Biofeedback and relaxation training with three kinds of headache: treatment effects and their prediction

Cluster Headache: Clinical Characteristics and Opportunities to Enhance Quality of Life

PURPOSE OF REVIEW

Cluster headache is a highly disabling primary headache disorder characterized by severe pain and autonomic features. We present the existing body of literature on psychological factors associated with cluster headache and recommendations to address gaps in current clinical care with regards to psychological treatments for cluster headache.

RECENT FINDINGS

People with cluster headache often endorse depressive symptoms, are more likely than the general population to report suicidal ideation and behaviors, and experience significantly decreased quality of life. Psychological treatments such as Acceptance and Commitment Therapy may be particularly valuable for patients with cluster headache given that they are transdiagnostic in nature and can therefore simultaneously address the disease burden and common psychiatric comorbidities that present. Greater understanding of the debilitating nature of cluster headache and behavioral interventions that seek to reduce the burden of the disease and improve the quality of life of people with cluster headache is paramount.

Prevalence of Posttraumatic Stress Symptoms and Associated Characteristics Among Patients With Chronic Pain Conditions in a Norwegian University Hospital Outpatient Pain Clinic

Introduction

Comorbid posttraumatic stress disorder (PTSD) in patients with chronic pain may have a negative effect on the course and outcome of both disorders. Nevertheless, the co-occurrence of the two conditions is often overlooked in clinical settings. Further, little is known about how PTSD is associated with biopsychosocial characteristics in this patient group. The first objective was to assess the prevalence of posttraumatic stress symptoms (PTSS) in patients with chronic pain in a Norwegian university hospital outpatient pain clinic. The second objective was to investigate possible associations between PTSS and adverse outcomes such as pain intensity, disability, and distress. The third objective was to compare the PTSS prevalence rates between primary versus secondary pain conditions.

Materials and methods

Six hundred and ninety-two patients meeting for pain assessment completed self-report questionnaires about PTSS and possibly associated factors. The Life Events Checklist and the Stressful Life Events Screening Questionnaire were used to screen for potentially traumatic life events. The Impact of Events Scale - Revised and the PTSD Checklist for DSM-5 were used to assess PTSS. Differences between patients with and without severe PTSS on the possibly associated variables were analyzed by chi-squared-, and t-tests.

Results

20.7% of the participants reported a level of PTSS qualifying for a PTSD diagnosis. These patients reported higher levels of pain intensity, pain bothersomeness, disability, and psychological distress, as well as lower levels of self-efficacy. They also reported higher levels of pain catastrophizing, perceived injustice, fatigue, and sleep difficulties. Finally, there was not a significant difference in prevalence rates between primary and secondary pain conditions.

Discussion

PTSS are frequent in patients with chronic pain, and a range of psychological characteristics is associated with a high level of such symptoms in this patient group. Patients with both conditions report a significantly higher symptom load, and the potential impact on the individual's life is major. In terms of pain condition, there were no differences in PTSS between primary pain conditions and secondary pain conditions in this pain population. This study emphasizes the importance of increased attention on PTSS when seeing patients with chronic pain conditions in clinical practice.

“Hey Dad, Watch Me”: The Effects of Training a Child to Teach Pain Management Skills to a Parent With Recurrent Headaches

This study examines the efficacy of a cognitive-behavioural program for recurrent headaches which was first implemented with an 8-year-old boy suffering from headaches. The child was subsequently trained to implement the same intervention with his father who also suffered from headaches. The treatment involved pain management skills, such as relaxation training, imagery, positive self-talk, and distraction techniques. In addition, a parent contingency management component involving the mother was employed. The treatment intervention was sequentially introduced to the child and father in a nonconcurrent multiple-baseline across-subjects design. Headache diaries and self-report measures were completed by both clients. From pre- to posttreatment there was respectively a 92.5% and 86.7% improvement in headache frequency, a 67% and 85% improvement in mean headache intensity and a 89.44% and 28% improvement in headache duration. Three-month follow-up data showed that both subjects had 100% improvement rates on all headache measures. The results highlight that some children can successfully teach their parents pain management skills. Possible implications of the results for the treatment of families, where multiple family members suffer from pain, are discussed.

The Role of Type A Behaviour Pattern in Chronic Headache

Chronic headache sufferers (N = 133) were assessed for Type A behaviour pattern using the Jenkins Activity Survey (JAS). The Type A score frequency distribution for all headache subjects combined, and each headache type separately were examined. Median scores of the all subjects combined group fell into the indeterminate range of Type A scores, that is, neither Type A or Type B. This was also the case for migraine and tension sufferers. Mixed subject's scores fell into the range of scores usually classified as Type A. Forty-five percent of the mixed subjects fit the criteria for Type A behaviour pattern. Follow-up bivariate and multivariate analysis using J AS subscale scores as independent predictors and headache activity scores, from daily diaries, as dependent variables revealed only three correlations which approached significance. These results argue against a clear linear relationship between chronic headache and Type A behaviour pattern. There may be some utility in this construct when differentiated by headache type.

