NFL Standings

All Times EST

AMERICAN CONFERENCE

East

W L T Pct PF PA

N.Y. Jets 7 3 0 .700 289 221

Miami 6 4 0 .600 209 197

New England 6 4 0 .600 219 194

Buffalo 5 4 0 .556 192 189

South

W L T Pct PF PA

Tennessee 10 0 0 1.000 244 131

Indianapolis 6 4 0 …

A lesser charge of affray is admitted

A Street woman who faced charges of blackmail and robbery haswalked from Taunton Crown Court after the charges were dropped bythe Crown Prosecution Service.

Gillian Seddon, 54, of Farm Road, pleaded guilty with ColinHealey, 53, of Newcastle-on-Tyne, to a lesser joint charge of affray- using or threatening unlawful violence to Trevor Morgan …

U.S. Beats Sweden 2-0 on Wambach Goals

CHENGDU, China - Playing with a sore toe and 11 stitches in her head doesn't seem to bother Abby Wambach.

The top U.S. striker scored both goals Friday in a 2-0 victory over Sweden in the women's World Cup. She now has three in two games, and the win puts the No. 1-ranked Americans in good position to make the quarterfinals.

Wambach converted a penalty in the 34th, and scored a textbook goal in the 58th, settling a long ball on her chest from Kristine Lilly and then driving a 15-yard, left-footed shot past Sweden keeper Hedvig Lindahl.

Wambach has scored 80 goals in 98 games for the U.S. national team, which is seeking its third World Cup to go with titles in '91 …

11 police killed in land mine explosion in India

Suspected Maoist rebels blew up a police van in India's restive east on Wednesday, killing at least 11 police, an official said.

The attackers detonated a land mine targeting a police patrol in West Singhbhum district, about 100 miles (160 kilometers) east of Ranchi, the capital of Jharkhand state, senior police official V.D. Ram said.

Six other police officials were critically injured in the attack, Ram said.

About 30 people were in the police van at the time, Ram added, but no details about the others were immediately …

Umm Kulthum (c. 1904–1975)

Umm Kulthum
(c. 1904–1975)

Umm Kulthum (also Om Kultum, Oum Kalsoum, Umm Kaltum, Um Kultum) Ibrahim al-Baltaji was one of the most famous singers of the Arabic-speaking world in the twentieth century. Her eventual role as a cultural icon made her arguably the most important Arab musician of her time.

PERSONAL HISTORY

Umm Kulthum was born in Tammay al-Zuhayra, a village in the Egyptian delta, probably in 1904. Her father, Ibrahim al-Baltaji, was the imam or prayer leader of the local mosque; her mother, Fatima al-Maliji, was a housewife. She had an older brother, Khalid, and sister, Sayyida. The family was poor and its lifestyle not different from most of her Egyptian contemporaries. To make extra money, Umm Kulthum's father sang religious songs for social occasions such as weddings or saints' days and trained his son to accompany him. Umm Kulthum learned these songs by virtue of proximity and surprised her family with her strong voice. Eventually, dressed as a boy, she joined her father's group and performed regularly in the eastern delta. Despite efforts to disguise her gender, she soon was known as the little girl with the powerful voice and became a local curiosity that attracted attention to the family troupe.

She also joined her brother in Qur'an school, or kuttab, small local schools designed to teach children to recite the Qur'an properly, to read, write, and sometimes to do some arithmetic. (During Umm Kulthum's childhood, British colonial authorities did not encourage further education for Egyptians.) Although attendance at kuttab was more routine for boys than girls, there were other girls in Umm Kulthum's class and, in fact, the lessons of the kuttab formed a common fund of knowledge for most Egyptian Muslims of Umm Kulthum's generation. Despite the predictable variability in teaching at these schools, the children tended to absorb a respect for careful pronunciation of Arabic and a sense of the beauty and elegance of the language that remained with many of them throughout their lives. These widely shared sensibilities informed Umm Kulthum's later aesthetic choices and helps explain the strong connections many of her compatriots felt for her art.

The then-new sound recordings—78 rpm gramophone records that circulated all over Egypt in the early years of the twentieth century—provided another means for Umm Kulthum and her family to learn the art of singing and new songs. Because record players often appeared in public spaces—coffeehouses, for example—even people who could not afford the equipment could hear the recordings. The father of one of Umm Kulthum's childhood friends also owned a record player and invited villagers to listen to records in his home. From these, Umm Kulthum learned to love the religious poetry (Arabic: qasa'id, singular: qasida) performed by al-Shaykh Abu'l-Ila Muhammad who later became her teacher in Cairo.

