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15 Psychosocial and Behavioral Approaches

15 Psychosocial and Behavioral Approaches
The Massachusetts General Hospital Handbook of Pain Management

15
Psychosocial and Behavioral Approaches

David K. Ahern

The pain of the mind is worse than the pain of the body.
—Publilius Syrus (1st century BC)

I. Psychosocial aspects: Depression, anxiety, and fear
II. Clinical interview: behavioral analysis, pain behavior, medication use, and disability

1. Clinical interview

2. Paper-and-pencil measures
III. Nonpharmacologic interventions

1. Modification of verbal behavior or pain behavior

2. Increased activity level

3. Somatic therapies

4. Cognitive interventions
Acknowledgement
Selected Readings

I. PSYCHOSOCIAL ASPECTS: DEPRESSION, ANXIETY, AND FEAR
It is well established that the experience of chronic pain can have serious adverse consequences for the psychological, social, and economic well-being of patients. Pain that becomes persistent following an acute injury places the patient at risk for depression, anxiety and fear, personality changes, and lifestyle disruptions that can be devastating, not only to the patient but to his or her family as well. For example, it has been estimated that 60% or more of patients with chronic pain are at risk for development of clinically significant depression, which complicates medical assessment and treatment of the pain per se. Depression can distort, color, and confound the pain experience such that the patient reports pain as excruciating and overwhelming (often using affect-laden terms to describe the pain), resulting in a nonanatomical presentation of symptoms, diagnostic uncertainty, and frustration for the clinician.
Anxiety and fear are equally common psychological and behavioral disturbances associated with chronic pain. In fact, a fear-avoidance model has been promulgated to help explain the progression from acute to chronic pain syndromes. Figure 1 presents the fear-avoidance model that illustrates the path from initial injury and acute pain to chronic pain and associated psychological disturbance and disability. For most patients, the course is one of relatively short-term pain that resolves. If, however, pain from an initial acute injury is perceived as threatening and a cognitive process of catastrophizing develops, pain-related fear will emerge. Subsequently, this pain-related fear leads to avoidance behaviors, a heightened awareness, and a focus on bodily sensations followed by disability, disuse, and depression.

Figure 1. The “fear avoidance” model. If pain, possibly caused by an injury, is interpreted as threatening (pain catastrophizing), pain-related fear evolves. This leads to avoidance behaviors and hypervigilance to bodily sensations, followed by disability, disuse, and depression. The latter will maintain the pain experience, thereby fueling the vicious circle of increasing fear and avoidance. In noncatastrophizing patients, no pain-related fear and rapid confrontation with daily activities is likely to occur, leading to fast recovery. Pain catastrophizing is assumed to be influenced also by negative affectivity and threatening illness information. (From Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain 2000;85:317–332.)