Psychiatric comorbidity and response to preventative therapy in the treatment of severe migraine trial

INTRODUCTION

Mood and anxiety disorders are comorbid with migraine and commonly assumed to portend a poor response to preventive migraine therapies. However, there is little evidence to support this assumption.

METHOD

We examined impact of a mood and/or anxiety disorder diagnosis using American Psychiatric Association Diagnostic and Statistical Manual criteria on response to the three preventative migraine therapies evaluated in the Treatment of Severe Migraine trial (n = 177): β-blocker, behavioral migraine management, or behavioral migraine management +β-blocker. Daily diaries assessed migraine activity for the 16 months of the trial. The Migraine Specific Quality of Life Questionnaire and Headache Disability Inventory assessed headache-related disability at regular intervals. Mixed models for repeated measures examined changes in these three outcomes with preventative migraine therapy in participants with and without a mood or anxiety disorder diagnosis.

RESULTS

Participants with a comorbid mood or anxiety disorder diagnosis recorded larger reductions in migraine days (p < .05) and larger reductions in the Migraine Specific Quality of Life Questionnaire (p < .001) and Headache Disability Inventory (p < .01) than did participants with neither diagnosis.

DISCUSSION

Significantly larger reductions in migraine activity and migraine-related disability were observed in participants with a mood and/or anxiety disorder diagnosis than in participants who did not receive either diagnosis.

Preservation of immune function in cervical cancer patients during chemoradiation using a novel integrative approach

Patients receiving chemoradiation for cervical cancer are at risk for distress, chemoradiation-related side-effects, and immunosuppression. This prospective randomized clinical trial examined effects of a complementary therapy, Healing Touch (HT), versus relaxation training (RT) and usual care (UC) for (1) supporting cellular immunity, (2) improving mood and quality of life (QOL), and (3) reducing treatment-associated toxicities and treatment delay in cervical cancer patients receiving chemoradiation. Sixty women with stages IB1 to IVA cervical cancer were randomly assigned to receive UC or 4 ×/weekly individual sessions of either HT or RT immediately following radiation during their 6-week chemoradiation treatment. Patients completed psychosocial assessments and blood sampling before chemoradiation at baseline, weeks 4 and 6. Multilevel regression analyses using orthogonal contrasts tested for differences between treatment conditions over time. HT patients had a minimal decrease in natural killer cell cytotoxicity (NKCC) over the course of treatment whereas NKCC of RT and UC patients declined sharply during chemoradiation (group by time interaction: p = 0.018). HT patients showed greater decreases in two different indicators of depressed mood (CES-D depressed mood subscale and POMS depression scale) compared to RT and UC (group by time interactions: p<0.05). No between group differences were observed in QOL, treatment delay, or clinically-rated toxicities. HT may benefit cervical cancer patients by moderating effects of chemoradiation on depressed mood and cellular immunity. Effects of HT on toxicities, treatment delay, QOL, and fatigue were not observed. Long-term clinical implications of findings are not known.

Cognitive Approaches to the Treatment of Chronic Benign Headache: A Review and Critique

Psychological treatments of headache are becoming increasingly influenced by cognitive therapy. This paper addresses three issues relevant to the development and evaluation of cognitive therapy. 1. It is argued that current assessment measures for evaluating treatment are founded on a theory of pain which is inadequate and as a result they are not sufficient for the evaluation of cognitive therapy. 2. The assumptions on which cognitive therapy for headache is based have not been verified. Recent research indicates a degree of complexity in the relationships between cognition, emotion and pain which has yet to be assimilated. 3. It is noted that cognitive therapy for headache lacks an explicit model of pain which would facilitate the precise formulation and testing of interventions.

Effects of Depression and Headache Type on Biofeedback for Muscle-contraction Headaches

The present study was designed to investigate further the possible interactive role of both depression and headache type on the outcome of a standard E.M.G. biofeedback therapy for muscle-contraction headache. Forty-eight patients applying for treatment at a headache treatment center were given forehead/posterior neck E.M.G. biofeedback therapy for 20 weeks. Twelve subjects in each of four groups had either depression with or without a history of head trauma, or were not depressed, with or without a history of head trauma. Results showed that headache activity was lowered more for non-depressed subjects and more for non-trauma subjects, although there was no interaction. However, post-hoc examination also showed that the possibility of monetary gain from legal action might have confounded the data for some of the trauma subjects. The study supports the need for separation of depressed and non-depressed patients in headache treatment and the probable need for treatment for the depression itself, aside from the headache.

Comorbid depression, chronic pain, and disability in primary care

OBJECTIVES

The objectives of this study were to provide estimates of the prevalence and strength of association between major depression and chronic pain in a primary care population and to examine the clinical burden associated with the two conditions, singly and together.