Following years of traveling the delta, Umm Kulthum came to the attention of musicians from Cairo, themselves traveling to perform at events often sponsored by local wealthy families. They encouraged her father to move the family to Cairo, where increased income and opportunities would be available. After some consideration, the family decided to join the large numbers of villagers migrating to the city in search of work. …

Lead with your tongue

OUTSIDE THE BOX

Each of us is possessed with great influence and a great influencer our tongues. The words we say matter very much. Even further, identifying those who should have influence over us is founded on whether their words are truly from heaven. Are they truly wise? How do we know? We know because those who have golden tongues are those whose speaking matches God's speech and whose speaking matches their God-shaped living.

The bishop of Constantinople (present day Istanbul) in the early days of official Christendom was John Chrysostom. In the late 300s A.D., Christianity had become the official religion of the Roman Empire. With this rise to prominence, the church …

IRS Announces Rebate Schedule

If you want to be the first on your block to get your $600 economic stimulus payment, the IRS has a tip: Sign up to get your 2007 tax refund via direct deposit.

Among those receiving rebate checks, people with Social Security numbers whose last two digits are low _ say, 06 _ will get their checks first, the agency announced Monday.

Taxpayers who receive their refunds _ or make payments _ through direct deposit will begin receiving payments by May 2, with all such deposits expected to be made within two weeks.

Then, starting by May 16, the rest of the 130 million stimulus payments will start going out as checks sent through the mail. Stimulus …

Survey to track sea mammals

A Survey of whales, dolphins and porpoises around the North-eastcoast is underway.

It is part of the annual UK National Whale and Dolphin Watch.

And the Sea Watch Foundation is keen to involve more people intracking the elusive sea mammals.

Volunteers are invited to take part in any of a series of mannedwatches.

Norcet surveys will be taking place on NorthLink ferries fromAberdeen to Shetland and …

Mergers and acquisitions

Peak Sulfur Purchases Arch Chemicals' Sulfuric Acid Business

Arch Chemicals, Inc. (Norwalk, CT; www.archchemicals.com) has sold its sulfuric acid business to Peak Sulfur, Inc. (Lenexa, KS; www.peakinvestments.com) to pursue growth opportunities in two key areas: treatment products and microelectronic materials. The assets include Arch's manufacturing plants in Shreveport, LA, and Beaumont, TX, which provide sulfuric-acid production and regeneration services to Gulf Coast oil refineries, as well as to the pulp-and-paper and water-treatment industries.

Stepan …

EU agrees to double EIB financing

European finance ministers agreed Saturday to use the EU's lending bank to help small- and medium-sized companies raise funds in a tight economic environment.

French Finance Minister Christine Lagarde said the plan called for a 50 percent increase in financing to the European Investment Bank in 2008 and 2009 _ to about euro15 billion (US$21 billion).

The funds would be part of an overall euro30 billion (US$42 billion) package to last until 2011, she said.

"We agreed that our economic area is facing various shocks, in particular a financial shock, inflation shock and an exchange rate shock, and that the common response is a strategy which is …

Braxton County slides by Point Pleasant: ; Berth is first trip to state title game for any team in schools 40- year history

Braxton County High School's baseball team is going where noother team in the history of the school has gone.

The unheralded Eagles (23-6-1) advanced to their first statechampionship game Thursday when they beat four-time defending Region1 champion Point Pleasant (15-15) 9-6 in the Class AA semifinals atAppalachian Power Park. They will play the winner of Thursdaynight's game between Sissonville (26-11) and James Monroe (16-12) inthe state championship game at 11 a.m. Saturday.

"Isn't that cool?" Braxton Coach Bill Morlan said after his teamrallied for six runs in the top of the sixth inning to overcome a 5-3 deficit. "Baseball is not a top sport at our school, so …

Simple precautions can cut risk of accidents at home

Working outdoors and around the house is one of the small joysof being a homeowner. Unfortunately, household accidents, many ofthem caused by the tools and supplies we keep in our garages, killabout 20,000 Americans and injure another 3 million each year,according to the National Safety Council.

Many of these accidents can be prevented if you take a fewsimple precautions. Here is a list of safety measures that can helpyou avoid common household mishaps.

