapy, magnetic therapy, homeopathy, manual manipulation, mind-body medicine, diet therapy and music therapy were identified. The RCTs had an average group size of 25 with the number of groups ranging from two to four. The quality score assessment of the RCTs yielded a mean score of 51 out of 100. The average methodological quality of the identified studies was fairly low. Best evidence was found for balneotherapy/hydrotherapy in multiple studies. Positive results were also noted for homeopathy and mild infrared hyperthermia in 1 RCT in each field. Mindfulness meditation showed mostly positive results in two trials and acupuncture mixed results in multiple trials with a tendency toward positive results. Tendencies for improvement were furthermore noted in single trials of the Mesendieck system, connective tissue massage and to some degree for osteopathy and magnet therapy. No positive evidence could be identified for Qi Gong, biofeedback, and body awareness therapy.

Rheumatol Int. 2009 Aug 12. Baranowsky J, Klose P, Musial F, Haeuser W, Dobos G, Langhorst J. Department of Internal Medicine, Complementary and Integrative Medicine, Kliniken Essen-Mitte, University Duisburg-Essen, Essen, Germany.

FULL TITLE: The effectiveness of hypnosis for reducing procedure-related pain in children and adolescents: a comprehensive methodological review

A comprehensive, methodologically informed review of studies of the effectiveness of hypnosis for reducing procedure-related pain in children and adolescents is provided. To be included in the review, studies were required to use a between-subjects or mixed model design in which hypnosis was compared with a control condition or an alternative intervention in reducing the procedure-related pain of patients younger than age 19. An exhaustive search identified 13 studies satisfying these criteria. Hypnosis was consistently found to be more effective than control conditions in alleviating discomfort associated with bone marrow aspirations, lumbar punctures, voiding cystourethograms, the Nuss procedure, and post-surgical pain. Furthermore, hypnosis was as at least as effective as distraction. Three hypnotic interventions met criteria as a possibly efficacious empirically supported therapy for reducing post-surgical or lumbar puncture pain. Several other hypnotic interventions would have achieved the status of a possibly efficacious therapy had studies used a treatment manual.

J Behav Med. 2009 Aug;32(4):328-39. Epub 2009 Mar 3. Accardi MC, Milling LS. Department of Psychology, University of Hartford, 200 Bloomfield Avenue, West Hartford, CT 06117, USA.

by Jane Nash, BEd, MEd, CHt, NLP Master

I met Anne at a community Weight Management program I was delivering. She learned and practiced Neuro Linguistic Programming techniques following a mixture of Paul McKenna, John Plester and my own techniques rolled into a four week program. During this time it became apparent that she really needed relief from the intense physical pain she experienced on a daily basis. Following a short discussion, we agreed to work together to relieve the symptoms in her body caused by emotional isAnnes which she believed were holding onto the body and adding to her pain levels.

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Suggestion, a powerful factor in everyday social interaction, is most effective during hypnosis. Subjective evaluations and brain-imaging findings converge to propose that hypnotic suggestion strongly modulates sensory processing. To reveal the brain regions that mediate such a modulation, we analyzed data from a functional-magnetic-resonance-imaging study on hypnotic-suggestion-induced pain on 14 suggestible subjects. Activation strengths in the right dorsolateral prefrontal cortex (DLPFC) during initiation of suggestion for pain correlated positively with the subjective intensity of the subsequent suggestion-induced pain, as well as with the strengths of the maximum pain-related activation in the in the secondary somatosensory (SII) cortex. Furthermore, activation of the insula and the anterior cingulate cortex predicted the pain-related SII activation. The right DLPFC, as an area important for executive functions, likely contributes to functional modulation in the modality-specific target areas of given suggestions. Hum Brain Mapp 2009. (c) 2009 Wiley-Liss, Inc.

Hum Brain Mapp. 2009 Jan 30. Raij TT, Numminen J, Närvänen S, Hiltunen J, Hari R. Brain Research Unit, Low Temperature Laboratory and Advanced Magnetic Imaging Centre, Helsinki University of Technology, FIN-02015 TKK, Finland.