METHODS

A random sample of Kaiser Permanente patients who visited a primary care clinic was mailed a questionnaire assessing major depressive disorder (MDD), chronic pain, pain-related disability, somatic symptom severity, panic disorder, other anxiety, probable alcohol abuse, and health-related quality of life (HRQL). Instruments included the Patient Health Questionnaire, SF-8, and Graded Chronic Pain Questionnaire. A total of 5808 patients responded (54% of those eligible to participate).

RESULTS

Among those with MDD, a significantly higher proportion reported chronic (i.e., nondisabling or disabling) pain than those without MDD (66% versus 43%, respectively). Disabling chronic pain was present in 41% of those with MDD versus 10% of those without MDD. Respondents with comorbid depression and disabling chronic pain had significantly poorer HRQL, greater somatic symptom severity, and higher prevalence of panic disorder than other respondents. The prevalence of probable alcohol abuse/dependence was significantly higher among persons with MDD compared with individuals without MDD regardless of pain or disability level. Compared with participants without MDD, the prevalence of other anxiety among those with MDD was more than sixfold greater regardless of pain or disability level.

CONCLUSIONS

Chronic pain is common among those with MDD. Comorbid MDD and disabling chronic pain are associated with greater clinical burden than MDD alone.

Allocation of patients to conditions in headache clinical trials: randomization, stratification, and treatment matching

Assuming control over the allocation of patients to treatment conditions is a fundamental element of any comparative clinical trial. There are three critical considerations investigators must balance in choosing an allocation scheme: reducing bias in patient allocation, producing balanced patient groups across treatment arms, and reducing the likelihood of errors attributable to chance variation. The authors review the principles of three key approaches to the allocation of patients to conditions within clinical trials, and their respective advantages with regard to these critical considerations. These allocation methods include randomization, stratification, and patient-treatment matching. Randomization is fundamental to most clinical trials. Stratification is an advanced step in a systematic program of research investigating the efficacy and effectiveness of an intervention. If the trial has less than 100 per arm and there is a known prognostic factor, stratification is the best choice to ensure equal allocation across groups. Treatment matching (tailoring) attempts to match the most appropriate treatment to a specific patient based on a priori hypotheses. Two techniques used for exploring treatment matching are: patient typologies (patient profiling), and aptitude-treatment interactions. Additional details pertaining to the rationale for selecting among these various approaches to patient allocation is provided, and their methodology is summarized with specific consideration for their application within clinical trials of headache treatment.

A randomized controlled trial of an internet-based treatment for chronic headache

Chronic headache is a significant public health problem in Western nations. Although controlled trials demonstrate the efficacy and cost-effectiveness of face-to-face behavioral therapy, most headache sufferers have limited access to these treatments. Delivery of behavioral interventions using Internet technology has the potential to reach a larger number of headache sufferers and reduce the burden of disease. This randomized controlled study evaluated an Internet-delivered behavioral regimen composed of progressive relaxation, limited biofeedback with autogenic training, and stress management versus a symptom monitoring waitlist control. Treatment led to a significantly greater decrease in headache activity than symptom monitoring alone. Thirty-nine percent of treated individuals showed clinically significant improvement on self-report measures of headache symptoms at post-treatment. At two-month follow-up, 47% of participants maintained improvement. Treatment had a significant impact on general headache symptoms and headache-related disability. There was a 35% within-group reduction of medication usage among the treated subjects. The Internet program was more time-efficient than traditional clinical treatment. Treatment and follow-up dropout rates, 38.1% and 64.8%, respectively, were typical of behavioral self-help studies. This approach to self-management of headache is promising; however, several methodological and ethical challenges need to be addressed.

The effect of laboratory-induced depressed mood state on responses to pain

Some researchers have suggested that a depressed mood state is associated with alterations in responses to pain. The authors examined cognitive, behavioral, and affective responses of 75 randomly assigned participants to depressed, neutral, or elated mood state induction conditions and subjected them to the cold-pressor task. Because they were unsuccessful in inducing elated moods, the authors used only the data for the depressed and neutral states as they measured pain threshold, tolerance, and unpleasantness during the test. After the task, the authors measured sensory, affective, and evaluative responses to the cold-pressor pain, as well as the participants' catastrophizing ideation about the painful procedure. The depressed mood state group, compared with the neutral group, had significantly lower cold-pressor tolerance times and higher pain catastrophizing scores. These results support previous findings that a depressed mood state may be associated with alterations in some pain responses.

Age comparisons in acquiring biofeedback control and success in reducing headache pain

This article presents a review and archival analysis to assess age differences in acquiring biofeedback control and success in treating recurrent headache by using data from 56 studies with either adult (total N = 503) or child (total N = 98) subjects. All studies focused on treating headache with temperature biofeedback (TBF) or electromyographic (EMG) biofeedback. To standardize the varied measures across studies, we calculated each study's percent change scores for biofeedback performance and headache activity. All headache activity scores included assessments of pain intensity. We then calculated subject-weighted means of percent change for biofeedback performance and for headache activity by summing the products of each relevant percent change score and N and then dividing by the total number of subjects contributing to those sums. Results showed that both children and adults reported substantial improvements in headache activity with TBF and EMG biofeedback treatment (Ms ranged from 34% to 81%), but children showed significantly greater improvement than adults. No age differences were found in the acquisition of biofeedback control. Further analyses revealed two additional findings. First, biofeedback control and headache improvement were strongly correlated. Second, headache activity continued to decrease in the weeks following treatment, and this decrease was significantly greater for children than adults.