For the patient, the chronic pain experience, if untreated or managed inappropriately, can lead to substantial and sustained emotional distress, psychological difficulties, and progressive impairment and disability. The extent of a patient’s disability is often greater than the documented medical and physical findings would support. This observation is not so surprising, however, when considering that psychosocial and behavioral factors can help to explain symptom amplification and disability disproportionate to the available medical findings, as predicted by the fear-avoidance model. Thus, in the clinic setting, assessment of psychosocial and behavioral factors are as important to understanding a patient’s pain experience and disability as the medical history and physical examination.
II. CLINICAL INTERVIEW: BEHAVIORAL ANALYSIS, PAIN BEHAVIOR, MEDICATION USE, AND DISABILITY
1. Clinical interview
A semistructured clinical interview is conducted to obtain detailed information related to psychosocial and behavioral aspects of the chronic pain problem. Attention is given to relationships between individual aspects of the pain experience, and data obtained are combined with supplementary data from medical chart review and standardized assessment instruments in individualized treatment planning and recommendations. Whenever possible, the interview is conducted with both patient and spouse or significant other to obtain a more complete picture of functioning and impact of pain on the marital relationship and family unit.
Behavioral analysis is the framework within which the clinical interview is conducted. This approach focuses on the contingencies of reinforcement, which serve to maintain or promote pain-related dysfunction. For example, a patient may exhibit increased pain complaints (i.e., pain behavior) in the presence of his or her spouse in part because the spouse has become associated with administration of pain relief procedures (e.g., massage). Likewise, a patient may report greater pain in anticipation of returning to work if the work environment is perceived as punitive. A behavioral analysis will identify the extent of depressive, anxiety-related, and fear-related symptoms and the degree to which these symptoms contribute to avoidance of activities and disability.
(i) Pain characteristics
The primary starting point is a focus on the actual pain complaint and its description. Location, intensity, duration, and fluctuations in actual pain patterns are assessed. Subjective descriptors (e.g., “dull,” “throbbing,” “shooting,”) should be noted. The use of affective descriptors, as well, is important in obtaining a more thorough understanding of the patient’s emotional response to his or her pain.
Self-report pain scales are another commonly used method of assessing the individual’s pain experience. The patient is asked to rate his or her pain on a scale (from 0 to 10, e.g.) for a given time period, either at that moment or for a specified time period such as an hour, a day, or longer. In the initial assessment, pain ratings are usually obtained for current pain level as well as the range of pain experience.
Determining overall parameters of pain leads naturally into elaboration of influencing factors: for example, those activities associated with pain exacerbation, and those activities or factors associated with pain relief, even if only temporary. Close attention is paid to both of these areas, as important information about the extent to which environmental or operant factors may play a part in the pain syndrome can be identified here.
(ii) Pain behavior
Paying attention to the patient’s verbal and nonverbal behavior is also very informative. Besides the use of pain descriptors, patients may communicate the extent of suffering by grimacing, groaning, or moaning, and by frequent postural shifts during the course of the interview. These behaviors are considered to be reflective of the patient’s pain experience; consequently, they are conceptualized as pain behaviors. Frequently, patients call attention to their suffering by pointing out their behavior or excusing themselves for it to the clinician. In other patients, these behaviors have become automatic aspects of their self-presentation and are not acknowledged. Some patients evidence the grimacing, guarding, or verbalizations but do so to a much lesser degree.
Still other individuals evidence very little or no pain behavior. In these patients, particularly, it is important to note any discrepancies between their verbalized reports of pain or distress, and their appearance. Pointing out such discrepancies to the patient can yield useful information about the patient’s preferred coping style, as some patients will acknowledge that they have pain but choose not to show it, whereas other individuals sometimes become rather defensive at the perceived questioning of their self-report. Clearly, the clinician must exhibit good judgment as to the appropriate timing and extent of questioning along these lines.
(iii) Medication use
Evaluation of medication use patterns can alert the clinician to problematic aspects of medication use that may in turn contribute to a worsening pain problem. These patterns are as follows:

Increasing frequency or quantity of medication use without related improvements in pain level (suggests habituation)

Multiple pain prescriptions from multiple providers; combining use

Signs of withdrawal symptoms with reduced or discontinued use of pain medication

Recurrent emergency room visits with resultant dispensing of medication

Prior or current history of alcohol or substance abuse

Medication used primarily for mood—rather than pain-altering effect (e.g., reduced anxiety, feeling “high”)