Twenty-two patients with multiple sclerosis (MS) and chronic pain we recruited into a quasi-experimental trial comparing the effects of self-hypnosis training (HYP) with progressive muscle relaxation (PMR) on pain intensity and pain interference; 8 received HYP and the remaining 14 participants were randomly assigned to receive either HYP or PMR. HYP-condition participants reported significantly greater pre- to postsession as well as pre- to posttreatment decreases in pain and pain interference than PMR-condition participants, and gains were maintained at 3-month follow-up. Most of the participants in both conditions reported that they continued to use the skills they learned in treatment and experienced pain relief when they did so. General hypnotizability was not significantly related to treatment outcome, but treatment-outcome expectancy assessed before and after the first session was. The results support the efficacy of self-hypnosis training for the management of chronic pain in persons with MS.

Int J Clin Exp Hypn. 2009 Apr;57(2):198-221. Jensen MP, Barber J, Romano JM, Molton IR, Raichle KA, Osborne TL, Engel JM, Stoelb BL, Kraft GH, Patterson DR. University of Washington School of Medicine, Seattle, Washington 98195-6490, USA. mjensen@u.washington.edu

The neural mechanisms underlying the antinociceptive effects of hypnosis still remain unclear. Using a parametric single-trial thulium-YAG laser fMRI paradigm, we assessed changes in brain activation and connectivity related to the hypnotic state as compared to normal wakefulness in 13 healthy volunteers. Behaviorally, a difference in subjective ratings was found between normal wakefulness and hypnotic state for both non-painful and painful intensity-matched stimuli applied to the left hand. In normal wakefulness, non-painful range stimuli activated brainstem, contralateral primary somatosensory (S1) and bilateral insular cortices. Painful stimuli activated additional areas encompassing thalamus, bilateral striatum, anterior cingulate (ACC), premotor and dorsolateral prefrontal cortices. In hypnosis, intensity-matched stimuli in both the non-painful and painful range failed to elicit any cerebral activation. The interaction analysis identified that contralateral thalamus, bilateral striatum and ACC activated more in normal wakefulness compared to hypnosis during painful versus non-painful stimulation. Finally, we demonstrated hypnosis-related increases in functional connectivity between S1 and distant anterior insular and prefrontal cortices, possibly reflecting top-down modulation.

Neuroimage. 2009 May 19. Vanhaudenhuyse A, Boly M, Balteau E, Schnakers C, Moonen G, Luxen A, Lamy M, Degueldre C, Brichant JF, Maquet P, Laureys S, Faymonville ME. Coma Science Group, Cyclotron Research Center, University of Liège, Belgium.

Twenty-two patients with multiple sclerosis (MS) and chronic pain we recruited into a quasi-experimental trial comparing the effects of self-hypnosis training (HYP) with progressive muscle relaxation (PMR) on pain intensity and pain interference; 8 received HYP and the remaining 14 participants were randomly assigned to receive either HYP or PMR. HYP-condition participants reported significantly greater pre- to postsession as well as pre- to posttreatment decreases in pain and pain interference than PMR-condition participants, and gains were maintained at 3-month follow-up. Most of the participants in both conditions reported that they continued to use the skills they learned in treatment and experienced pain relief when they did so. General hypnotizability was not significantly related to treatment outcome, but treatment-outcome expectancy assessed before and after the first session was. The results support the efficacy of self-hypnosis training for the management of chronic pain in persons with MS.

Int J Clin Exp Hypn. 2009 Apr;57(2):198-221. Jensen MP, Barber J, Romano JM, Molton IR, Raichle KA, Osborne TL, Engel JM, Stoelb BL, Kraft GH, Patterson DR. University of Washington School of Medicine, Seattle, Washington 98195-6490, USA. mjensen@u.washington.edu

This study describes the effect of hypnosis on pain relief during labor and childbirth. Using a qualitative approach, 6 pregnant women were trained to use self-hypnosis for labor. Outcomes were analyzed using Colaizzi's procedure. Women described their feelings about hypnosis during labor as: a sense of relief and consolation, self-confidence, satisfaction, lack of suffering labor pain, changing the feeling of pain into one of pressure, a decrease in fear of natural childbirth, lack of tiredness, and lack of anxiety. They expressed increased concentration on the uterus and cervical muscle, awareness of all the stages of labor, and having "positive thoughts." Births were perceived as being very satisfactory compared to their previous experiences.

Int J Clin Exp Hypn. 2009 Apr;57(2):174-83. Abbasi M, Ghazi F, Barlow-Harrison A, Sheikhvatan M, Mohammadyari F. Middlesex University, London, United Kingdom. M.abbasi@mdx.ac.uk