Negative affect, self-report of depressive symptoms, and clinical depression: relation to the experience of chronic pain

OBJECTIVE

The goal of this study was to examine the relative importance of global affective distress, self-report of depressive symptoms, and presence or absence of major depression to the experience of chronic pain.

SETTING

A multidisciplinary pain program at a university medical center was the setting for this study.

PATIENTS

Subjects in this study were 211 consecutive patients with chronic pain.

OUTCOME MEASURES

Pain duration, compensation, and litigation status were controlled for in the statistical analyses, as each correlated significantly with at least one of the measures of affect. Global affective distress was assessed using the Global Severity Index (GSI) from the Brief Symptom Inventory. The Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale were used as measures of self-report of depressive symptoms. Presence or absence of major depression was based on DSM-IV criteria.

RESULTS AND CONCLUSIONS

The GSI, Beck Depression Inventory, and Center for Epidemiological Studies Depression Scale were significantly correlated with each measure of the experience of pain, although clinical depression was only significantly related to self-reported disability and negative thoughts about pain. The self-report measures of depression maintained their relation to the dependent measures when the somatic items from the scales were removed, suggesting that the relations were not spuriously due to the influence of pain symptoms on the scales. When examining the unique contribution of each variable to the experience of pain (by simultaneously controlling for the other measures of affect), the GSI was uniquely related to the sensory and affective components of pain. Self-report of depressive symptoms was more highly related to a measure of the evaluative component of pain and uniquely related to self-reported disability and negative thoughts about pain. The results are discussed within the context of theoretical models of the relation between pain and affect, and suggestions for future research are presented.

Recurrent headache, coping, and quality of life in children: a review

OBJECTIVES

To clarify the concepts of coping with pain and quality of life (QoL) and to present a literature review of the strategies that children with recurrent headaches use to cope with their pain, the impact of recurrent headaches on children's QoL, and the influence of personal and situational variables on headache, coping, and QoL in children.

METHODS

The literature search encompassed published articles that were found by means of a CD-ROM search of MEDLINE (1966 to December 1998) and PsycLIT (1974 to December 1998) and the snowball method.

RESULTS

In pediatric headache research, only three studies have been found in which children report the use of various coping strategies, and only two studies considered QoL. Demographic factors and psychological variables such as depression, anger, and anxiety influence headache prevalence. The impact of headache-related variables such as headache type, severity, perceived cause, and prior experience on QoL has only been studied in adults.

CONCLUSIONS

More research on coping and QoL is needed in pediatric headache. The conceptual model that is presented in this article may serve as a guide.

Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis

OBJECTIVE

This study examined the ability of two self-report questionnaires, the Beck Depression Inventory (BDI) and the Center for Epidemiological Studies-Depression Scale (CES-D), to discriminate between chronic pain patients with and without major depression. Since previous research has suggested that medical conditions such as chronic pain can influence the endorsement of items that measure neurovegetative symptoms of depression, the accuracy of each of these questionnaires was also assessed eliminating these items.

SUBJECTS

These included 132 consecutive patients with chronic pain, 44 of whom were diagnosed as suffering from major depression according to DSM-IV criteria.

METHODS

Patients were administered a battery of questionnaires that included the CES-D and BDI. They were also interviewed by a clinical psychologist to determine the presence or absence of major depression.

RESULTS

Both questionnaires were able to discriminate significantly between persons with and without major depression. Removal of the somatic items on each questionnaire did not improve their accuracy. Discriminant function analysis revealed an optimal cut-off score of 21 for the BDI, and 27 for the CES-D. Overall hit rates at these cut-offs for the two questionnaires were comparable, while the CES-D had somewhat better sensitivity (81.8% vs. 68.2%). Conversely, the BDI had slightly better specificity (78.4% vs. 72.7%).

CONCLUSION

The results suggest that both questionnaires have good predictive validity among chronic pain patients, and decisions regarding the use of one questionnaire rather than the other may depend upon the goals of the user and the setting within which the questionnaire is used.

[Multidisciplinary treatment program on chronic low back pain, part 3. Psychosocial aspects]

PROBLEM

The majority of authors agree today that psychosocial factors have more influence on a successful treatment of chronic back pain than other variables, in particular medical findings. Therefore treatments aim to integrate psychotherapeutic intervention in order to lessen emotional impairment, to change behavioral patterns (which advocate rest and the avoidance of physical activity), and to change cognitive attitudes and fears concerning exercise and work ability. Nevertheless, the interplay of cognitive measures and disability in treatment programs still remains an unclear issue.

