The practice of pain management has expanded exponentially over the past 150 years—from the introduction of opioids, advances in surgical intervention, and the introduction of electromedical devices,1 to our understanding the psychosocialbiological model of pain management.
However, even with these advances, only 25% of patients with chronic neuropathic pain do better after 1 year of treatment.2
Therefore, pain physicians may have to look beyond the “conventional” medical toolbox to help their patients cope with chronic pain. In this article, I review the rise of one area of alternative treatment—that of guided imagery, mindful meditation, and hypnosis.
History of Hypnosis
The concept of hypnosis and psychophysiology really began with Franz Anton Mesmer (1783-1815), a scientist who theorized that the “tidal” influences of the planets also operate on the human body through a universal force, which he termed “animal magnetism.”3 His work led him to experiment with altering gravitational tides in the body (hypnotic suggestion) to treat painful maladies, but his showmanship led to distain from his medical colleagues.
James Braid (1795-1860) is often credited as being the “Father of Hypnotism” for moving “mesmerism” from the occult into medical practice.4 Despite his excellent work, and considerable additional investigations by numerous other psychologists and physicians, hypnosis was not accepted widely until the mid-20th century.
At the beginning of the 20th century, physicians throughout Europe began seriously investigating hypnosis, but were often rejected by their peers. In 1902, James Esdaile, a British surgeon working in India, performed hundreds of surgical operations on mesmerized patients.5 Despite the success of the operations, most of Esdaile’s peers remained skeptical of mesmerization.
By 1912, a German psychiatrist, Johannes H. Schultz, was quite successful at hypnotherapy. However, he did not like the fact that patients became dependent upon him to go into a trance. Questioning patients as they descended into deeper states of hypnosis, Schultz concluded that patients could self-hypnotize by repeating certain phrases and imagery. His first book on Autogenic Training was published in 19326 and in 1969 the first of 6 volumes on the practice was published with co-author Wolfgang Luthe.7
With 2,600 scientific references, the authors concluded that 80% of stress-related illnesses could be well-controlled with Autogenic Training (Table 1). They reported great success in treating headache, back pain, depression, anxiety, and hypertension. In addition, students, athletes, and even business executives were said to have achieved considerable improvement in their activities.
Despite fairly widespread use of hypnosis by some psychologists and a few psychiatrists, the major impetus for a significant increase in professional interest in the field was the development of biofeedback training by Elmer Green, MD, in the early 1970s. Interestingly, Green initially called the technique autogenic feedback, and he included the imagery associated with the basic autogenic phrases.8 In 1973, after hearing about his 84% success rate in migraine patients, I asked him about its use in back pain. He said: “Buy yourself some equipment and try it.”
Over the next few years, I tried electroencephalography (EEG), temperature, Galvanic Skin Response, and electromyography (EMG)-guided muscle tension biofeedback, always including appropriate guided imagery, and most often accompanied with relaxing background music. Over the next 4 years, 195 patients were treated with a comprehensive 2- or 3-week biofeedback-guided imagery program.
All of the patients were severely disabled with chronic pain, mostly the result of failed back surgeries. Upon completion of the program, 80% of patients were able to discontinue pain medication, with marked increase in physical activity, marked improvement in mood, and pain reduction of 50% to 100%. Follow-ups visits conducted at 1- to 2-years revealed a 60% long-term improvement.9
Meanwhile, Wilbert Fordyce, MD, published his work on Operant Conditioning.10 Over a 5-year period, he had enrolled 100 chronic pain patients, mostly from failed back surgeries, in a 2-month inpatient program. Fordyce’s protocol included:
- Withdrawal of all pain and mood drugs
- Pain complaints and behavior were ignored
- Patients were assigned minor physical activity, such as walking, sitting for specific and increasing periods of time
- No physical therapy or psychotherapy
The program cost $5,000 and Fordyce stated that a 10% success rate would allow the insurance system to recover their costs because of the high medical costs of these patients. He reported an initial 60% success rate with significant decrease in pain, improvement in activity, and freedom from medications. However, at 6 months, only 40% of the men and 25% of the women maintained this improvement.
In 1975, Herb Benson’s book Relaxation Response opened the door to a broad variety of alternative approaches.11 Since then, the variety of tools for relieving pain has multiplied exponentially. Options now include guided imagery, biofeedback, self-hypnosis, meditation, music therapy, and yoga.
Evidence for Guided Imagery and Meditation
Since 1980, a number of studies have shown the efficacy of guided imagery and relaxation in a variety of pain conditions. I will present an overview of some of these studies:
Twenty-four patients undergoing cholecystectomy were randomly assigned to receive either guided imagery or a quiet period (controls). The investigators assessed 3 measures of recovery: state anxiety, levels of urinary cortisol, and wound inflammatory responses. The guided imagery group demonstrated significantly less state anxiety, lower cortisol levels 1 day following surgery, and less surgical wound erythema than the control group.12
Cupal et al reported that 10 sessions of relaxation and guided imagery after anterior cruciate ligament (ACL) reconstruction significantly improved knee strength, pain, and anxiety, and decreased reinjury.13 The authors concluded: “Relaxation and imagery may be beneficial to ACL rehabilitation.”
Lambert reported significantly less pain, shorter hospital stays, and decreased anxiety after surgery in 52 children treated with guided imagery.14 The therapy included asking children to visualize a successful procedure.
Guided imagery significantly improved postoperative pain, anxiety, and opioid use in patients after colorectal surgery.15 Although patients entered the study with identical levels of anxiety, those who underwent guided imagery reported less anxiety immediately before the procedure, whereas patients in the control group reported an increase in anxiety (P<0.001). Patients in the imaging group also reported less pain, and required fewer opioids postoperatively, than those in the control group (P<0.001).