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Neurofeedback Treatment for Pain Associated with Complex Regional Pain Syndrome Type I

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Abstract

Introduction. Complex Regional Pain Syndrome Type I (CRPS-I) is a devastating pain condition that is refractory to standard care. Preliminary evidence suggests the possibility that neurofeedback training might benefit patients with chronic pain, including patients with CRPS-I. The current study sought to address the need for more information about the effects of neurofeedback on pain in persons with chronic pain by (1) determining the average decrease in pain in patients with CRPS-I following neurofeedback training, (2) identifying the percent of patients reporting pain decreases that are clinically meaningful, and (3) documenting other benefits of neurofeedback training.Method. Eighteen individuals with CRPS-I participating in a multidisciplinary treatment program were administered 0–10 numerical rating scale measures of pain intensity at their primary pain site, as well as pain at other sites and other symptoms, before and after a 30 minute neurofeedback training session. A series of t-tests were performed to determine the significance of any changes in symptoms observed. We also computed the effect sizes and percent change associated with the observed changes in order to help interpret the magnitude of observed improvements in symptoms.Results. There was a substantial and statistically significant pre- to post-session decrease in pain intensity at the primary pain site on average, with half of the study participants reporting changes in pain intensity that were clinically meaningful. Five of seven secondary outcome measures also showed statistically significant improvements following neurofeedback treatment.Conclusions. The findings suggest that many patients who receive neurofeedback training report significant and substantial short-term reductions in their experience of pain, as well as improvements in a number of other pain- and nonpain-specific symptoms. The findings support the need for additional research to further examine the long-term effects and mechanisms of neurofeedback training for patients with chronic pain.
... Past research examining EEG for pain relief has aimed to supress theta and higher beta (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30) and reinforce alpha or lower beta power. For example, Jensen et al. 1 reinforced alpha (8)(9)(10)(11)(12) Hz) that resulted in pain reduction. Similarly, Kayiran et al. 8 supressed theta (3)(4)(5)(6)(7)(8) while reinforcing low beta (13)(14)(15) Hz) that also resulted in pain reduction. ...
... This study is part of a larger research programme to develop a neurofeedback protocol to relieve CNP after SCI [13][14][15] . The current study aims to understand which MB lead to neurofeedback success with this protocol by answering the following research questions: (1) "what MB, including affect (emotional experience during neurofeedback), are associated with success at neurofeedback?" and (2) "what are the relationships between general learning factors (i.e. LoC, SE, motivation, and difficulty) and neurofeedback performance?" ...
... In the interview, participants were asked two distinct questions: (1) what they did to try and achieve the neurofeedback task and (2) how they felt during the neurofeedback training. The MB were divided into two categories based on these questions: mental strategies (a goal-directed mental action; MS) and affect (the emotional experience during neurofeedback). ...
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EEG-based neurofeedback uses mental behaviours (MB) to enable voluntary self-modulation of brain activity, and has potential to relieve central neuropathic pain (CNP) after a spinal cord injury (SCI). This study aimed to understand neurofeedback learning and the relationship between MB and neurofeedback success. Twenty-five non-CNP participants and ten CNP participants received neurofeedback training (reinforcing 9–12 Hz; suppressing 4–8 Hz and 20–30 Hz) on four visits. Participants were interviewed about the MB they used after each visit. Questionnaires examined the following factors: self-efficacy, locus of control, motivation, and workload of neurofeedback. MB were grouped into mental strategies (a goal-directed mental action) and affect (emotional experience during neurofeedback). Successful non-CNP participants significantly used more imagination-related MS and reported more negative affect compared to successful CNP participants. However, no mental strategy was clearly associated with neurofeedback success. There was some association between the lack of success and negative affect. Self-efficacy was moderately correlated with neurofeedback success (r = < 0.587, p = < 0.020), whereas locus of control, motivation, and workload had low, non-significant correlations (r < 0.300, p > 0.05). Affect may be more important than mental strategies for a successful neurofeedback performance. Self-efficacy was associated with neurofeedback success, suggesting that increasing confidence in one’s neurofeedback abilities may improve neurofeedback performance.