Medication use results in decreased activity or cognitive functioning

Discrepancies between patient-reported use and other information sources (medical records, spouse report)
(iv) Functional disability
Assessment of functional disability consists of determining the activities that the patient avoids or that are limited by pain. A useful technique in helping formulate a picture of the patient’s current functional level is to ask him or her to describe a typical day in as much detail as possible. For example, time of awakening, getting dressed, eating breakfast (including type and amount of meal, who prepares it, and kitchen cleanup), and reading the paper might be noted as standard daily routines. The amount of time required to complete each activity is also important to ascertain, as for some patients the general routine might take 45 minutes, whereas for others it could take 2 hours.
When patients with pain lose a sense of structure to their day and have many hours to fill, it is not uncommon to find that a good amount of the day is spent lying down or resting. For these patients, treatment might focus on increasing the range and scope of daily activities in order to increase physical endurance as well as combat depressive syndromes resulting from inactivity and loss of reinforcing activities or social interaction. Alternatively, some individuals have full, if not hectic, schedules with few or no rest periods. Still others exhibit a pattern of prolonged periods of inactivity and “recovery” from sporadic bursts of high activity. Again, the treatment is based on the individual’s stated level and pattern of activity.
2. Paper-and-pencil measures
The role of standardized assessment instruments in chronic pain evaluation is crucial. An instrument can provide detailed self-report information about an individual’s specific condition (helpful in providing a quick overview of the patient’s problem as well as in providing reliability and validity checks on verbal interview data), and in many cases the patient’s responses can be compared to existing norms to assess where the individual lies in relation to other patients with the same or similar problems. In addition, previous research can highlight the probability of success or appropriateness of a given treatment protocol or approach.
A number of instruments are commonly used to evaluate psychosocial and behavioral aspects of chronic pain syndromes:
(i) Sickness impact profile
The Sickness Impact Profile (SIP) is one of the most widely used measures of health status in pain clinics. It consists of 136 items, in checklist format, that assess the impact of health problems on 12 areas of functioning: ambulating, mobility, body care and movement, social interaction, communication, alertness, emotional behavior, sleep, eating, work, home management, and recreation. It is scored to form three composite scales: physical, psychosocial, and total (which includes physical, psychosocial, and work and recreational pastime information). Its reliability and validity as a measure of dysfunction in pain patients has been well established.
(ii) Pain and impairment relationship scale
Because attitudes, beliefs, and expectations have been implicated in determining response to pain rehabilitation, the patient’s beliefs regarding his or her pain must be assessed. Often, as a result of lengthy and unsuccessful (or unsatisfactory) treatment, patients can develop beliefs and expectations that can complicate further treatment efforts. One such belief is that they are unable to live normal, productive lives as long as they experience pain.
The Pain And Impairment Relationship Scale (PAIRS) was developed to assess the extent to which patients with chronic pain believe that they cannot function normally because of their pain. It is a 15-item measure designed to assess the degree to which patients perceive their functional status as related to their pain level. Each statement measures a given thought, attitude, or opinion about pain. Patients endorse each item along a seven-point Likert-type scale (i.e., strongly disagree to strongly agree). Responses are summed to obtain an overall score. High scores indicate a person’s greater tendency to equate pain with impairment, and to restrict functioning when pain is present.
(iii) Multidimensional pain inventory
The Multidimensional Pain Inventory (MPI) is a comprehensive 52-item self-report measure of pain and pain-related characteristics including pain severity, interference with activity, affective distress, and support or concern from significant others. The measure has good reliability and validity and has been used to assess change with pain treatment.
(iv) Coping strategies questionnaire
The Coping Strategies Questionnaire (CSQ) is a 50-item questionnaire that assesses the range of ways that patients cope or deal with their pain. It is designed to assess seven coping strategies: diverting attention, reinterpreting pain sensation, use of coping self-statements, ignoring pain sensations, praying and hoping, catastrophizing, and increasing activity level. The CSQ helps to identify patients who tend to catastrophize or use fewer adaptive coping strategies for dealing with their pain.
To conclude, it is clearly important to determine the contribution of psychosocial and behavioral factors to a patient’s pain complaints in order to conduct an adequate chronic pain evaluation. As important, identifying relevant psychosocial and behavioral factors will very likely increase the potential for a more favorable response to medical management, because these factors have been found to contribute to protracted symptoms and disability and to poor response to interdisciplinary treatment. Indeed, psychosocial and behavioral factors have been shown to be better predictors of treatment outcome than either medical or physical factors. Table 1. presents a summary of potential psychosocial and economic predictors of response to treatment.

Table 1. Summary of potential psychosocioeconomic predictors of response to treatment

III. NONPHARMACOLOGIC INTERVENTIONS
Intervention is predicated, in part, on the patient’s willingness to accept learning how to better manage pain and attaining maximal function despite residual pain. Overall goals of treatment are as follows:

