By Nicole Davis
Many patients find that managing chronic pelvic pain conditions can sometimes be difficult. Oftentimes there is no one “thing” or pathology that symptoms can be tied to which, understandingly, can be frustrating or overwhelming. More accurately, chronic pelvic pain is a complex interaction of both physiological and psychosocial components. It is not only the body but the mind and the environment that can contribute to a pain experience.
In her presentation at the 3rd World Congress of Abdominal and Pelvic Pain Conference this past October, Dr. Afton Hassett addressed the impact of psychosocial factors on chronic pain. Dr. Afton Hassett is a licensed clinical psychologist and an Associate Research Scientist in the Department of Anesthesiology at the University of Michigan Medical School. Her research efforts at the Chronic Pain and Fatigue Research Center and those presented at the conference focus on how resilience factors such as positive emotions impact functional and neurological outcomes in individuals with chronic pain. Her lecture, Revisiting the Importance of Resilience in Pain, is summarized below:
To understand how to effectively treat chronic pain and how to promote and incorporate resilience as an intervention, we have to understand the nature of pain. It is important to note that pain is processed by many areas of the brain and that these areas of the brain are interconnected. That is, areas of the brain that are involved in pain processing are also responsible for functions such as attention and emotions. In a study completed by Frey et al., investigators looked at the relationship between pain and attention. Researchers took a group of women who chose to have a medication-free delivery and had them use virtual reality goggles as a way to distract them from the pain. The women that utilized the virtual reality goggles reported a 40% decrease in pain during their first stage of labor compared to the control group.3 Similarly, Dunbar et al., reported that patients participating in Duchenne laughter a.k.a. from your gut laughter, had increased pain thresholds.1 *There is a such thing as laughter therapy! From these studies and many following, Dr. Hassett and colleagues suggest that thoughts, emotions and pain are processed by many of the same areas of the brain and therefore, thoughts and emotions can influence the experience of pain.
So how exactly might your thoughts or emotions affect your pain? Depends on if they are positive or negative. The literature consistently links negative affect to key factors in chronic pain such as high clinical pain intensity, greater use of pain medication and poor quality of life. On the other hand, many experimental studies have associated positive affect to lower overall pain ratings, decreased use of pain medications and decreased induced pain tolerance. This means that managing depression, anxiety and anger whilst promoting happiness, enthusiasm and gratitude could positively alter the pain experience. The leading theory behind this impact of positive affect on behavior is Broaden and Build Theory proposed by Dr. Barbara Fredrickson which asserts that positive emotions: (1) broaden our thoughts and actions, (2) undo effects of negative emotions, and (3) build resiliency.2
In a collection of other studies researchers determined that positive emotions are diminished in individuals with chronic pain conditions such as fibromyalgia, chronic low back pain and chronic pelvic pain.4,5 Another study by Verbrugge et al., found, and that is often echoed by my patients with chronic pelvic pain, is that those with chronic pain often give up the things they love or value to do the things that they must do.9 This can disrupt one’s ability to seek joy and may negatively feed into the pain experience. But if positive emotions can alter the pain experience then can’t I or you or your patients do something to promote positive affect? Yes! – With “Positive Activity” interventions. And the greatest thing about positive activity interventions? They can be inexpensive, are easily accessible and effective. Doing things such as savoring a beautiful day, performing acts of kindness or participating in loving kindness meditation can help enhance resilience. Muller et. al reported that in a randomized control trial of 96 participants with pain, those that participated in eight weeks of tailored positive activity interventions reported improvements in pain intensity, pain control, life satisfaction, positive affect and depression. Even more encouraging, about 74% of these participants continued incorporating positive activities at two and a half months follow-up.7 In a randomized control trial nearly three times as large, Peter et al., identified improvements in happiness and depression that remained at six months follow-up in patients with chronic musculoskeletal pain that participated in either cognitive behavioral therapy or positive activity interventions.8
In her lecture at the conference, Dr. Hassett presented preliminary findings of her PRISM, Promoting Resilience with Innovative Self-Management, study. PRISM is a randomized control trial of 300 participants with back pain and comorbid fibromyalgia that participate in eight weeks of online self-management programs of either cognitive behavioral therapy (eCBT), resilience-enhanced cognitive behavioral therapy (PRISM) or usual care. The key differences in intervention between the eCBT and PRISM groups is that those in the PRISM group also participate in four positive activity interventions: signature strengths, savoring, acts of kindness and positive piggy bank.6 Signature strengths involves identifying your strengths and using them in a new way (check out your strengths here, it’s free and kind of fun!); savoring involves two to three minutes of mindful appreciation of a positive experience; and acts of kindness involves doing something kind for others and yourself. Of the four, the positive piggy bank might be my favorite. It requires you to write down something that made you happy that day for 30 days. At the end of the 30 days, you read through each memory and recall details of that event that made you happy.6 I did an abbreviated, week-long version of the positivity piggy bank and let me tell you, with all the crazy in the world, it was refreshing to slow down and reflect on something positive!
So, what does all of this mean for physical therapists or other clinicians that treat patients with chronic pain? With education we can help promote and enhance positive affect in our patients in a reliable and scalable manner! And what does all of this mean for patients with chronic pain? Partaking in positive activity interventions, whether that’s mindfulness or doing something kind for another, CAN help build resilience and mitigate the pain experience. Providers and patients, check out these other free, helpful resources that provide positive interactive activities for patients: FibroGuide and Happify.
We thank Dr. Hassett for a fantastic presentation! The entire lecture is available here, starting on page 220. You can also follow her on Twitter @AftonHassett.
- Dunbar et al. Proc R Sco B 2011;1373
- Fredrickson. AM Psychol 2001;56:218-226
- Frey, Hassett, Bell, Housey, Low & Bauer. New data for the Society of Obstetric Anesthesiology and Perinatology, 2017.
- Hassett et al. Arthritis Care Res 2008;59:833-40
- Hassett et al. Clin J Pain 2016;32:907-14
- Hassett & Williams R01 NRO17096 NIH-NINR
- Mueller et al. Clin J Pain 2016;32-44.
- Peters et al. Clin J Pain 2017 Apr 4 Epub ahead of print
- Verbrugge et al. Rheum Disease Clin North Am 1990;16:741-61