... Later research examined larger cohorts of patients (Jensen et al., 2008(Jensen et al., , 2013a(Jensen et al., , 2014Stokes and Lappin, 2010) and found promising findings. Jensen et al. (2007) conducted a study with 18 patients with complex regional pain syndrome and found a statistically significant decrease in pain reported pre to post training, with over half of participants reporting a clinically meaningful decrease of >30% (Moore et al., 2013). Stokes and Lappin (2010) and Jensen et al. (2013aJensen et al. ( , 2014 found similar results, however, Jensen et al. (2013a) found their decrease in pain was not clinically meaningful. ...
... Despite the existence of an established cortical pain matrix, variation in EEG activity at different frequency bands and scalp sites is still likely as a result of heterogenous pain aetiology and individual factors such as head shape, and a few studies have utilized individualized protocols. Jensen et al. (2007), for example, used initial SMR up-regulation at T3/T4 in individuals with Complex Regional Pain Syndrome, but then employed progressively different protocols if the patient failed to report improvement until an optimal individual protocol was found. Prinsloo et al. (2018) used patient-specific protocols and found NFB to reduce pain in cancer survivors (although the authors did not report details of the electrode sites or frequencies that were trained). ...
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Background Neurofeedback (NFB) attempts to alter the brain’s electrophysiological activity and has shown potential as a pain management technique. Existing studies, however, often lack appropriate control groups or fail to assess whether electrophysiological activity has been successfully regulated. The current study is a randomized controlled trial comparing changes in brain activity and pain during NFB with those of a sham-control group.Methods An experimental pain paradigm in healthy participants was used to provide optimal control of pain sensation. Twenty four healthy participants were blind randomized to receive either 10 × NFB (with real EEG feedback) or 10 × sham (with false EEG feedback) sessions during noxious cold stimulation. Prior to actual NFB training, training protocols were individually determined for each participant based on a comparison of an initial 32-channel qEEG assessment administered at both baseline and during an experimental pain task. Each individual protocol was based on the electrode site and frequency band that showed the greatest change in amplitude during pain, with alpha or theta up-regulation at various electrode sites (especially Pz) the most common protocols chosen. During the NFB sessions themselves, pain was assessed at multiple times during each session on a 0–10 rating scale, and ANOVA was used to examine changes in pain ratings and EEG amplitude both across and during sessions for both NFB and sham groups.ResultsFor pain, ANOVA trend analysis found a significant general linear decrease in pain across the 10 sessions (p = 0.015). However, no significant main or interaction effects of group were observed suggesting decreases in pain occurred independently of NFB. For EEG, there was a significant During Session X Group interaction (p = 0.004), which indicated that EEG amplitude at the training site was significantly closer to the target amplitude for the NFB compared to the sham group during painful stimulation, but this was only the case at the beginning of the cold task.Conclusion While these results must be interpreted within the context of an experimental pain model, they underline the importance of including an appropriate comparison group to avoid attributing naturally occurring changes to therapeutic effects.
... For this, Gao et al. (2016) have found that there was a significant association between the beta brainwave and mindfulness state. In addition, the sensorimotor cortex was granted as the affective component of physical condition due to its role in manipulating emotions such as calm, agitation, anxiety and fear (Jensen, Grierson, Tracy-Smith, Bacigalupi & Othmer, 2008). Therefore, the enhancement of mindfulness skills via rewarding the low beta brainwave on the left sensorimotor cortex, C3 was believed to reduce the ruminative thoughts and anxious feeling of K. ...
... This is primarily due to the vital role of P4 in anxiety resilience, whereby the right parietal lobe was found to be significant in responding and attenuating stress, which pertains to its functions as the sensory input processor (Grieder, Homan, Federspiel, Kiefer & Hasler, 2020). Meanwhile, P4 training was commonly implemented in tackling the sleep issues, such as the sleep difficulty that resulted from the anxiety symptoms of individuals (Jensen et al., 2008). Therefore, the present neurofeedback training protocol was adopted and implemented to enhance the sleep quality of K. ...