1.
Reduction of pain behavior and the degree to which pain is a focus

2.
Increased activity level and functional capacity

3.
Reduction of distress and the attendant emotional suffering

4.
Rearranging contingencies to pain behavior by family and significant others
1. Modification of verbal behavior or pain behavior
A primary treatment goal is to decrease pain behavior and related dysfunctional behaviors while increasing functional activities and “well” behaviors. Often, specific pain behaviors targeted for elimination or reduction are enumerated in a treatment contract filled out and signed by both patient and therapist during the second session. More adaptive behaviors targeted for increase are likewise specified in the treatment contract.
Most commonly seen is an increase in pain behaviors such as facial grimacing, groaning, guarding, and frequent postural shifts. Concomitant behaviors not apparent on clinical exam are related decreases in previous levels of activity. These include, but are not limited to, reductions in work (either at home, at the office, or on the job site); recreational activities such as hobbies, sports, family interactions, and sex; and broader-based social interactions, such as family and friend involvement. Amount of time spent in or out of bed (up-time) provides another good indicator of current activity level. To the extent that these behaviors have come under the influence of external factors, behavior modification designed to eliminate or reduce their frequency is an initial target of treatment.
Typically, reduction in pain behaviors is achieved through use of learning theory techniques. For example, the therapist and members of the treatment team ignore pain behavior. Moans, pain complaints, grimacing, and guarding are not responded to, nor does treatment staff engage in talk about pain-related behavior or activity except when medically indicated (new symptoms suggestive of objective changes in health status such as neural involvement, for example). Instead, the staff reinforces the patient for gains made in his or her exercise program, time spent walking, or time out of bed, for example. Emphasis is on gains in function, with increased independence despite pain.
2. Increased activity level
The patient is reinforced for meeting functional activity goals, which can include decreasing “down” time as well as increasing repetitions of exercises and engaging in other functional activities such as walking or increasing social interactions. This is accomplished through a variety of techniques, as described in the following sections.
(i) Self-monitoring, or behavior charting
Patients are encouraged to keep records of their activities on a daily basis. Such events as relaxation sessions (complete with before-and-after ratings of both pain and tension) are recorded, as are physical therapy exercises. Time spent walking, or engaging in social activities is also noted. Again, emphasis is on noting patterns of behavior, with expected increases in functional and positive activities with concomitant decreases in dysfunctional behaviors (e.g., inordinate bedrest, social isolation). Patients quickly begin to be able to track their own activity patterns and progress once they have become accustomed to self-monitoring. Treatment sessions use the logs, or patient notations, to pinpoint problem areas and find solutions, or to reinforce patient gains and initiative. During later treatment phases, activity logs can be used as a goal-setting aid, with progressive increases in those behaviors leading to goal attainment.
(ii) Goal setting
Initially, goal setting serves as a means of preparing the patient for behavior change and as an educational tool. Patients learn the basic principles of taking an activity and breaking it into manageable and achievable behaviors. For example, “going out to dinner” involves building sufficient sitting tolerance to handle a multicourse meal. As skills are acquired, behaviors are shaped to resemble the goal (meeting a friend for coffee). Finally, goals are met, and new ones building on old skills are set to take their place. Not all goals involve purely physical activities—increasing contact with friends or former colleagues, job seeking, and socializing all serve to increase functioning of the patient.
(iii) Pacing
Being able not only to regulate the type of activity in which one engages, but also to determine appropriate timelines for doing so is addressed in teaching pacing. Patients learn to engage in certain behaviors for set periods of time to prevent overdoing (i.e., sitting in front of the computer for 25 minutes, then taking a 2- to 5-minute break before returning). Breaking a large task into smaller components is another method of pacing; for example, preparing a meal in phases rather than waiting until dinnertime.
(iv) Health care utilization
Treatment also encourages a reduction in the amount of pain-related office and emergency room visits, number of surgeries, and number of pharmacists contacted. This objective is achieved through coordination and communication among all members of the treatment team, so that the patient receives consistent messages and treatment approach from all relevant care providers.
MEDICATION INTAKE. Patients with chronic pain frequently use a variety of pain-relieving medications. Treatment focuses on appropriate medication reduction. Again, medication reduction is usually accomplished within the framework of increased strength, endurance, and physical capacity training, as well as with relaxation, stress management, and pacing skills utilization. After the initial assessment period, the patient’s schedule for taking pain-related medications is shifted, if necessary, from an activity- or pain-contingent basis to a time-contingent system. This lays the groundwork for breaking the learned association between the occurrence of pain and automatic medication use.
Concurrently, either the prescribing physician decreases the dosage (the strength or amount prescribed per allotted time period), or the patient is encouraged to decrease dosage within preset limits established in consultation with the physician, the behavioral medicine psychologist, or both. The desired goal of this aspect of treatment is to achieve as great a reduction as reasonably possible in the patient’s medical regimen, especially in opiate or narcotic use. Understandably, some patients require some degree of ongoing analgesic use, but others are able to eliminate these drugs entirely or switch to less habit-forming medications.
3. Somatic therapies