Lawn and garden equipment Wear long pants, close-fitting clothes and shoes with a good treadwhen working with lawn mowers. Clear the lawn of litter and rocks before mowing. Disconnect the spark plug before working on the lawnmower. Wait until the lawn mower's engine cools before refueling to avoidflash explosions. If you must use a chain saw, use only an up-to-date model. Recentsafety features, such as brakes that stop the chain quickly duringkickback, nose-tip guards and low kickback guidebars, can reduceinjuries dramatically. Wear protective clothing when using a chain saw - safety glasses,ear plugs and a hard hat. Flammable and toxic liquids

Gasoline can be as dangerous as explosives. Gas can explodeeven if the garage door is open. Also, many hot-water heaters arelocated in garages, and the pilot light can ignite gas vapors. Toprevent major mishaps: Store gas in a tightly closed container designed for the task andkeep it in a separate shed or building. Keep a home fire extinguisher handy. Other liquid menaces in the garage are paint, paint thinner, oil,varnish, weed killer and insecticides. Store these products in theiroriginal containers. Be sure they are properly labeled and lockedaway so children can't get at them. Power tools Don't use any tool unless you've read the instructions. Ground all power tools - power saws, heavy-duty staplers, powergrinders, buffers and sanders - unless they are double-insulated. Keep work areas clean. Never remove blade guards. Ladders Make sure ladders are placed on a solid, level surface so the legsdon't slip or sink. Wear dry shoes with good soles. Don't lean to either side or stand on the top rung. Remember that aluminum ladders conduct electricity; wooden laddersare usually safer. Electricity The best way to avoid shocks is by replacing ordinary wall outletsor standard circuit breakers with electrical safety devices calledground fault circuit interrupters (GFCIs). These devices cut offcurrent within microseconds if they detect current flowing to groundand setting up potential shock. If you have to use extension cords with power tools, be sure thatthe cord's current rating matches, or is greater than, the rating ofthe equipment. Don't operate power tools while wearing damp shoes. Don't evenenter a wet basement or garage if you suspect any electrical wiringhas made contact with water. Garage doors

Models that came on the market after 1982 incorporate safetycircuits that reverse doors if any obstruction, such as a foot, isencountered. But even with these newer models, the safety circuits,exposed to heat and cold, may not always work. One way to check: seta 4-inch-high board in the doorway and activate the switch. If thegarage door doesn't reverse once it touches the board, the safetycircuts are not adjusted properly or are malfunctioning.

Report: 25 Killed in China Karaoke Blast

BEIJING - A blast ripped through a karaoke parlor and bath house in northeast China, killing 25 people and injuring 33 others, state media reported Thursday.

Xinhua News Agency said the cause of the Wednesday night blast in Tianshifu township in Liaoning province was being investigated. Several employees and the wife of the parlor owner, who was killed, were being questioned, it said, without saying if they were suspects.

Xinhua initially put the death toll at five, but said 25 bodies were found when rescuers had finished clearing away debris from the blast.

China has suffered a string of blasts, fires and accidents in shopping malls, movie theaters and other public places despite repeated government promises to improve safety. Many are blamed on lax safety procedures and negligence.

In 2005, a fire in an illegally run bar in the southern city of Zhongshan killed 26 people. Local officials said the bar lacked fire extinguishers and its emergency exit was too narrow.

In China's worst recent nightclub disaster, a fire blamed on a welding accident tore through a disco in the central city of Luoyang in December 2000, killing 309 people.

Local reports at the time said the building had failed 18 safety checks in two years.

Britons honored for helping Holocaust victims

British Prime Minister Gordon Brown on Tuesday honored Britons whose extraordinary actions helped save Jews and other Holocaust victims during World War II, calling them a source of national pride.

Brown met two surviving recipients _ Nicholas Winton and Denis Avey _ at a reception at his Downing Street home, and praised the role of 26 others in saving the lives of those persecuted by the Nazis.

Britain has minted a new "Hero of the Holocaust" medal _ a silver medallion _ after a campaign by Jewish groups and lawmakers to win recognition for the bravery of those involved in the rescues.

The 100-year-old Winton organized the rescue of 669 mainly Jewish children by train from Prague in 1939, before the outbreak of war. Many of their parents were later killed.

Avey, 91, says he switched places with a Jewish prisoner at the Auschwitz concentration camp to gather information about the facility, and helped a fellow inmate to survive by sharing food.

"These individuals are true British heroes and a source of national pride for all of us," Brown said. "They were shining beacons of hope in the midst of terrible evil because they were prepared to take a stand against prejudice, hatred and intolerance."

During a visit to the Auschwitz concentration camp last year, Brown promised to honor the group.

Among those receiving posthumous awards are a group of British prisoners of war who saved the life of 15-year-old Hannah Sara Rigler, by hiding her in a hayloft and secretly taking food to her.