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A case report on enhancing self-regulation skills through QEEG-guided neurofeedback was conducted for a subject who has been diagnosed with Wilson Disease (WD). The trauma-informed neurofeedback training protocols were developed to improve the client’s self-regulation skills in order to address his psychological symptoms and cognitive impairment. The protocols were developed based on the findings of the prior empirical research as well as the QEEG brain mapping assessment of the client. In this case report, the utilisation of expressive art therapy application was highlighted in facilitating the therapeutic process for the clients having difficulty in verbal communication. The QEEG brain mapping assessment result pre-and-post intervention were compared to determine the progress of the client’s brainwave activity pattern. Meanwhile, the self-report diary of the client’s parent was used to follow up his conditions. The outcome indicated that the developed protocols of trauma-informed neurofeedback training and expressive art application were helpful in improving the self-regulation skills of the client.
... A variety of neurofeedback protocols are currently being practiced to retrain the brain to minimize the deviated EEG patterns thereby restoring normal brain activity (Hammond, 2011;Heinrich et al., 2007;Miró et al., 2016;Sherlin et al., 2011). Among these protocols of NF, some intend to suppress sensory information processing by reducing specific brain activity (such as alpha activity in combination with theta activity) for pain reduction whereas other NF protocols augment the activity of the brain (such as an alpha activity) that is hypothesized to be associated with relaxation, enhanced cognitive processing speed and cognitive performance along with improved executive functioning and increased performance quality (Allen et al., 2001;Al-Taleb, 2019;Angelakis et al., 2007;Biswas, 2019;Hanslmayr et al., 2005;Hord et al., 1975;Ibric & Dragomirescu, 2009;Jensen et al., 2007Jensen et al., , 2013Markovska-Simoska et al., 2008;Martindale & Armstrong, 1974;Mikicin & Kowalczyk, 2015;Regestein et al., 1973;Schmeidler & Lewis, 1971;Vučković et al., 2019;Zoefel et al., 2011). ...
... Analogously, the alpha-theta protocol of neurofeedback training at frontal and parietal locations (i.e. FP1-FP2 or F3, Fz, F4, P3, Pz, and P4) is reported to improve executive functions as well as cognitive performance thereby decreases obsessive thoughts (Hanslmayr et al., 2005;Jensen et al., 2007). Alpha neurofeedback training from the occipital region has been reported to influence mood and reduces anxiety when Oz, O1, and C3 locations were targeted (Hardt & Kamiya, 1978;Plotkin & Rice, 1981;Schmeidler & Lewis, 1971). ...
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Neurofeedback (NF) training based on alpha upregulation has been widely used on patient and healthy populations. However, active voluntary modulation of central or widespread posterior alpha in response to central alpha feedback is still ambiguous. The objective of this study is to confirm whether patients learn to truly increase alpha power and to determine if patients modulate central or widespread alpha power when alpha feedback is provided from central brain region. This EEG-based NF study was conducted on seven paraplegic patients with same injury type, pain location, and sensitization to ensure homogeneity. In addition to routine NF training sessions, various experiments were performed to compare alpha NF modulation received from C4 with alpha shift during cognitive tasks, occipital or parieto-occipital cortex, and Laplacian montage which is expected to separate localized alpha from widespread alpha, to attain objectives. Moreover, imaginary coherence analysis in alpha band was also performed to check whether C4 training site is coupled with other brain regions and to confirm whether activity at training site leads/lags the activity of other brain regions. The results indicate widespread alpha modulation in patients during regular NF sessions (p < 0.05) with large effect size (> 0.8), sufficiently high statistical power (> 80%), and a narrower confidence interval (CI) in response to NF provided from the central brain region reflecting less uncertainty and higher precision. However, small effect size obtained with Laplacian montage require patients to be trained with Laplacian feedback to achieve a reliable conclusion regarding localized alpha modulation. The outcomes of this study are not only limited to validate true alpha modulation in response to central alpha feedback but also to explore the mechanism of central alpha NF training.
... The number of neurofeedback sessions in RCTs ranged from 7 to 24, with a duration of 20 to 45 minutes, while the number of sessions varied considerably in the included non-randomised studies, from only one session56,57 to a mean of 58 sessions across participants 20 , and the ...
