Susan ayers cambridge handbook of psychology he

and trunk extension and flexion exercises (Burns et al., 2000;
Crombez et al., 1999; Fritz et al., 2001; McCracken et al., 1992;
Nederhand et al., 2004; Picavet et al., 2002; Swinkels-Meewisse
et al., 2003; Verbunt et al., 2003; Vlaeyen et al., 1995). These
findings are particularly impressive given that they have been
obtained even after controlling for important variables which
might explain adjustment to pain such as pain intensity and
duration.
Comment
The consistency of findings emerging from studies of the fear–
avoidance model is impressive. This model is clinically useful
because it links well to exposure-based interventions (see
‘Behaviour therapy’). These interventions teach patients to
overcome pain-related anxiety and fear through graded exposure
to a series of pain-related fears. Preliminary findings from studies
using single case designs suggest such interventions are helpful in
reducing pain-related anxiety, disability and increasing activity level
in patients with chronic low back pain (Vlaeyen et al., 2001; Vlaeyen
et al., 2002). Controlled studies are needed to test the efficacy of
such interventions with larger samples of chronic pain patients.
Future research also needs to examine the degree to which the
fear avoidance–model is useful in understanding the adjustment
to disease-related pain (e.g. pain due to arthritis or cancer.)
The acceptance model
Recently, there has been growing interest in acceptance as a
pain coping approach (McCracken et al., 2004). Interest in acceptance
comes from the clinical observation that the lives of many
patients having persistent pain are dominated by the struggle to
control a problem that is in part uncontrollable. There is growing
recognition that maladaptive efforts to control or avoid pain can
exacerbate pain and lead to heightened suffering and disability
(Asmundson et al., 1999; McCracken et al., 1996).
Recent studies of acceptance and persistent pain have utilized the
Chronic Pain Acceptance Questionnaire (CPAQ; Geiser, 1992), a reliable
and standardized measure which assesses two dimensions of
acceptance: a) willingness to experience pain – the absence of
attempts to reduce or avoid pain; and b) activity engagement –
the extent to which a person actively pursues valued life activities.
McCracken et al. (1998) found that patients who scored higher on
this measure not only had significantly lower levels of pain-related
anxiety and depression, but also had lower levels of disability.
These findings regarding acceptance were particularly noteworthy
in that they were apparent even after controlling for pain intensity.
McCracken and Eccleston (2003) compared the predictive utility of
the CPAQ and a commonly used pain coping measure (the Coping
Strategies Questionnaire) and found that the CPAQ accounted for
almost twice as much variance as coping variables in explaining
pain, disability, depression, uptime and work status. Finally, a
recent study found that acceptance of pain was predictive of fewer
health care visits for pain and pain medication intake (McCracken
et al., 2004).
Comment
Although the acceptance model of coping with pain is relatively
new, it appears to have promise in fostering our understanding
of adjustment to pain. Recent promising findings regarding this
model have generated renewed interest in acceptance-based
intervention protocols, such as the mindfulness-based stress
reduction protocol developed by Kabat-Zinn and his colleagues
(1985). To date, no rigorous randomized clinical trial has been
conducted to assess the efficacy of acceptance-based interventions
for patients having persistent pain. Also, the utility of the
acceptance model has largely been examined in patients
having chronic pain syndromes (e.g. chronic low back pain) and
the utility of this model for disease-related pain conditions is
unknown.
General conclusions
Coping efforts which focus on thinking rationally about pain
and taking concrete cognitive and behavioural steps to control
pain seem to be the most efficacious methods for chronic pain management.
Coping strategies which lead the individual to withdrawal
or become passive when dealing with pain appear to be the least
effective pain management techniques. Research has clearly shown
that effective coping can help the chronic pain sufferer to manage
pain and maintain higher levels of psychological health.
Intervention and treatment programmes which help patients learn
new ways of coping with pain have met with considerable success
(Keefe et al., 2004).
Our understanding of the ways in which individuals cope
with chronic pain and relationships of coping to psychological,
physical and behavioural adjustment is not complete. Research in
this area is currently exploring the usefulness of new assessment
methods such as daily coping diaries and interviews that ask
patients to describe, in detail, the thoughts and behaviours which
they engage in when coping with pain. In addition, research is
now examining the relationships between pain and coping over
longer periods of time. Some coping methods may not impact
adjustment in the short term but may contribute to disease progression
and quality of life over many years time. Chronic disease is now
the leading cause of death for individuals in most industrialized
nations (see ‘Coping with chronic illness’) and chronic pain plays
a central part in many of these conditions. Future research in
this area will help pain researchers and clinicians to design programmes
to help individuals learn how to cope with chronic, painful
disease.
Acknowledgements
Preparation of this chapter was supported, in part, by the following
grants from the National Institutes of Health: NIAMS AR 46305,
AR047218, P01 AR50245, NIMH MH63429; Cancer Institute grants:
R21-CA88049-01, CA91947-01, National Institute of Neurological
Diseases and Stroke grant: NS46422 and by support from the
Arthritis Foundation and Fetzer Institute.
Coping with chronic pain 53