METHODS

Ninety disabled patients with chronic low back pain were admitted to an 8-week outpatient program of functional restoration and behavioral support. The program consisted of a pre-program (education, stretching and calisthenic exercises) and an intensive treatment period (physical exercises, back school education, cognitive behavioral group therapy, relaxation training, occupational therapy, vocational counseling), which took place for 5 weeks, 7 h a day, as an outpatient program. The targets of the psychological interventions were (a) to change maladaptive behavior (inactivity, social withdrawal) and increase the patient's activity level at home, (b) to alter maladaptive cognitions (somatization, catastrophizing, passive expectations concerning treatment) and to improve their own positive coping skills, (c) to identify and stop operant conditioned behavior, and (d) to prevent depressive symptoms and strengthen the level of emotional control. The program's philosophy encouraged the patients' active efforts to improve their functional status within a therapeutic environment that reinforced positive behavior traits conductive to getting well. The main therapeutic target was to facilitate a return to work. Apart from a medical examination and a personal interview, the patients' physical impairment, pain descriptions, and psychological distress (according to different criteria for evaluation) were also measured. This included variables such as depression, psychovegetative complaints, quality of life and workplace satisfaction, disability, and coping with disease. Measurements were repeated at the end of the 8-week program, and following 6- and 12-month intervals.

RESULTS

In comparison with the initial values, a statistically significant improvement became evident in reducing pain, disability, depression, and psychovegetative signs (P < 0.001). Nearly all results remained stable at the 6- and 12-months examinations. Apart from these results, coping measurements demonstrated little improvement in the three factorial coping dimensions. By use of regression analyses, a differentiated description of psychosocial connections became apparent in three different ways of coping (catastrophizing, searching for information, cognitive control) and parameters of disability. Disability levels corresponded poorly with pain descriptions, physical impairment and coping dimensions. This result indicates that disability should be viewed as a separate component in assessing the patients' description of low back pain.

CONCLUSION

An analysis of coping dimensions demonstrated that current cognitive measures might be too general to explain low back disability adequately. In addition, the results indicate that the use of the 'catastrophizing' factor as a separate variable is questionable, since it may simply be a symptom of depression. The relevance of coping as a sensitive parameter for change is also addressed. It is suggested that an alteration in coping strategies may be an important treatment effect, but is subject to individual prerequisites to maximize treatment response. Thus, future research must focus on the complex interactions between personality variables, environmental factors, and the coping demands posed by the specific nature of pain problems. A more lengthy evaluation of so-called 'fear-avoidance beliefs' in combination with 'disability' and coping dimensions could possibly lead to further treatment on the development of chronicity in chronic low back pain patients.

A retrospective, follow-up study of biofeedback-assisted relaxation therapy in patients with posttraumatic headache

Although biofeedback in the treatment of migraine and tension-type headache has been widely researched, there is little research examining biofeedback therapy in posttraumatic headache (PTH). In this retrospective study, 40 subjects with PTH who had received biofeedback-assisted relaxation at our headache clinic were questioned at least 3 months following the completion of therapy. Subjects were queried about improvements in headache, increases in ability to relax and cope with pain, and overall benefits, lasting effectiveness, and continued use of biofeedback in daily life. Results indicate 53% reported at least moderate improvement in headaches; 80% reported at least moderate improvement in ability to relax and cope with pain; 93% found biofeedback helpful to some degree; 85% felt headache relief achieved through biofeedback had continued at least somewhat; and 95% stated they were continuing to use biofeedback skills in daily life. A correlation analysis revealed a negative relationship between response to biofeedback and increased chronicity of the disorder. In other words, the more chronic the disorder, the poorer the response to treatment. A stepwise regression analysis found that chronicity of the disorder and number of treatment sessions significantly affected response to treatment. Data suggest that biofeedback-assisted relaxation should at least be considered when planning treatment strategies for posttraumatic headache.

Presurgical anxiety treated with cognitive behavioral therapy in a 13-year-old female with cleft lip and palate: a psychological case report

This case report describes presurgical anxiety in a 13-year-old female with complete cleft lip and palate, treatment of the anxiety with cognitive-behavioral therapy and progressive relaxation with biofeedback prior to a septorhinoplasty, and the treatment outcome.

Correlates of depression in chronic pain patients: a comprehensive examination

This study examined the relations between depression and demographic, pain-related, and work-related variables in 254 chronic pain patients. Regression analyses were conducted, initially by category (i.e., demographic, pain-related, and work-related), and finally a comprehensive regression analysis was performed, containing the significant independent variables from each category. Among the demographic variables, education level and marital status were related to depression, and an interaction between age and gender was associated with depression, with younger women and older men reporting more depression. Among the pain-related variables, longer duration of pain was associated with increased depression. Among the work-related variables, unemployment was associated with depression, and there was an interaction between work status and litigation status, with working and litigating being associated with depression and not working and not litigating being associated with depression. In the comprehensive analysis, work status, education level, and marital status accounted for a significant amount of the variance in depression scores. These findings, together with future research directions, are discussed.