Article
Electroencephalographic (EEG) neurofeedback has been utilised to regulate abnormal brain activity associated with chronic pain. In this systematic review, we synthesised the evidence from randomised controlled trials (RCTs) to evaluate the effect of EEG neurofeedback on chronic pain using random effects meta-analyses. Additionally, we performed a narrative review to explore the results of non-randomised studies. The quality of included studies was assessed using Cochrane risk of bias tools, and the GRADE system was used to rate the certainty of evidence. Ten RCTs and 13 non-randomised studies were included. The primary meta-analysis on nine eligible RCTs indicated that although there is low confidence, EEG neurofeedback may have a clinically meaningful effect on pain intensity in short-term. Removing the studies with high risk of bias from the primary meta-analysis resulted in moderate confidence that there remained a clinically meaningful effect on pain intensity. We could not draw any conclusion from the findings of non-randomised studies, as they were mostly non-comparative trials or explorative case series. However, the extracted data indicated that the neurofeedback protocols in both RCTs and non-randomised studies mainly involved the conventional EEG neurofeedback approach, which targeted reinforcing either alpha or sensorimotor rhythms and suppressing theta and/or beta bands on one brain region at a time. A post-hoc analysis of RCTs utilising the conventional approach resulted in a clinically meaningful effect estimate for pain intensity. Although there is promising evidence on the analgesic effect of EEG neurofeedback, further studies with larger sample sizes and higher quality of evidence are required. https://onlinelibrary.wiley.com/share/author/E4K7B3D7XC3PFZDSJ65D?target=10.1111/ene.15189
... 57 Rannsóknir hafa verið gerðar á lífraenni endurgjöf (biofeedback), oft með viðunandi árangri. 58 ...
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Complex regional pain syndrome, CRPS, occurs with severe disabling pain, usually in the leg or hand, coupled with changes in pain perception, hyperesthesia and allodynia. There is as well, edema, changes in the color of the skin, trophic changes, and dystonia. The pain syndrome is often triggered by minor trauma. The pain perception is severe and out of context with the initial trauma. The syndrome is rare, occurring in a population-based study in the United States, with an incidence of only 5.5 per hundred thousand people per year. The incidence in Iceland, from the National Register of Diseases from the Directorate of Health, was 1.3 per annum, per hundred thousand people. The exact etiology of the disease is unknown. It is presumed that inflammation is the cause, often resulting from an autoimmune reaction. The term pain sensitization is also used to describe the pain mechanism, both in peripheral nerves and in the central nervous system. There are changes and displacement of the area of the neocortex that is coupled with pain perception. The criteria of the International Association for the Study of Pain (IASP) were the basis for the diagnosis. Interdisciplinary team management according to the biopsychosocial model is thought to be the preferred treatment approach. The members of the team are occupational therapists, physiotherapists, social workers, psychologists, nurses, and medical doctors, augmented by other disciplines as needed. One treatment option is mirror therapy, where the diseased extremity is held behind a mirror during the training and the patient observes movements of the healthy extremity. Initially treatment is aimed at treating the inflammation, often with NSAID drugs, or with steroids. Medical treatments are the same as apply for the treatment of neural pain, with drugs such as Gabapentin, or anti depressive agents as duloxetine or imipramine. There is an indication to use bisphosphonates such as alendronate, especially if there is osteoporosis. It is assumed that the function of the NMDA receptor has changed in the central nervous system and treatment with intravenous ketamine, is an option. Spinal cord stimulation of the dorsal horns of the spine has been effective as well. In majority of cases the syndrome resolves in the first two years, but for the rest the prognosis is dire, symptoms getting worse and persisting for years and even decades.
... The results of data analysis showed that twelve weeks of NFT led to the pain reduction, which is in line with the following studies: Kayıran et al, examining the effect of NFT (8 weeks, 4 times a week and 30 minutes in each session) on pain reduction in patients with fibromyalgia syndrome [13]; and Jensen et al, investigating the effect of NFT (20 days and 30 minutes per session) on pain reduction patients with complex regional pain syndrome [33]. To understand the mechanism of efficacy, it is necessary to describe the mechanism of pain perception. ...
