Psychological Factors that Influence Elective Surgical Outcome for Chronic Pain Patients

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Since the 1960s, psychological approaches to chronic pain have been greatly influenced by the work of Ron Melzack, PhD, FRSC, and Patrick Wall, MA, DM, FRCP. Their introduction of the Gate Control Model of Pain in 1964 offered a legitimate alternative to the dualistic approach to chronic pain. Since its publication in 1964, there have been over 2000 published peer-reviewed studies based on the Gate Control Model. Both Pat Wall (now deceased) and Ron Melzack have up-dated the original model. I would refer the reader to the Pain Neuromatrix Model for more recent discussions. The early development of the Gate Control Model can be traced back to the 1950s when William Livingston, MD, was chairman of the Department of Surgery at the University of Oregon Medical School. Dr. Livingston's interest in treating pain started during WWII when he was a Navy surgeon treating patients with peripheral nerve injuries. I would recommend to the reader his classic book, Pain and Suffering, edited by Howard Fields, MD and published by the ISAP press. Dr. Livingston formed the first pain management program in the U.S. at the University of Oregon Medical School. One of the first fellows he invited to join the pain program was a young psychologist by the name of Ron Melzack. According to Dr. Fields, Dr. Livingston had a profound influence on Dr. Melzack's early thinking and the importance of psychological factors in understanding the nature of pain and its subsequent treatment. Dr. Melzack included a motivational or cognitive component to the Gate Control Model which can be traced back to Dr. Livingston's influence. It is important to note that Dr. Livingston stated that pain is a perception, which implies the importance of neocortical involvement in understanding pain. In my opinion, I consider Dr. Livingston to be the founder of modern pain medicine.

As I mentioned above, one of the unique and profound contributions of the Gate Control Model was the inclusion of higher neocortical or motivational influences. This was a significant departure from previous linear, stimulus-response, dualistic pain theories. The gate model is circular and reciprocal in nature which reflected contemporary physiologic thinking regarding feedback systems. I would strongly recommend the thinking and writing of C. Richard Chapman, PhD. His most recent focus article, "Pain and Stress: A Systems Perspective," published in the Journal of Pain in February 2008, is an excellent overview reflecting current thinking.

Thirty years ago, when I became interested in pain management, I reviewed the pain literature in depth. I was looking for a framework or model from which to evaluate and treat chronic pain patients. At that time I was also interested in psychophysiology and biofeedback, which I felt was complimentary to my interest in pain management. Ron Melzack's model of chronic pain appealed to me since it was based on creditable, empirical evidence and it has practical face validity. Melzack believes there are three primary interdependent factors that influence pain: the sensory factory, the affective factor (or how we cope with chronic pain), and the evaluative/cognitive factor (or how we think about our pain). When I evaluate a pain patient who is being considered for elective surgery, my clinical impressions are based on Melzack's model. Most of my pain referrals are not overly receptive about being evaluated by a pain psychologist due to the misperception that the psychologist's role is to determine if the patient's pain is real or imaginary. This stereotype is based on outdated, invalid, dualistic assumptions about the either/or nature of pain.

Updated on: 09/08/16
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