Nonpharmacological management of headaches during pregnancy

Concerns about the effects of maternal medications on the growing baby limit the use of medication treatment for benign conditions, such as recurring headaches, during pregnancy and lactation. Nonpharmacological therapies hold particular promise for pregnant women due to the limited medication options. No controlled studies, however, have reported on the efficacy of nonpharmacological treatments for pregnant women. The first study evaluated the effectiveness of a combined nonpharmacological treatment (CT) consisting of relaxation, skin-warming biofeedback, and physical therapy for pregnant women with chronic headaches. In a second study, the CT protocol was compared with an attention control (AC) that received headache education and skin-cooling biofeedback. The first study resulted in significant symptom improvement in 79% of subjects, with an overall 72.9% reduction in headaches. In the second study, both groups improved with treatment; however the CT group was more likely to experience significant headache relief (72.7%) than the AC group (28.6%, chi 2(1) = 4.97, p < .03). Significant improvement was maintained at a 6-month follow-up for over 50% of patients. It is concluded that the combined nonpharmacological treatment was more effective than an attention control in reducing headaches during pregnancy. This treatment was effective regardless of predisposing variables.

Assessment of treatment outcome in patients with craniomandibular dysfunction

Psychosocial, socio-demographic and symptom characteristics have been shown to be associated with treatment outcome in patients with craniomandibular dysfunction (CMD). This study was performed to assess to what extent symptoms and correlates of CMD change as a consequence of conservative treatment for CMD. Treatment outcome in a group of CMD patients treated with a stabilization splint (experimental group) was compared with that of a group of patients with CMD who were not treated for CMD (control group). Patients in the experimental group had fewer symptoms of CMD at the end of treatment. However, several symptoms and correlates of CMD also improved in the control group (severity of pain, joint noises, ear symptoms). It was therefore questioned whether all improvements in symptoms and correlates of CMD in the experimental group could be attributed to the treatment received. Results suggest that the main improvement that might be ascribed to therapy was a decrease in 'jaw symptoms'. There was a noticeable decrease in depression and an increased use of 'planned actions and rational thinking' as a coping style in the experimental group whereas these variables did not change in the control group. Implications and suggestions for further research are discussed.

Craniomandibular dysfunction: patient characteristics related to treatment outcome

In a previous study it was concluded that only a few changes in symptoms related to craniomandibular dysfunction (CMD) could be attributed to therapy. It was suggested that psychosocial and socio-demographic variables, as well as symptom characteristics, could be responsible for the unconvincing treatment outcome in patients treated with a splint. The present study was performed to investigate whether socio-demographic characteristics, symptom characteristics and various psychosocial variables are associated with treatment outcome in patients with CMD treated with a splint. Treatment outcome was determined by using self-reported follow-up data. Results showed that patients with a negative treatment outcome were older, reported more and more severe symptoms and correlates of CMD, reported fewer stressors and more frequently considered health to be determined by external factors than patients who were treated successfully. The two groups could not be differentiated with regard to anxiety and depression. Results are interpreted with regard to the prediction of treatment outcome.

Catastrophizing, depression and the sensory, affective and evaluative aspects of chronic pain

Research has shown that catastrophizing is related to increased depression and chronic pain. However, some researchers have questioned the utility of catastrophizing as a separate construct, suggesting that it may just be a symptom of depression. The present investigation used path analysis to determine if catastrophizing was related to McGill Pain Questionnaire scores when controlling for depression as assessed by the Beck Depression Inventory in a group of 85 chronic pain patients. According to Fields' model of the relationship between pain and depression, we predicted that catastrophizing would mediate the the relationship between depression and the evaluative and affective aspects of pain, but not the sensory aspect. The resulting path coefficients appear to support these predictions. The results suggest that catastrophizing is a separate construct which may impact on pain perception and treatment. The data also provide some support for Field's neurobiological model of the relationship between depression and pain.

Long-term efficacy of combined relaxation: biofeedback treatments for chronic headache

Thirty-four patients having chronic idiopathic headaches participated in a long-term study comparing autogenic relaxation training alone (REL) with combinations of relaxation and electromyographic biofeedback (REL + EMG) or relaxation and temperature biofeedback (REL + TEMP). Assignment to treatment conditions was balanced on demographics and clinical characteristics, as well as headache classification according to muscle contraction or vascular headache symptomatology. The results indicate that REL + TEMP produced no additional improvements over REL following the 8-week treatment program, or at 6-month, or 12-month follow-up. However, REL + EMG produced significantly greater reductions in headache activity measures than the REL and REL + TEMP conditions at all post-treatment time points. Headache activity continued to improve over the follow-up period independent of treatment condition. These data indicate that EMG biofeedback augments long-term clinical improvements in headache patients who undergo autogenic relaxation training.

