. 2013 Winter;19(1):61–77. doi: 10.1310/sci1901-61

Table 2.

Behavioral treatments

Study, study type, and scale score	No. of participants, type of pain, and diagnostic tool	Intervention and pain scale	Results
Behavioral management
Norrbrink et al,2006²²/Sweden Prospective controlled trial D&B = 19	N = 38 Pain: Neuropathic pain Tool: not stated	Treatment: 27 patients participated in a 10-wk twice weekly treatment program (20 sessions) vs 11 controls receiving regular care. Each treatment session consisted of 1.5 hr of education, 1.5 hr of CBT, and 1 hr each of stretching & relaxation and body awareness training. Pain scale: Borg CR10 scale	Pain intensity and unpleasantness, health-related QOL, and life satisfaction did not change over time for either group. Treatment group: anxiety and depression were reduced from baseline to 12-mo evaluation, with a significant difference between treatment vs controls. Sleep improved in the treatment group. When assessing QOL scores (Nottingham Health Profile), a significant improvement was noted for the Emotional Reaction subscale only (P <.01). A significant decrease in the number of visits between baseline and the 12-mo assessment was noted for the treatment group (from 15 to 5; P <.03), along with a reduction in the median number of visits to physicians (from 3 to 1; P <.03). Significant decreases in health care visits were also seen for the control group.
Hypnosis
Jensen et al, 2009²⁰/USA RCT PEDro = 5	N = 37 Pain: Mixed Tool: Not stated	Treatment: Participants were randomly assigned to receive either hypnosis or biofeedback. Individuals receiving hypnosis underwent 10 sessions of training daily or weekly. The biofeedback group received 10 sessions of EMG biofeedback. Pain scale: NRS	For individuals with neuropathic pain, a significant decrease in daily pain intensity was seen in the hypnosis group post session (P <.01) but not in the biofeedback group. Neither treatment was effective in reducing pain for individuals without neuropathic pain.
Jensen et al, 20002³/USA Pre-Post D&B = 16	N = 22 Pain: Mixed Tool: Not stated	Treatment: Hypnotic suggestions were provided to individuals for pain relief. Pain scale: Self-report	86% reported decrease in pain intensity and unpleasantness from before induction to just after induction. A significant time effect emerged for both pain intensity (P <.001) and pain unpleasantness (P <.001). Significant effect for analgesic suggestion on pain intensity over and above the effects of the induction alone was observed, with a significant decrease occurring in reported pain intensity before and after the analgesic suggestion (P <.05). Pre-induction, post-induction, and post-analgesia suggestion pain intensity ratings were all significantly lower than average pain during the previous 6 mo (P <.01, P <.0001, P <.0001, respectively). Statistical significance was noted for 2 of the associations: effect of pain plus analgesia suggestion on pain intensity (P <.01) and effect of induction alone relative to least pain (P <.05).
Soler et al, 2010¹⁶/Spain RCT PEDro = 8	N = 39 Pain: Neuropathic Tool: Clinical interview	Treatment: Patients were randomly divided into 4 groups: tDCS and visual illusion group received direct current stimulation over C3 or C4 at a constant 2-mA intensity for 20 min and after 5 min of tDCS, video with someone walking was shown and the legs of person for 15 min with a vertical mirror so patients could see themselves walking; tDCS group with control visual illusion received the above-mentioned tDCS; the visual illusion only group received a video of faces or landscapes; visual illusion group and sham tDCS had electrodes placed on the same area as the treatment group but the stimulator was turned off after 30 sec of stimulation; placebo group consisted of both the control visual illusion and the sham tDCS. Pain scale: NRS	The most significant reduction in NRS of pain perception was seen in the combined tDCS and visual illusion group compared with the visual illusion group (P = .008) or the placebo group (P = .004). Pain reduction was also greater in the tDCS and visual illusion group than in the other 3 groups at first and last follow-up; however, no difference was seen at second follow-up. Visual illusion group was shown to have significant reduction in neuropathic pain intensity on last day of treatment (P = .02); however, this effect was not maintained over the long term. Combined tDCS and visual illusion group also showed significant improvement in ability to work, perform daily tasks, enjoyment, and interference of pain with sleep (P <.05). tDCS sessions were found to be safe with minor side effects including mild headache.
Gustin et al,2008²⁴/Australia Pre-Post D&B = 18	N = 15 Pain: Mixed Tool: Not stated	Treatment: All participants were trained in movement imagery for 7 days. Each participant was asked to imagine right ankle plantar flexion and dorsiflexion for 8 min. Pain scale: VAS	Individuals with neuropathic pain reported a significant increase in pain intensity during movement imagery (P <.01). Individuals without neuropathic pain reported a significant increase in non-pain intensity during movement imagery (P <.01).
Moseley,2007²⁸/UK Pre-Post D&B = 11	N = 5 Pain: Neuropathic pain Tool: Not stated	Treatment: Individuals with SCI (n=5) engaged in (1) virtual walking exercise; (2) guided imagery with a psychologist who took them through a scene in which they were pain free and doing something they liked; (3) watching an animated film. During the second part of the study, participants performed 10 min of virtual walking on 15 consecutive weekdays. Pain scale: MPQ; VAS	Pain decreased by approximately 65% with virtual walking; less so for guided visual imagery and film viewing. The amount of time to return to pre-task pain VAS after virtual walking was 34.9 min; after guided imagery, 13.9 min; and after watching a film, 16.3 min. The decrease in perceived foreignness of the legs was 43 mm during virtual walking, 4 mm during guided imagery, and 3 mm while watching the film. Change in foreignness was related to change in pain during virtual walking (P = .04). During the 3-wk trial of virtual walking, overall pre-task pain gradually decreased, and pain relief gradually increased; these effects persisted at 3-mo follow-up.

Note: B = Downs and Black quality assessment scale score; MPQ = McGill Pain Questionnaire; NRS = numeric rating scale; PEDro = Physiotherapy Evidence Database rating scale score; QOL = Quality of Life; VAS = Visual Analogue Scale; VRS = verbal rating scale.