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Background: Patellofemoral pain syndrome (PFPS) has been reported as one of the most common reasons for knee pain which accounts for about 30% of all injuries seen in sport medicine clinics. These group of patients have Postural Balance disorder that can cause pain, dysfunction in proprioception and decreased muscle strength. We aimed to study a twelve-week neurofeedback training (NFT) on pain, proprioception, strength and Postural Balance in PFPS patients. Methods: This randomized controlled trial included 32 patients with PFPS who were randomly allocated into experimental (n=16) and control (n=16) groups. The variables measured included pain, knee proprioception 20 and 60 degrees, muscular strength quadriceps and hip abductors and Postural Balance that were evaluated before and after intervention. The experimental group performed NFT during twelve weeks, three times per week and 30 min per session, while the control group did not receive any treatment during this time. Covariance statistical method was used for data analysis. Results: The results of data analysis showed that the experimental group had significant improvement in postural balance index anterior-posterior (P<0.004), overall stability (P<0.003), knee proprioception 20 degrees (P<0.004), knee proprioception 60 degrees (P<0.004), quadriceps muscle strength (P<0.007) and pain reduction (P<0.001). However, postural balance index medial-lateral (P>0.140) and hip abductor muscle strength (P>0.164) had no improvement after twelve weeks of NFT. Conclusions: The NFT through thalamus inhibition led to reduced pain and improved sensory pathways, sensory integrity, increased attention and cognition. They also led to improved proprioception, Postural Balance, overall stability and quadriceps muscle strength. It is suggested that future studies examine the impact of long-term and short-term NFT on the variables of the present study.
... The alpha power on Pz was lower in the cognitive decline group than in the control group. The increase in alpha power in the posterior parietal region, which is reflected by Pz, is a physiological index indicating a state of mental relaxation (Jensen et al., 2007). It has been shown that people with cognitive decline have been feeling mental stress for a long time due to lack of understanding or misunderstanding from those that surround them (Sharp, 2019). ...
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Robot-assisted activity (RAA) is a non-pharmacological therapy used to treat behavioral and psychological symptoms of dementia. This study investigated the immediate effects of RAA on psychological and neurophysiological indices. Twenty-eight elderly people were assigned to the cognitive decline group ( n = 11) or control group ( n = 17) based on their Mini-Mental State Examination scores. After 5-min RAA sessions that involved patients interacting with a communication robot, patient emotions and mood states were measured, and resting-state EEG activity and salivary cortisol were assessed before and after RAA. We found that compared with those in the control group, participants in the cognitive decline group did not enjoy RAA using the communication robot. This was corroborated by EEG findings indicating decreased relaxation immediately after RAA exposure. These results suggested that participants with cognitive decline had difficulty understanding the contents of communication with the robot. Our results indicated that elderly people who have cognitive decline and use day-service centers are less likely to experience the immediate benefits of RAA, including positive emotions and mental relaxation. To conduct effective RAA for such populations, it may be useful to select a method that is better understood and enjoyed by participants.
... Several neurofeedback studies have shown pain reduction following neurofeedback. Key randomized controlled trials in the field have been summarized in Table 2. Reduction in pain has been reported across several pain conditions such as Fibromyalgia [27,29,36,41], Central Neuropathic Pain in Paraplegic patients [28,43,[47][48][49], Traumatic Brain Injury [39,50], Chemotherapy-Induced Peripheral Neuropathy [51], Primary Headache [52], Complex Regional Pain Syndrome Type I [53], Post-Herpetic Neuralgia [37] and chronic lower back pain [54]. There is a wide [17]. ...
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Neurofeedback is a novel neuromodulatory therapy where individuals are given real-time feedback regarding their brain neurophysiological signals in order to increase volitional control over their brain activity. Such biofeedback platform can be used to increase an individual’s resilience to pain as chronic pain has been associated with abnormal central processing of ascending pain signals. Neurofeedback can be provided based on electroencephalogram (EEG) or functional magnetic resonance imaging (fMRI) recordings of an individual. Target brain rhythms commonly used in EEG neurofeedback for chronic pain include theta, alpha, beta and sensorimotor rhythms. Such training has not only been shown to improve pain in a variety of pain conditions such as central neuropathic pain, fibromyalgia, traumatic brain injury and chemotherapy induced peripheral neuropathy, but has also been shown to improve pain associated symptoms such as sleep, fatigue, depression and anxiety. Adverse events associated with neurofeedback training are often self-limited and resolve with decreased frequency of training. Provision of such training has also been explored in the home setting whereby individuals have been encouraged to practice this as and when required with promising results. Therefore, neurofeedback has the potential to provide low-cost yet holistic approach to the management of chronic pain.