Rigler, who is still alive and lives in New York, wrote an account of her rescue called "10 British Prisoners of War Saved My Life."

Aetna to trim work force 13%

HARTFORD, Conn. Aetna Inc. said it will cut about 5,000 jobs, or13 percent of the company's work force, and take $565 million infourth-quarter charges as the No. 1 U.S. health insurer tries toboost profits that lag behind those of its competitors. Aetna sharesrose as much as 19 percent.

Aetna, which has 40,000 employees, plans to fire 2,400 people, andeliminate the other positions through attrition. The company alsoplans to trim about 10 percent of its 19.2 million customers bydropping unprofitable business.

Aetna's profit margin is about half that of its competitors, andthe company has been under shareholder pressure to boost its stockprice. Aetna sold financial services and international units to INGGroep NV last week to focus on health care as it tries to stem lossesat the Prudential Healthcare unit it bought for $1 billion last year.

"They just have to follow through on their plan," said ArgusResearch Corp. analyst Edward Klebanow.

The restructuring is expected to raise Aetna's profit margin to alevel closer to that of competitors UnitedHealth Group Inc., CignaCorp. and WellPoint Health Networks Inc., Chief Executive John Rowetold investors and analysts in a conference call. Rowe said the moveswill leave Aetna with more profitable customers and lower costs.

"We believe we are on a course to steadily improve our financialresults," Rowe said.

On Jan. 1, Aetna will drop about 340,000 members from its Medicarehealth-maintenance organizations. The company also will drop about300,000 to 350,000 customers from its employer HMOs and about 1.5million Prudential customers. About 1 million other Prudentialcustomers will be moved to Aetna plans.

The company said it will raise prices next year about 11 percentto 13 percent for employer health plans and about 4 percent in itsremaining Medicare markets.

It expects medical costs to rise by about 10 percent for HMOs andabout 11 percent to 13 percent in its other plans during 2001, Aetnasaid. Still, Aetna said, it expects to cut its HMO medical-cost ratio-the amount of every premium dollar that pays for medical costs-by 1percent to 2 percent.

The company said it expects to take a $100 million charge thisquarter for the job cuts. It will also record a $235 million chargerelated to leaving some Medicare markets as of Jan. 1 and a $35million charge related to the spinoff of Aetna.

Turkmenistan allows Internet access for private citizens

Turkmenistan has begun allowing private citizens to connect to the Internet in the latest sign the reclusive Central Asian nation is opening up to the world.

The country's only Internet provider, Turkmentelekom, said Thursday that it has been connecting up to 20 homes daily since the start of the week, mainly in the capital Ashgabat. It said it has a waiting list of 2,000 people.

"As of this week we have begun connecting customers, regardless of their professional status," a Turkmentelekom statement said.

Since becoming president, Gurbanguli Berdymukhamedov has reversed some of the most draconian restrictions imposed by his eccentric predecessor, Saparmurat Niyazov, who died in 2006.

Last year, Berdymukhamedov allowed the country's first Internet cafe. Until then, Internet use had been restricted solely to government employees, diplomatic posts and offices of major international companies.

But the average monthly salary in Turkmenistan is US$200, so it was unclear how many people will be able to afford home connections. Nor is it known whether the government will block certain Web sites.

Surfing the net will cost around US$ 1 per hour, on top of a monthly charge of US$8. Initial hookup costs are US$42. Most of the few Internet cafes that have opened in the past year charge up to US$2 an hour and are closely monitored.

Turkmentelekom also is offering exceptionally slow dial-up connection speeds, which may frustrate Web surfers.

Under Niyazov, people in the energy-rich ex-Soviet republic were largely cut off from the world. State-run television broadcast persistent paeans to Niyazov and devoted extensive coverage to his travels and ceremonies. All newspapers were government-controlled.

In recent years, however, satellite TV dishes have become popular, particularly in Ashgabat and other larger cities, giving more affluent Turkmen families access to Russian, Turkish and other foreign television.

Report: Hispanics fear backlash over immigration

MIAMI (AP) — Hispanics are increasingly concerned about a backlash against them, even as they are split over the effects of illegal immigration on the country. Their anxiety comes as illegal immigration and border security are playing major roles in election campaigns nationwide.

More than 60 percent of Latinos say discrimination against Hispanics is a "major problem," up from 54 percent who said the same in 2007, according to a report to be released Thursday by the nonpartisan Pew Hispanic Center.

Three years ago, Hispanics were most likely to cite language skills as the biggest reason for discrimination. Now, more than a third believe immigration is the biggest factor.

