More Emphasis Needed on Preventing Relapse of Chronic Pain

Although the interdisciplinary pain rehabilitation approach to management of chronic pain is effective, some patients relapse following successful treatment, back to their previous level of function. This is often referred to the goal violation effect (GVE). The authors of this article write that despite the relapses, little attention has been placed on the reasons why they may occur.

This study investigated the unmet goals in five categories (coping strategies, medication, exercise, social activities, and work). The researchers felt that the GVE could be greater for certain goals than others. The study investigated if patients' attributions to the unmet goals were consistent with the GVE and if the GVE was different depending on the individual unmet goal.

One hundred patients with chronic pain (longer than six months) that interfered with their daily living completed the study. They participated in a four-week program that provided them with a review of pain medications and appropriate adjustment or termination of medications, progressively increasing exercise and physical activity, pain coping and relaxation skills, and psychologic, social, family and vocational issues were identified and treated.

In the final week, issues related to relapse were addressed. The facilitator used an example of a gambler and the high-risk behaviors that can lead to relapse. Coping skills were discussed to encourage study subjects to recognize the issue and to find ways to avoid relapse.

Follow up was six months later; the subjects received in the mail a questionnaire asking them if they had met their goals. If the goals were unmet, they rated them according to why. According to the scoring system, a higher score indicated internal causes, rather than external. A GVE was calculated for each unmet goal.

According to the findings, 46 of the 100 patients failed to meet less than one-third of their goals. Thirty eight failed to meet between one-third and two-thirds, and 16 failed to meet more than two-thirds.

The researchers found that the results were consistent with those from previous studies. Patients who live with chronic pain and who don't meet their objectives, make attributions consistent to the GVE. Interestingly, the attributions differed according to the unmet goal. For example, work and social goals had lower internal attributions than did the other three goals. In fact, work had the highest external attribution because of reasons that were often out of control of the subject.

Since the causes of unmet coping skills, medication, and exercise were mostly internal, patients could end up feeling more guilt and self-blame, which could be the beginning of a cycle that resulted in relapse.

The authors wrote, "Teaching patients how to deal with lapses, flare-ups, and set backs is one component of proposed relapse prevention strategies. Other relapse program components include discussion of the importance of adherence, addressing the patient's understanding of the recommendations, anticipating high-risk situations, encouraging self-monitoring and self-reinforcement, and enlisting the support of others."

In conclusion, the authors noted that the use of cognitive-behavioral relapse prevention strategies have been advocated but not followed through. The results of this study suggest that this type of approach would be beneficial for patients with chronic pain.

Thomas P. Guck, PhD, et al. Attributions Regarding Unmet Treatment Goals After Interdisciplinary Chronic Pain Rehabilitation. In Clinical Journal of Pain. June 2008. Vol. 24. No. 5. Pp. 415-420.

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