Progressive muscle relaxation is a deep relaxation technique that is designed to help teach the patient awareness of overall muscle tension levels and to maintain relaxation baselines at low levels, rather than letting muscle tension build throughout the course of the day or a particular activity and in this way exacerbate the pain.
Additional benefits of engaging in deep muscle relaxation are increases in peripheral circulation and a heightened sense of body awareness that can cue appropriate pacing or coping measures. Finally, some patients report that taking a few seconds out between sets of physical therapy exercises to relax their worked muscles is a helpful pacing technique.
Three basic approaches to muscle relaxation are taught in pain clinics. Although the overall desired result is the same, techniques differ. Basically, the three techniques are progressive muscle relaxation, autogenic muscle relaxation, and diaphragmatic breathing.
(i) Progressive muscle relaxation
In this technique, after beginning with several deep breaths, the patient alternately tenses, holds, and then relaxes groups of muscles in his or her body. Attention is paid to the sensations of tightness felt while contracting and tensing the muscles, and this is then compared to the sensations produced by sudden and immediate relaxing of those muscle groups.
Patients are instructed to pay attention to the sensations of warmth, heaviness, and relaxation in their body, and to review each muscle group individually, spending some (but not too much) additional time on problem areas.
Over several weeks (usually 2 to 4, if patients have been compliant with at-home practice sessions), the number of individual muscle groups addressed decreases as patients tense the entire leg instead of upper and lower individual components, the entire arm instead of upper and lower parts, and so forth. Patients will be able to relax just as deeply with this streamlined technique as with more detailed one.
(ii) Autogenic relaxation
DIAPHRAGMATIC BREATHING. This technique is similar in many respects to muscle relaxation, but it is favored by some therapists for its relative ease of learning and quickness of implementation, as well as its “portability.” The only specific instruction the therapist needs to make to the patient is teaching where the diaphragm is located. The therapist lets the patient practice feeling his or her chest expanding as diaphragmatic breathing takes place. (Some patients find it interesting to hear that this is the type of breathing frequently practiced by professional singers, not just patients who are experiencing stress or in chronic pain.)
4. Cognitive interventions
Cognitive-behavioral treatment typically includes restructuring cognitive schemata that may perpetuate excessive pain and disability. Among these are general beliefs (such as those assessed by the PAIRS) that increased pain levels automatically call for cessation of activity, and that pain is linked invariably with impairment as well as self-defeating and catastrophizing self-statements, such as “Oh, no, here it comes again! Why won’t it stop? I can’t do anything about it. This is terrible!” Additional emphasis is placed on teaching cognitive techniques directed specifically at coping with the pain. Among these are the following:
(i) Attention/diversion
The patient is taught to divert attention away from pain sensations by focusing on activities, behaviors, and thoughts that require redirection of effort. Encouraging physical activities, for example, shifts from somatic preoccupation, provides incompatible behavior, and provides reinforcing activity, all of which enhances coping.
(ii) Reinterpretation of pain sensations
Emotion-laden labels are removed from the patient’s vocabulary. In addition, patients are taught to recognize an increase in pain as a signal to alter pacing or to modify the activity rather than cease altogether or to engage in catastrophizing thoughts.
(iii) Problem-solving strategies
Problem solving requires using not only specific pain reduction techniques but also a host of other cognitive coping strategies. Success in this area depends not only on the patient’s awareness of the techniques but also on his or her ability to draw on and use a variety of different approaches to meet specific challenges. The aim of treatment, therefore, is not only to provide the patient with specific techniques but also to be able to recognize and use them together to cope effectively.
Patients should be taught the basic principles of behavioral/situational analysis. Breaking situations into separate components (e.g., before, during, and after) helps pinpoint problem areas and determine specific strategies. For example, an upcoming wedding poses a challenge to the patient because of the sheer number of tasks to be done. Breaking the event into components helps the patient pace appropriately (shopping for attire, arranging catering, and so on). Learning how to delegate tasks helps reinforce a sense of pacing, as well as being another appropriate coping technique. Successes in these areas enhance self-control and mastery experience, furthering cognitive coping abilities. Finally, the patient learns that by breaking down tasks into component parts and with appropriate planning, required behaviors can be accomplished without undue hardship.
Frequently, as in the preceding case, time-management skills are as important in preventing pain flare-ups as the more pain-focused coping strategies of relaxation or medication intake. This is true of other strategies as well. In addressing problem-solving skills in therapy, therefore, patients should be taught to take stock of all aspects of the situation in planning appropriate pain management strategies. If stress increases pain level, appropriate stress management techniques are crucial components of treatment. Using an abbreviated relaxation method may be helpful in decreasing muscle tension levels as well as in maintaining some degree of emotional calm.
(iv) Assertiveness training
This can help not only in stress management itself but in aiding the patient to carry out other components important to pain management: for example, learning to say no, appropriately, to unreasonable requests by others, especially when pacing is important. As important is the ability to graciously decline well-meaning but unhelpful overtures by others to do for the patient what he or she can do alone. In general, the ability to assert oneself is of benefit in all areas of interaction and should be addressed as part of pain treatment.
(v) Pain-management skills training
The interventions just described are all potentially beneficial to patients who deal with chronic pain. To facilitate implementation of these approaches, Table 2 presents a list of the tasks and interventions in the order they are introduced in pain-management skills training.