Treatment integrity of relaxation training for tension headaches

Treatment integrity procedures, generally lacking in previous research, were employed for evaluation of relaxation training for tension headaches. Treatment integrity is the extent to which the therapist implements the relaxation procedure as described, and the degree to which the patients comply with the therapist's instructions. Objective compliance with the home practice of relaxation training was assessed using a microcomputer-based method which required the patient to squeeze a hand control when instructed to tense a muscle. A single-case replication design with three tension headache patients was used. The dependent variables were taken from patients' self-reported daily headache data. Results indicate that: (a) the therapist accurately adhered to the relaxation training protocol; (b) headache frequency decreased in all patients from baseline to 1-year follow-up (improvements ranged from 72.7% to 98.2%); and (c) improvement was greater with higher compliance.

Electromyographic biofeedback training for tension headache in the elderly: a prospective study

This study evaluated the effects of a 12-session frontal electromyographic biofeedback training regimen on the headache activity of eight tension headache sufferers aged 62 and older. The biofeedback sessions were slightly modified for a geriatric population, essentially to increase comprehension and retention of rationale and instructions. Post-treatment assessment at three months revealed significant decreases in overall headache activity (50% or greater) in 50% of the subjects, and moderate improvement (35%-45%) in three of the remaining four subjects. Significant clinical and/or statistical pre-post differences were also found for the number of headache-free days, peak headache activity, and medication index. This is the first prospective study of biofeedback training for tension headache in an elderly population and, unlike previous retrospective studies, suggests that such therapy may be an effective intervention in the treatment of tension headaches in the elderly.

Inability to demonstrate physiologic correlates of subjective improvement among patients taught the relaxation response

OBJECTIVE

To assess whether the regular elicitation of the relaxation response produces sustained physiologic changes coincident with symptomatic relief or improved psychological state.

DESIGN

Prospective, cohort pilot study.

SETTING

Clinical research center within a teaching hospital.

PATIENTS

Thirteen athletic men, mean age 44.8 years, with borderline or labile hypertension, taking no medication. All 13 completed the study.

INTERVENTIONS

Three baseline assessments of psychological state, symptom checklist, and assessment of autonomic response to infusion of beta agonist (isoproterenol). Daily relaxation response exercises for five consecutive weeks followed by repeat assessment of all parameters. Discontinuation of relaxation exercises for subsequent five weeks followed by repeat assessment of all parameters.

MEASUREMENTS AND MAIN RESULTS

After eliciting the relaxation response, subjects demonstrated significant decreases in anxiety (p less than 0.014) and somatic symptoms (p less than 0.02). Psychological and somatic variables returned toward baseline after the subsequent discontinuation of relaxation exercises. No significant concomitant change in urinary catecholamines, heart rate response to isoproterenol, blood pressure, pulse rate, or serum cholesterol was demonstrated.

CONCLUSION

The regular elicitation of the relaxation response can improve psychological performance and reduce symptoms. However, the physiologic mechanism whereby these psychological and symptomatic improvements occur remains poorly understood and warrants further investigation.

An emotional component analysis of chronic pain

The present study sought to determine the relative contribution of frustration, fear, anger and anxiety, to the unpleasantness and depression pain patients experience. Sixty-nine women and 74 men, with an average age of 47 years, were included. Patients underwent psychological evaluation which included use of the Minnesota Multiphasic Personality Inventory (MMPI), Beck Depression Inventory (BDI), and 7 visual analog scales (VAS) measuring degree of emotional unpleasantness, pain intensity, anxiety, frustration, fear, anger and depression. Test-retest reliability coefficients were significant for the negative feeling VAS yielding an average reliability coefficient of 0.82. Analyses relating the negative feeling state VAS to pain unpleasantness and depression indices from the MMPI (scale 2) and BDI (sum score) yielded significant canonical correlations. Multiple regression was used to clarify the relationships between negative feeling VAS, pain-related unpleasantness, and indices of depression. After statistically controlling for intensity of pain, anxiety and frustration predicted unpleasantness. Regression analyses indicate that anger is an important concomitant of the depression that pain patients experience. The results suggest that anger and frustration are critical concomitants of the pain experience. Treatment techniques specifically targeting anger and frustration in these patients may prove efficacious.

The mind/body program for infertility: a new behavioral treatment approach for women with infertility

There is increasing evidence that a behavioral treatment approach might be efficacious in the treatment of the emotional aspects of infertility and may lead to increased conception rates. The first 54 women to complete a behavioral treatment program based on the elicitation of the relaxation response showed statistically significant decreases in anxiety, depression, and fatigue as well as increases in vigor. In addition, 34% of these women became pregnant within 6 months of completing the program. These findings established a role for stress reduction in the long-term treatment of infertility. They further suggest that behavioral treatment should be considered for couples with infertility before or in conjunction with reproductive technologies such as intrauterine insemination and gamete intrafallopian transfer.

An adolescent girl with headache and syncope

A 14-year-old girl with a 3-month history of multiple syncopal episodes followed by headache was diagnosed as having basilar artery migraine. She did not improve on anticonvulsant, anticholinergic, or beta-blocker therapy. Her symptoms resolved during a course of skin temperature biofeedback training, and she remains asymptomatic at 1 year follow-up.

