Original article by Michael Vlessides for Pain Management News, Dec 11, 2018
Boston—Although challenging to master, hypnosis can play an important role as part of a multidisciplinary approach to pain management, even in patients with refractory chronic pain, according to a team of Japanese researchers. By creating what the investigators called “analgesic non-pain experiences,” hypnosis can assist in even the most stubborn pain cases, they said.
“I met a patient [with complex regional pain syndrome (CRPS)] at the beginning of my career in pain treatment, when cognitive-behavioral therapy (CBT) and other treatments were not so effective for those patients,” said Miyuki Mizutani, PhD, a clinical psychologist at Aichi Medical University, in Aichi, Japan. “However, I thought hypnosis might be effective and started to learn the technique. “I’ve now been performing hypnosis for 18 years, and have found it very effective in those patients, though it can be difficult to administer in chronic pain,” Dr. Mizutani continued. “It takes time, and complete remission is not very common. However, our experience is that repeated analgesic experiences can lead to long-term improvements in chronic pain.”
The process of successful personalized hypnosis practice begins with patient selection. Study participants were chosen if they suffered refractory pain after undergoing multidisciplinary pain treatment. These patients were then introduced to a clinical psychologist.
The participants underwent analysis with the Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale and Pain Disability Assessment Scale. Observed biological and psycho-social factors were grouped into 10 domains; voluntary patient experiences during in-session analgesic experiences also were recorded.
The principal hypnosis procedure comprised a number of phases. “Before hypnosis induction, we speak at length about the patients’ pain experiences,” Dr. Mizutani explained. “At that time, the pain experience comes into their consciousness; and during the conversation, some part of their pain experience is changed.”
As part of the hypnosis process, the practitioner facilitated nonpain body sensations and muscle relaxation in the patient. As the trance deepened, the practitioner offered somatic suggestions such as breathing, proprioception and/or ideomotor responses. Patients in the study underwent biweekly or monthly 60-minute sessions.
Reporting at the 2018 World Congress on Pain (abstract PFR560), the investigators revealed that 121 patients agreed to hypnosis, whereas 40 declined; those who agreed to hypnosis were significantly more likely to be anxious. Of note, hypnosis was readily accepted by patients with certain chronic pain conditions, including phantom limb pain, cancer-related pain, headache or orofacial pain, and visceral pain (Figure). Patients who accepted hypnosis also were significantly younger than their counterparts who declined.
To help quantify improvements in patient pain, the clinicians categorized their relief as “in-session analgesia” (relief occurring during a hypnosis session with a pain management practitioner) and “out-of-session analgesia” (relief that occurred extended into the patients’ daily lives). The study found that 71% of patients who agreed to hypnosis (n=86) experienced in-session analgesia. Several factors found to be associated were successful in-session analgesia, including a greater number of years having suffered pain, lower scores on the Pain Disability Assessment Scale and lower levels of intrinsic motivation.
Among the patients who experienced in-session analgesia, 65% (n=56) saw their pain relief extend beyond the session, and were thereby classified as out-of-session analgesia. Among these, a lower number of bio-psychosocial factor domains were significantly associated with successful out- of-session analgesia. These individuals also were significantly more likely to have mastered self-hypnosis, Dr. Mizutani added.
Treating the ‘Untreatable Part’ Of Chronic Pain
Despite these results, the researchers were quick to note that successful treatment of CRPS pain with hypnosis requires significantly more sessions than other forms of pain. Indeed, patients who experienced successful in session analgesia required a mean of 3.75±3.85 sessions (range, one to 20). Those whose pain relief extended to out-of-session analgesia required a mean of 4.35±6.30 sessions after the drst in-session analgesia (range, zero to 35).
Classifying exactly how hypnosis works for these patients is another challenge. As Dr. Mizutani explained, in-session analgesia is a distinct analgesic experience, and not simply an alteration of patients’ pain sensation or a distraction from their pain. “A non-pain experience becomes an analgesic non-pain experience when it shares the ‘neural network’ with the pain experience, competes with it, and wins it over in a focused and narrowed consciousness during hypnosis,” she told Pain Medicine News. In the end, Dr. Mizutani believes hypnosis can be an important part of a multidisciplinary approach to treatment in people with chronic pain. “These patients have all undergone multidisciplinary pain treatment, including medication, physiotherapy and CBT,” she added. “And ultimately, they did not respond completely to those treatments. So we believe the untreatable part of the pain can be treated by hypnosis.”
A systematic review presented at the meeting (abstract PST451) demonstrated the efficacy of hypnosis in pediatric patients suffering from cancer pain. Investigators at St. Jude Children’s Research Hospital, in Memphis, Tenn., included a total of 17 articles in the review, comprising 12 randomized controlled trials and five non–randomized controlled trials with sample sizes ranging from 12 to 80 patients.
The analysis concluded that scientific evidence supports the preliminary efficacy of hypnosis in pain, distress and symptom management among youth undergoing cancer treatments. These benefits extended to procedure related pain and anxiety as well as chemotherapy-related nausea and vomiting.
As Mark P. Jensen, PhD, a professor of rehabilitation medicine at the University of Washington, in Seattle, explained, most pain patients get at least some relief when employing hypnosis. “Hypnosis can be extremely beneficial for some patients, moderately beneficial for others and have limited beneficial effects in others,” Dr. Jensen said. “Almost everyone reports some benefit, however.”
Yet, as Dr. Jensen went on to discuss, there are several important considerations with such treatment, including the recognition that there is nothing “magical” about hypnosis. “When people are invited to focus their minds and are with someone they trust, they are more open to suggestions, and this includes suggestions for comfort, being able to ignore pain and experiencing improved sleep, among many others,” he said. “It is also useful to remember that every patient responds differently to hypnosis treatment,” Dr. Jensen continued. “As a clinician, it is best to approach it with curiosity, wonder just how each patient will respond and try to maximize outcomes consistent with each patient’s goals. It’s useful to think of hypnosis as a skill set that patients learn to get more control over their own responses, including their pain responses.
“Finally, it is important for patients to obtain this treatment from someone who is a licensed health care provider,” he added. “There are many ‘hypnotherapists’ that have a hypnosis practice who are not otherwise licensed as health care providers.”