Table 2. Sequential tasks in pain management training

ACKNOWLEDGEMENT
The author would like to express thanks to the former staff, interns, and fellows of the MGH Behavioral Medicine Unit for their contributions to behavioral chronic pain management.
SELECTED READINGS

1.
Aberger EW, Adams A, Ahern DK, Follick MJ. Clinical assessment of chronic low back pain. Clin Rehabilitation 1987;1:19–46.

2.
Follick MJ, Ahern DK, Aberger EW. Development of an audiovisual taxonomy of pain behavior: Reliability and discriminant validity. Health Psychol 1986;17:445–449.

3.
Follick MJ, Ahern DK, Laser-Wolston N. Evaluation of a daily activity diary for chronic pain patients. Pain 1984;19:373–382.

4.
Follick MJ, Smith TW, Ahern DK. The sickness impact profile: A global measure of disability in chronic low back pain. Pain 1985; 21:67–76.

5.
Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: Mosby, 1976.

6.
Gallagher RM. Chronic pain. Med Clin North Am 1999;83: 823–849.

7.
Gatchel RJ, Turk DC, eds. Psychosocial factors in pain. New York: Guilford Press, 1999.

8.
Guck TP, Fleischer TD, Willcockson JC, et al. Predictive validity of the pain and impairment relationship scale in a chronic nonmalignant pain population. Arch Phys Med Rehabil 1999;80: 91–95.

9.
Kerns RD, Haythornthwaite JA. Depression among chronic pain patients: Cognitive-behavioral analysis and effect on rehabilitation outcome. J Clin Consulting Psychol 1988;56:870–876.

10.
Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory. Pain 1985;21:345–356.

11.
Linton SJ. The socioeconomic impact of chronic back pain: Is anyone benefiting? Pain 1998;75:163–168.

12.
McCracken LM. Learning to live with the pain: Acceptance of pain predicts adjustment in persons with chronic pain. Pain 1998;74:21–27.

13.
NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. JAMA 1996; 276:313–318.

14.
Rainville J, Ahern DK, Phalen L, et al. The association of pain with physical activities in chronic low back pain. Spine 1992;17:1060–1064.

15.
Riley JF, Ahern DK, Follick MJ. Chronic pain and functional impairment: Assessing beliefs about their relationship. Arch Phys Med Rehabil 1988;69:579–582.

16.
Slater MA, Hall HF, Atkinson JH, Garfin SR. Pain and impairment beliefs in chronic low back pain: validation of the Pain and Impairment Relationship Scale (PAIRS). Pain 1991;44:51–56.

17.
Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain 2000;85:317–332.

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