Abstract
The application of operant learning theory on chronic pain by Fordyce has had a huge impact on chronic pain research and management. The operant model focuses on pain behaviors as a major component of the pain problem, and postulates that they are subject to environmental contingencies. The role of operant learning in pain behaviors generally has been supported by experimental studies, which are reviewed in the present article. Subsequently, the rationale, goals, and methods of operant behavioral treatment of chronic pain are outlined. Special attention is paid to three therapeutic techniques (graded activity, activity pacing, and time-contingent medication management), which are discussed in detail with regard to their operationalization, effectiveness, and (possible) mechanisms of action. Criticisms of the operant model are presented, as are suggestions for the optimization of (operant) behavioral treatment efficacy.
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Fordyce WE. Behavioral methods for chronic pain and illness. Saint Louis: Mosby; 1976.
Flor H, Birbaumer N, Schulz R, et al. Pavlovian conditioning of opioid and nonopioid pain inhibitory mechanisms in humans. Eur J Pain. 2002;6:395–402.
Goubert L, Crombez G, Peters M. Pain-related fear and avoidance: a conditioning perspective. In: Asmundson GJG, Vlaeyen JWS, Crombez G, editors. Understanding and treating fear of pain. New York: Oxford University Press; 2004. p. 25–50.
• Klinger R, Matter N, Kothe R, et al. Unconditioned and conditioned muscular responses in patients with chronic back pain and chronic tension-type headaches and in healthy controls. Pain. 2010;150:66–74. This study experimentally showed how, through a process of classical conditioning, one might come to exhibit increased muscular reactivity to nonpainful stimuli.
Schneider C, Palomba D, Flor H. Pavlovian conditioning of muscular responses in chronic pain patients: central and peripheral correlates. Pain. 2004;112:239–47.
Seymour B, O’Doherty JP, Koltzenburg M, et al. Opponent appetitive-aversive neural processes underlie predictive learning of pain relief. Nat Neurosci. 2005;8:1234–40.
Goubert L, Vlaeyen WS, Crombez G, et al. Learning about pain from others: an observational learning account. J Pain. 2011;12:167–74.
Sullivan MJL. Toward a biopsychomotor conceptualization of pain: implications for research and intervention. Clin J Pain. 2008;24:281–90.
Williams ACC. Facial expression of pain: an evolutionary account. Behav Brain Sci. 2002;25:439–56.
Karsdorp PA, Vlaeyen JWS. Active avoidance but not activity pacing is associated with disability in fibromyalgia. Pain. 2009;147:29–35.
Prkachin KM, Schultz IZ, Hughes E. Pain behavior and the development of pain-related disability: the importance of guarding. Clin J Pain. 2007;23:270–7.
Sullivan MJL, Thibault P, Savard A, et al. The influence of communication goals and physical demands on different dimensions of pain behavior. Pain. 2006;125:270–7.
Leeuw M, Goossens MEJB, Linton SJ, et al. The fear-avoidance model of musculosceletal pain: current state of scientific evidence. J Behav Med. 2007;30:77–94.
Moseley GL, Nicholas MK, Hodges PW. Does anticipation of back pain predispose to back trouble? Brain. 2004;127:2339–47.
Verbunt JA, Seelen HA, Vlaeyen JS, et al. Disuse and deconditioning in chronic low back pain: concepts and hypotheses on contributing mechanisms. Eur J Pain. 2003;7:9–21.
Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculosceletal pain: a state of the art. Pain. 2000;85:317–32.
Skinner BF. Science and human behavior. New York: Macmillan; 1953.
Fordyce WE. Behavioural science and chronic pain. Postgrad Med J. 1984;60:865–8.
Fordyce WE. Psychological factors in the failed back. Int Disabil Stud. 1988;10:29–32.
Fordyce WE, Steger JC. Chronic pain. In: Pomerleau OF, Brady JP, editors. Behavioral medicine: theory and practice. Baltimore: The Williams & Wilkins Company; 1979. p. 125–53.
Fowler RS, Fordyce WE, Berni R. Operant conditioning in chronic illness. Am J Nurs. 1969;69:1226–8.
Jensen MP, Nielson WR, Kerns RD. Toward the development of a motivational model of pain self-management. J Pain. 2003;4:477–92.
Labus JS, Keefe FJ, Jensen MP. Self-reports of pain intensity and direct observations of pain behavior: when are they correlated? Pain. 2003;102:109–24.
