Publications

APS Bulletin • Volume 14, Number 2, 2004

Pain Clinic Perspectives

Steven Sanders, PhD, Department Editor

Operant Therapy: Evidence for Its Effectiveness

Steven H. Sanders, PhD

Editor’s Note:This is the first in a series of summaries of articles published in Seminars in Pain Medicine, Volume 1, 2003, edited by Allen Lebovits, PhD. This issue of the journal reviews most of the mainstream psychological/behavioral interventions used with pain patients today, with an emphasis on critiquing the scientific evidence supporting their use. Application of these methods to children and as part of an interdisciplinary pain treatment program also is critically reviewed. As Dr. Lebovits highlights in his introduction, “Only through an evidence-based approach can the specialty of pain psychology be advanced, and, more significantly, patients suffering from pain can be helped.”

In keeping with the increasing demand for empirical documentation on the efficacy of treatments across disciplines that treat pain patients, psychological/behavioral interventions also must be subject to scrutiny. The articles in Seminars in Pain Medicine, Volume 1, summarized here and in future APS Bulletin issues, provide up-to-date information that reviews and critiques the empirical science behind psychological/behavioral treatment for pain patients. The APS Bulletin editorial staff extends thanks to Dr. Lebovits for his help in arranging for the publication of these summaries and to Elsevier, the publisher of Seminars in Pain Medicine, for giving permission to do so.

As always, comments and thoughts are encouraged and welcomed. Please send your correspondence to ssanders@siskinrehab.org.

This article summarizes a recently published review (Sanders, 2003) of the basic learning/conditioning model for clinical pain, and the empirical evidence supporting this model, with a focus on operant conditioning. Since the early work of Fordyce and his colleagues in the 1970s, operant conditioning concepts and strategies have played a major role in our understanding and treatment of pain. These concepts are based on more than 50 years of empirical science that have demonstrated virtually all voluntary, and most emotional, behaviors can be influenced significantly by their contingent consequences and the surrounding environmental context in which they occur. The application of operant conditioning with pain patients draws upon this rich scientific basis, and focuses mainly on changing overt pain behaviors through the systematic manipulation of environmental consequences (rewards and punishments) and associated discriminate stimulus conditions.

Learning and Conditioning Concepts

The operant conditioning approach to clinical pain is part of a more general interactional/mixed model of learning involving operant, respondent, and observational learning/conditioning effects. With this approach, clinical pain in its entirety can be defined as an interacting cluster of individualized overt, covert, and neurophysiological responses capable of being produced by relevant tissue damage or irritation, and also produced and maintained by other antecedent or consequent stimulus conditions. Table 1 delineates this pain response conceptualization with examples. The gross motor responses in Table 1 have been the focus of operant conditioning methods with pain patients.

Evidence for Operant Conditioning

There have been a number of excellent controlled outcome studies on operant and other behaviorally based therapies during the past 25 years. In general, these therapies have been applied to chronic painful conditions of 3 months’ duration or longer. The majority of studies have focused on chronic low-back patients. Treatment has included operant methods, alone and in combination with other treatment strategies, applied to inpatients and outpatients. Some 30 studies, 15 being prospective, randomized, controlledoutcome studies with follow-up from 6 to 12 months, provide strong empirical evidence for the application of operant conditioning therapy for chronic low-back-pain patients. Clinically significant improvement has been shown in function and activity, as well as a reduction in the use of analgesics and in subjective pain intensity ratings. In contrast, there is a lack of research on the efficacy of operant methods with other chronic painful conditions, acute pain states, cancer pain states, pediatric and geriatric pain patients, and pain across cultures.

Conclusions

Operant therapy has strong empirical support for use with chronic low-back-pain patients. In clinical practice, this is typically applied within the context of an interdisciplinary treatment protocol; however, the evidence demonstrates operant conditioning can be used as standalone treatment for certain low-back patients. Sufficient research to determine its efficacy with other types of acute and chronic pain has yet to be conducted.

Reference