Feeling the pain: distraction/relaxation or exposure

It’s not the pain, it’s the judgement of the pain that makes it so distressing – or at least, that’s how the cognitive behavioural model of pain views our experience of pain. As a result, most pain management therapies working to help people manage when their pain can’t be removed involves reviewing how people judge their pain. Of course, we’ve all had experience of pain since we were babies (at least, those of us with normal nervous systems), so we’ve all learned that pain is not something to enjoy and that it’s really something we should avoid. This works well when it’s short-term or acute pain, we learn not to do whatever caused the pain, and we carry on in life a little wiser.

When pain persists, we usually bring this same judgement to bear on the experience. Persistent pain always starts with an acute pain, so it makes sense that our first impulse is to judge it as something negative and to try to get rid of it. It’s just that it doesn’t go away, so the ways in which we deal with it need to change, or we find the pain gets in the way of important things in life like family, work and fun.

There is a fine tradition of learning relaxation techniques in pain management. Relaxation, or self regulation techniques, can help alter the ‘fight, flight or freeze’ response, help a person feel in control, and act as a distraction especially during a flare-up or exacerbation of pain. Used as a ‘first aid’ strategy, it can help the person remain in a situation even when they have a flare-up, and maintain engagement with an activity.

In this interesting, albeit small-scale study by Flink, Nicholas, Boersma & Linton, a group of patients were taught to use relaxation/distraction and ‘a form of interoceptive exposure’ when experiencing pain. The study design involved half the group using relaxation/distraction for three weeks, then crossing over to use the interoceptive exposure (details shortly!) for the second three weeks. The other group did the reverse.

Measures of pain intensity and pain-related distress were taken daily using an 11 point scale (0 = no pain at all; 10 = excruciating pain) for pain, and a six point numeric scale (0 = not at all/never; 5 = absolutely/always).
Acceptance of pain was measured every other week – this was used as a stand-in for experiential avoidance, using the Chronic Pain Acceptance Questionnaire (McCracken et al., 2004). The Pain Catastrophizing Scale (Sullivan, Bishop & Pivik, 1995) was used to measure pain-related catastrophising. The Tampa Scale of Kinesiophobia (Kori, Miller & Todd, 1990) was used to measure kinesiophobia or avoidance of painful movements. Finally, the Quebec Back Pain Disability Scale (Kopec et al. 1990) was used to measure disability

Three months after the programme, the same measures were used to review longer-term effects.

Following a basic education about psychological perspectives of pain and the fear-avoidance model, half of the participants were introduced to relaxation/distraction and half were introduced to the interoceptive exposure technique.
In the interoceptive exposure (IE), a brief explanation and discussion of the basic theory behind the technique was provided during session one. Basically this involved the participants learning to ‘calmly focus’ their attention on their sensations, while doing a usually painful movement (or sitting quietly). They were asked to do this for 15 minutes or until the pain didn’t bother them as much. They were advised that their pain may initially bother them more, but that it would gradually fade, and if they found themselves ‘wandering’ or losing focus, they needed to gently bring their focus back onto their pain for the full 15 minutes.

The relaxation strategy was not described in this study, but participants were given a guided relaxation to use on an MP3 player, and asked to use this and breathing techniques, to ‘calm’ themselves and were asked not to focus on the pain.

I’ve used both of these approaches with patients (and myself!), so I have some personal reflections on how each can be helpful, but firstly, the results from this study.

In the paper, individual ratings are graphed, and regression lines plotted on the graph to enable the reader to see the changes. Regression lines all reduce from baseline, but in three participants the changes are small. Basically, all the participants scores for distress reduce with no difference between the two conditions.
Pain intensity ratings were similarly mixed, with no real difference between the groups.
Acceptance scores similarly don’t show any difference between the groups, but acceptance increased overall.
The measures after three months tend to show ‘relatively large improvements’.

The first observation is that this is a very small, and what’s more, very brief study – yet the findings on the scores are actually quite large, especially in catastrophising and disability. As large as in some full-size pain management programmes in fact. Pain acceptance increased by around 30% from baseline.

Curious. Of course, a small sample size, and that these participants were recruited from a newspaper advertisement rather than the typical pain management centre patient, but it’s still a very tiny treatment compared with the usual offerings. The point is made in the paper that this is a single treatment modality, and it’s rare for just one type of treatment to be tested. Good point – most of the criticism of CBT approaches to pain management currently is that no-one knows the elements that actually ‘do the work’ to create change.

As I reflect on strategies I’ve used for myself during both acute and chronic pain experiences, and on those I’ve helped other people use, I find that to use relaxation I tend to have to be aware of and deliberately let go my attention to the painful area. Perhaps this is part of the interoceptive exposure method – to be aware of and then deliberately let go of the emotional distress/judgement is possibly what happens when learning to be aware of but not allowing the sensation to overwhelm. Food for thought maybe.

Flink, I., Nicholas, M., Boersma, K., & Linton, S. (2009). Reducing the threat value of chronic pain: A preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain Behaviour Research and Therapy, 47 (8), 721-728 DOI: 10.1016/j.brat.2009.05.003

McCracken, L. M., Vowles, K. E., & Eccleston, C. (2004). Acceptance of chronic pain:
component analysis and a revised assessment method. Pain, 107, 159–166.



  1. n a stressful world, everybody deserves to relax. This article would tackle about the importance of relaxation. It is very important since it helps to keep our stress levels down and of course, it improves our health.

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