The refractory headache patient--I. Chronic, daily, high intensity headache

Two studies on patients with Chronic, Daily, High Intensity Headache (CDHIHA) are presented. In the first, their response to various self-regulatory (biofeedback, relaxation) treatments was compared to that of case controls matched for age, duration and Ad Hoc Committee diagnoses who had 1-2 headache-free days per week (Group II) and 3-5 headache-free days per week (Group III). The CDHIHA patients had a significantly poorer response to treatment (12.7 vs 49.8% improvement for Groups II and III combined). In the second study, the psychological profiles of an enlarged sample of CDHIHA patients were compared to matched case controls from Group II and Group III. The CDHIHA patients tended to be more anxious, more hysterical and to have more non-headache somatic complaints than Groups II and III combined.

Relationships between depressive symptoms and descriptions of chronic pain

The present study investigated the relationship between the severity of depressive symptoms and various qualitative and quantitative aspects of pain reported by chronic pain patients. The sample consisted of 73 patients from a heterogeneous pain population admitted to the Victoria General Hospital Pain Management Unit. Patients completed a comprehensive pain evaluation battery that included the Beck Depression Inventory (BDI) and the McGill Pain Questionnaire (MPQ). They rated their loss of desire and ability for various social and recreational activities, and the intensity of their pain for 8 periods of a typical day. Multivariate analyses of variance were used to assess the sensory, affective, and evaluative indices of the MPQ, daily pain intensity ratings, and reported impairment of activities of non-depressed, mildly depressed and moderate/severely depressed patients. The results indicate significant relationships between the degree of depression and (a) the number of sensory descriptors endorsed on the MPQ; (b) pain intensity ratings in the late evening and at bedtime; and (c) reported loss of ability for social and recreational activities. Depression is related to loss of desire for activity in women, but not in men. A discriminant analysis suggests that depressed and non-depressed pain patients can be distinguished with 78% accuracy on the basis of their MPQ Sensory scores, reported loss of ability for activities, and global pain ratings at late evening and bedtime. The findings are discussed in terms of their implications for research as well as for the assessment and treatment of chronic pain patients.

Prediction of early termination from the self-regulatory treatment of chronic headache

The ability of demographic, psychological testing and history information to predict which patients will terminate early from nonpharmacological treatment of headache (relaxation and biofeedback) was tested. Information from each of these areas was initially examined for differences between dropouts and treatment completers using univariate analyses. These analyses were followed by a canonical discriminate function analysis that predicted whether patients would complete treatment or drop out. Information from the three predictor sets combined resulted in 77.4% of the patients being correctly classified.

Meta-analysis of non-medical treatments for chronic pain

A meta-analysis was conducted on 109 published studies which assessed the outcome of various non-medical treatments for chronic pain. Of these studies, 48 provided sufficient information to calculate effect sizes. The remainder were examined according to proportion of patients rated as improved. Studies were compared as a function of type of treatment, type of pain, and type of outcome variable. In general, effect sizes were positive and of modest magnitude indicating the short-term efficacy of most treatments for most types of pain. This finding suggests that the effectiveness of treatments may be attributable not to the differences between treatments, but to the features they have in common. Mood and number of subjective symptoms consistently showed greater responses to treatment than did pain intensity, pain duration, or frequency of pain, indicating the importance of using a multidimensional framework for pain assessment. This finding also suggests that the benefit of psychological approaches to pain management may lie in reducing the fear and depression associated with pain, rather than relieving the pain itself. The present study also highlights the advantages of meta-analytic reviews.

Evaluation of a minimal-therapist-contact thermal biofeedback treatment program for essential hypertension

We compared a clinic-based regimen of 16 individual sessions (2 per week) of thermal biofeedback with a largely home-based regimen of 5 sessions (spread over 8 weeks) for the treatment of essential hypertension in patients who required at least two drugs to maintain control of blood pressure (BP). On the basis of the clinical end point of being successfully withdrawn from the second stage medication while BP remained under control, the clinic-based regimen (5 of 9) was superior (chi less than (1) = 4.0, p less than .05) to the home-based regimen (1 of 9). Internal analyses point to more frequently obtaining a hand temperature of at least 95 degrees F by the office-based patients as possibly the reason for the difference.

Client variables and the behavioral treatment of recurrent tension headache: a meta-analytic review

Meta-analysis revealed that in studies evaluating behavioral treatments for tension headaches, the treatment outcome has varied with the client samples (e.g., age, gender, referral source) that have been used but not with the treatment procedures (e.g., type of behavioral intervention, length of treatment, whether or not efforts were made to facilitate transfer of training) or the research designs (e.g., internal validity, explicitness of diagnostic criteria) that have been used. Mean client age proved the best predictor of treatment outcome, accounting for 30% of the outcome variance following behavior therapy. Significantly poorer outcomes have also been reported in recent studies than were reported in early studies. These findings suggest that outcomes obtained with behavioral interventions have been less dependent upon the treatment variables that have been the primary focus of research attention than upon characteristics of client samples and behavioral interventions may be less effective in reducing headache activity than has previously been assumed.