Osborne TL, Raichle KA, Jensen MP. Psychologic interventions for chronic pain. Phys Med Rehabil Cli. 2006;17:415–33.
Romano JM, Turner JA, Friedman LS, et al. Sequential analysis of chronic pain behaviors and spouse responses. J Consult Clin Psychol. 1992;60:777–82.
Newton-John TRO. Solicitousness and chronic pain: critical review. Pain Rev. 2002;9:7–27.
Linton SJ, Götestam KG. Controlling pain reports through operant conditioning: a laboratory demonstration. Percept Motor Skill. 1985;60:427–37.
Lousberg R, Groenman NH, Schmidt AJ, et al. Operant conditioning of the pain experience. Percept Motor Skill. 1996;83:883–900.
Jolliffe CD, Nicholas MK. Verbally reinforcing pain reports: an experimental test of the operant model of chronic pain. Pain. 2004;107:167–75.
Lousberg R, Vuurman E, Lamers T, et al. Pain report and pain-related evoked potentials operantly conditioned. Clin J Pain. 2005;21:262–71.
Flor H, Knost B, Birbaumer N. The role of operant conditioning in chronic pain: an experimental investigation. Pain. 2002;95:111–8.
Hölzl R, Kleinböhl D, Huse E. Implicit operant learning of pain sensitization. Pain. 2005;115:12–20.
Becker S, Kleinböhl D, Klossika I, et al. Operant conditioning of enhanced pain sensitivity by heat-pain titration. Pain. 2008;140:104–14.
•• Becker S, Kleinböhl D, Baus D, et al. Operant conditioning of perceptual sensitization and habituation is impaired in fibromyalgia patients with and without irritable bowel syndrome. Pain. 2011;152:1408–17. In this experiment, intrinsic reinforcers and punishers were used for the operant conditioning of nonverbal pain reports, as measured with a behavioral discrimination task.
•• Kunz M, Rainville P, Lautenbacher S. Operant conditioning of facial displays of pain. Psychosom Med. 2011;73:422–31. To our knowledge, this is the only experiment that has focused on the operant conditioning of facial pain expressions. The authors used a very delicate methodology.
Butler S. A personal experience learning from two pain pioneers, J. J. Bonica and W. Fordyce: lessons surviving four decades of pain practice. Scand J Pain. 2010;1:34–7.
Morley S, Eccleston C, Williams ACC. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13.
van Tulder MW, Ostelo R, Vlaeyen JWS, et al. Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine. 2000;26:270–81.
•• Eccleston C, Williams ACC, Morley S (2009) Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Db Syst Rev. 2009;2:CD007407. This article describes the latest Cochrane review on the effectiveness of cognitive-behavioral therapy and behavioral therapy for the management of chronic pain.
Sanders SH. Operant therapy with pain patients: evidence for its effectiveness. Semin Pain Med. 2003;1:90–8.
Keefe FJ, Gil KM. Behavioral concepts in the analysis of chronic pain syndromes. J Consult Clin Psychol. 1986;54:776–83.
Domjan M. The essentials of conditioning and learning. 3rd ed. Belmont: Wadsworth Publishing; 2004.
Sundel M, Sundel SS. Behavior change in the human services. Behavioral and cognitive principles and applications. 5th ed. Thousand Oaks: Sage Publications, Inc.; 2005.
Vlaeyen JWS, Groenman NH, Thomassen J, et al. A behavioral treatment for sitting and standing intolerance in a patient with chronic low back pain. Clin J Pain. 1989;5:233–7.
Keefe FJ. Behavioral assessment and treatment of chronic pain: current status and future directions. J Consult Clin Psychol. 1982;50:896–911.
Otis JD. Managing chronic pain: a cognitive-behavioral therapy approach. Therapist Guide. Oxford University Press; 2007.
Lindström I, Öhlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. Phys Ther. 1992;72:279–90.
Moss-Morris R, Sharon C, Tobin R, et al. A randomized controlled graded exercise trial for chronic fatigue syndrome: outcomes and mechanisms of change. J Health Psychol. 2005;10:245–59.
White PD, Goldsmith KA, Johnson AL, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomized trial. Lancet. 2011;377:823–36.
Geraets JJXR, Goossens MEJB, de Groot IJM, et al. Effectiveness of a graded exercise therapy program for patients with chronic shoulder complaints. Aust J Physiother. 2005;51:87–94.
Ostelo RWJG, de Vet HCW, Vlaeyen JWS, et al. Behavioral graded activity following first-time lumbar disc surgery: 1-year results of a randomized clinical trial. Spine. 2003;28:1757–65.