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Introduction. This study examines recovery of attentional measures among a heterogeneous group of clients in a pre-and post-comparison using inter-hemispheric EEG training at homologous sites. A continuous performance test was used as an outcome measure. The client population was divided into three categories: (a) primarily attentional deficits, (b) primarily psychological complaints, and (c) both.Method. Neurofeedback protocols included T3-T4, Fp1-Fp2, F3-F4, C3-C4 and P3-P4. A wide range of reward frequencies was used, and these were individually selected to optimize the subjective experience of the training. Participants were 44 males and females, 7 to 62 years old, who underwent treatment for a variety of clinical complaints. Dependent variables were derived from a continuous performance test, the Test of Variables of Attention (TOVA), which was administered prior to EEG training and 20 to 25 sessions thereafter.Results. After EEG training a clear trend towards improvement on the impulsivity, inattention, and variability scales of the TOVA was evident. Participants with normal pre-training scores showed no deterioration in their performance, indicating that homologous site inter-hemispheric EEG training had no deleterious effect on attention. In addition reaction time was predominately in the normal range for this population and remained unchanged following training.Conclusion. Normalization of attentional variables was observed following training irrespective of the primary clinical complaint. These results suggest that inter-hemispheric training at homologous sites provides another “generic” EEG biofeedback protocol option for addressing attentional deficits. Inter-hemispheric training likely serves as a general challenge to the regulation of cerebral timing, phase, and coherence relationships. Such a challenge may result in more effective regulation of cerebral networks, irrespective of whether these are involved in attentional or affective regulation.
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Introduction. Trigeminal neuralgia is characterized by brief episodes of extremely intense facial pain often radiating down the jaw. These episodes can occur spontaneously or be triggered by light touch, chewing or changes in temperature. The pain can be so intense as to be completely disabling. This case study concerns a 46 year-old nurse with a 15-month history of trigeminal neuralgia. She had been maintained poorly on propoxyphene napsylate/apap 100/650 mg (Darvocet-N100) over the previous year. Her neurologist's next planned intervention was to sever the trigeminal nerve.Method. Over a period of nine months, this client had 10 peripheral biofeedback training sessions (including dynamic EMG biofeedback) and diaphragmatic breathing in conjunction with a program of stress management and counseling. She also received 29 sessions of neuro-feedback (including T4, C3, C4, C3-C4 and T3-T4). C3 seemed to be the most effective placement for sleep maintenance issues, and T3-T4 seemed to be the most effective placement for pain issues.Results. The client experienced a substantial reduction in pain and bruxism as well as improvement in sleep quality. Symptom reduction fluctuated with life stress issues and with adjustment in both peripheral and neurofeedback protocols. The success of this treatment allowed the client to avoid radical surgery (severing of the trigeminal nerve) and to discontinue use of propoxyphene napsylate/apap 100/650 mg. In a 13-month follow-up, the client reports having an active life style and managing her pain quite well on 20 mg of tramadol (Ultram) every 12 hours as long as she uses her self-regulation techniques.Conclusion. This case study suggests that a multi-modal approach of neurofeedback, peripheral biofeedback, stress management and counseling was clinically efficacious in treating the symptoms of this difficult and painful condition.
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purpose of this chapter is to critically evaluate the available self-report measures of pain / our hope is that the chapter will assist clinicians and researchers to select the procedures that best serve their purposes / begin with a brief discussion of issues relevant to the use of self-report pain scales / describe and critique the methods currently available for assessing three dimensions of the pain experience: pain intensity, pain affect, and pain location (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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A patient with chronic pain due to a reflex sympathetic dystrophy in his hand and arm was successfully treated with temperature biofeedback after several months of conservative standard medical care brought little relief. Over the 18 treatment sessions the patient learned to emit a reliable handwarming response of 1 to 1.5 degrees C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.
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