Lambeek LC, van Mechelen W, Knol DL, et al. Randomized controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. Brit Med J. 2010;340:c1035.
Staal JB, Hlobil H, Twisk JWR, et al. Graded activity for low back pain in occupational health care: a randomized, controlled trial. Ann Intern Med. 2004;140:77–84.
Anema JR, Steenstra IA, Bongers PM, et al. Multidisciplinary rehabilitation for subacute low back pain: graded activity or workplace intervention or both? Spine. 2007;32:291–8.
Veenhof C, Köke AJA, Dekker J, et al. Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: a randomized clinical trial. Arthrit Care Res. 2006;55:925–34.
Vonk F, Verhagen AP, Twisk JW, et al. Effectiveness of a behaviour graded activity program versus conventional exercise for chronic neck pain patients. Eur J Pain. 2009;13:533–41.
Smeets RJ, Severens JL, Beelen S, et al. More is not always better: cost-effectiveness analysis of combined, single behavioral and single physical rehabilitation programs for chronic low back pain. Eur J Pain. 2009;13:71–81.
Smeets RJEM, Vlaeyen JWS, Kester ADM, et al. Reduction of fear catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain. 2006;7:261–71.
Leeuw M, Goossens MEJB, van Breukelen GJP, et al. Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial. Pain. 2008;138:192–207.
Bailey KM, Carleton RN, Vlaeyen JWS, et al. Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pain: a preliminary review. Cogn Behav Ther. 2009;39:46–63.
Vlaeyen JWS, de Jong J, Leeuw M, et al. Fear reduction in chronic pain: graded exposure in vivo with behavioral experiments. In: Asmundson GJG, Vlaeyen JWS, Crombez G, editors. Understanding and treating fear of pain. New York: Oxford University Press; 2004. p. 313–43.
Harding VR, Williams ACC. Activities training: integrating behavioral and cognitive methods with physiotherapy in pain management. J Occup Rehabil. 1998;8:47–60.
Nielson WR, Jensen MP, Hill ML. An activity pacing scale for the chronic pain coping inventory: development in a sample of patients with fibromyalgia syndrome. Pain. 2001;89:111–5.
Rundell SD, Davenport TE. Patient education based on principles of cognitive behavioral therapy for a patient with persistent low back pain: a case report. J Orthop Sport Phys. 2010;40:494–501.
• Gill JR, Brown CA. A structured review of the evidence for pacing as a chronic pain intervention. Eur J Pain. 2009;13:214–6. This article highlights the gaps in research with respect to pacing, and therefore, the need for a theoretical consensus regarding its definition.
Karsdorp PA, Vlaeyen JWS. On the validity of ‘activity pacing’: comment on Jensen “Research on coping with chronic pain. The importance of active avoidance of inappropriate conclusions”. Pain. 2009;147:305.
Vlaeyen JWS, Karsdorp P, Gatzounis R, et al. The PACE trial in chronic fatigue syndrome. Lancet. 2011;377:1834.
Murphy SL, Lyden AK, Smith DM, et al. Effects of a tailored activity pacing intervention on pain and fatigue for adults with osteoarthritis. Am J Occup Ther. 2010;64:869–76.
The ME Association. Managing my M. E. What people with ME/CFS and their carers want from the UK’s health and social services. 2010. Available at http://www.meassociation.co.uk. Accessed 29 Jun 2011.
Bailey BP, Konstan JA. On the need for attention-aware systems: measuring effects of interruption on task performance, error rate, and affective state. Comput Hum Behav. 2006;22:685–708.
Trafton JG, Monk CA. Task interruptions. In: Boehm-Davis DA, editor. Reviews of human factors and ergonomics. Santa Monica, CA: Human Factors and Ergonomics Society; 2008. p. 111–26.
Højsted J, Sjøgren P. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain. 2007;11:490–518.
Martell BA, O’Connor PG, Kerns RD, et al. Opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146:116–27.
Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain. 2008;24:497–508.
Koes BW, van Tulder MW, Ostelo R, et al. Clinical guidelines for the management of low back pain in primary care. Spine. 2001;26:2504–14.
Berntzen D, Götestam KG. Effects of on-demand versus fixed-interval schedules in the treatment of chronic pain with analgesic compounds. J Consult Clin Psychol. 1987;55:213–7.
Von Korff M, Merrill JO, Rutter CM, et al. Time-scheduled vs. pain-contingent opioid dosing in chronic opioid therapy. Pain. 2011;152:1256–62.
Sharp TJ. Chronic pain: a reformulation of the cognitive-behavioural model. Behav Res Ther. 2001;39:787–800.
Kirsch I, Lynn SJ, Vigorito M, et al. The role of cognition in classical and operant conditioning. J Clin Psychol. 2004;60:369–92.
Mitchell CJ, De Houwer J, Lovibond PF. The propositional nature of human associative learning. Behav Brain Funct. 2009;32:183–98.
McCracken L. A behavioral analysis of pain-related fear responses. In: Asmundson GJG, Vlaeyen JWS, Crombez G, editors. Understanding and treating fear of pain. New York: Oxford University Press; 2004. p. 51–69.
Pfingsten M, Leibing E, Harter W, et al. Fear-avoidance behavior and anticipation of pain in patients with chronic low back pain: a randomized controlled study. Pain Med. 2001;2:259–66.
Lang EV, Hatsiopoulou O, Koch T, et al. Can words hurt? Patient–provider interactions during invasive procedures. Pain. 2005;114:303–9.
Dahl J, Wilson KG, Nilsson A. Acceptance and Commitment Therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: a preliminary randomized trial. Behav Ther. 2004;35:785–801.
McCracken LM, Vowles KE, Eccleston C. Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase. Behav Res Ther. 2005;43:1335–46.
Hayes SC, Duckworth MP. Acceptance and commitment therapy and traditional cognitive behavior therapy approaches to pain. Cogn Behav Pract. 2006;13:185–7.
• Cano A, Williams ACC. Social interaction in pain: reinforcing pain behaviors or building intimacy? Pain. 2010;149:9–11. The authors provided an alternative explanation of spousal responses to pain patients’ verbal pain expressions.
Hadjistavropoulos T, Craig KD. A theoretical framework for understanding self-report and observational measures of pain: a communications model. Behav Res Ther. 2002;40:551–70.
• Hadjistavropoulos T, Craig KD, Duck S, et al. A biopsychosocial formulation of pain communication. Psychol Bull. 2011;in press. The authors synthesize elements from different perspectives to create a broad framework for the understanding of social interactions in the context of pain.
Thieme K, Flor H, Turk DC. Psychological pain treatment in fibromyalgia syndrome: efficacy of operant behavioural and cognitive behavioural treatments. Arthritis Res Ther. 2006;8:R121.
McCracken L, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine. 2002;27:2564–73.
Vlaeyen JWS, Morley S. Cognitive-behavioral treatments for chronic pain: what works for whom? Clin J Pain. 2005;21:1–8.
Thieme K, Turk DC, Flor H. Responder criteria for operant and cognitive-behavioral treatment for fibromyalgia syndrome. Arthritis Rheum. 2007;57:830–6.
Friedberg F. Does graded activity increase activity? A case study of chronic fatigue syndrome. J Behav Ther Exp Psy. 2002;33:203–15.
Kraemer HC, Wilson GT, Fairburn CG, et al. Mediators and moderators of treatment effects in randomized clinical trials. Arch Gen Psychiat. 2002;59:877–83.
Thorn BE, Burns JW. Common and specific treatment mechanisms in psychosocial pain interventions: the need for a new research agenda. Pain. 2011;152:705–6.
Perepletchikova F, Treat TA, Kazdin AE. Treatment integrity in psychotherapy research: analysis of the studies and examination of the associated factors. J Consult Clin Psychol. 2007;75:829–41.
Waller G. Evidence-based treatment and therapist drift. Behav Res Ther. 2009;47:119–27.
Leeuw M, Goossens MEJB, de Vet HCW, et al. The fidelity of treatment delivery can be assessed in treatment outcome studies: a successful illustration from behavioral medicine. J Clin Epidemiol. 2009;62:81–90.
Bellg AJ, Borrelli B, Resnick B, et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. 2004;23:443–51.
Acknowledgements
This study was supported by the Odysseus Grant “The Psychology of Pain and Disability Research Program” funded by the Research Foundation—Flanders, Belgium (Fonds Wetenschappelijk Onderzoek [FWO] Vlaanderen).
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Gatzounis, R., Schrooten, M.G.S., Crombez, G. et al. Operant Learning Theory in Pain and Chronic Pain Rehabilitation. Curr Pain Headache Rep 16, 117–126 (2012). https://doi.org/10.1007/s11916-012-0247-1
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DOI: https://doi.org/10.1007/s11916-012-0247-1