That said, the number of Latinos who reported they, their family or close friends have experienced discrimination remained unchanged from last year and actually dropped from 2007.

Hispanics make up about 15 percent of the U.S. population and also comprise the vast majority of the country's roughly 11 million illegal immigrants.

The rise in concern comes as candidates, particularly Republicans, are increasingly featuring illegal immigration in their campaigns. U.S. Senate hopeful Republican Sharon Angle in Nevada has released ads linking her opponent Democratic Sen. Harry Reed to illegal immigrants with video of what appear to be scary-looking Latino gang members.

Mark Lopez, associated director of the Pew Hispanic Center and the report's co-author, believes the rising concern comes in part from media reports about what could happen in the future.

"There's been a lot of discussion in the media about the potential impacts of different policies that have been proposed, such as Arizona's law and how that might affect immigrants — and how it affects Latinos," he said. "But we've noticed no change and, frankly, Arizona's law has not been implemented."

Earlier this year a judge blocked some of the most controversial parts of the state's new law including a requirement that officers automatically investigate the immigration status of individuals they stop and automatically detain those stopped for a minor crime who immediately can't prove they are in the country legally.

Lopez also noted that while the number of deportations has jumped in the last two years, the majority of those now being deported are convicted criminals, many of whom may already be in law enforcement custody.

Despite their fears, Hispanics are hardly unified as to their views on illegal immigration itself: roughly equal parts believe it has had a positive influence, no effect or a negative influence on the U.S.

But on the larger issue of what to do about illegal immigrants already in the country, the vast majority support a path to citizenship if the individuals pass background checks, pay a fine and have a job. And they believe the children of these immigrants who are born in the U.S. should retain their U.S. citizenship.

The survey of 1,375 Latino adults was conducted in Spanish and English via cellular and landline phones between Aug. 17 and Sept. 19. The margin of error for the poll was 3.3 percentage points.

___

Online:

http://pewhispanic.org/

(This version CORRECTS Replaces last graf to correct 'percent' to 'percentage points.')

US man in joking mood despite nail in brain

OAK LAWN, Illinois (AP) — Gail Glaenzer still can't believe that her fiance unknowingly shot a nail into his skull, let alone that he posted a picture of the X-ray on Facebook during his ambulance ride between hospitals for surgery.

But she was joking about the circumstances Friday, a day after doctors successfully removed the 3.25-inch (8.25-centimeter) nail from Dante Autullo's brain.

"Dante says, 'I want it to make a necklace out of it,'" Glaenzer said.

Glaenzer sat Friday in the lobby of Advocate Christ Medical Center, where Autullo, 32, was listed in fair condition in the hospital's intensive care unit. She was still trying to process just how lucky the father of her four children was.

"He feels good. He moved all his limbs, he's talking normal, he remembers everything," said Glaenzer, 33. "It's amazing, a miracle."

Autullo was in his workshop using the nail gun Tuesday when it recoiled near his head, Glaenzer said.

He felt what he thought was the point of the gun hit his head. But what really happened was that when the gun came in contact with his head, the sensor recognized a flat surface and fired, she said.

"I looked at it when he got home, and it just looked like (his head) was cut open," she said.

With nothing to indicate that a nail had not simply "whizzed by his ear," as Autullo explained to her, she cleaned it with peroxide.

While there are pain-sensitive nerves on a person's skull, there aren't any within the brain itself. That's why he would have felt the nail strike the skull, but he wouldn't have felt it penetrate the brain.

Neither thought much about it, and Autullo went on with his day, even plowing a bit of snow. But the next day when he awoke from a nap, feeling nauseated, Glaenzer sensed something was wrong and suggested they go to the hospital.

At first Autullo refused, but he relented after the two picked up their son at school Wednesday evening.

A couple hours later an X-ray was taken, and there in the middle of his brain was a nail. Doctors told Autullo and Glaenzer that the nail came within millimeters from the part of the brain that controls motor function.

Hospital spokesman Mike Maggio said the surgery took two hours, and the part of the skull that was removed for surgery was replaced with a titanium mesh. The surgeon didn't want to put that part of the skull back in place, fearing it might have been contaminated by the nail, he said.

Glaenzer said that while Autullo hasn't really talked about how scared he was about what might have happened, he did express a recognition about coming close to death.

"He was joking with me, (after surgery), 'We need to get the Discovery Channel up here to tape this,'" she recalled him saying. "'I'm one of those medical miracles.'"

Japanese crafts exhibit leaves children smiling

"When children see these religious Japanese artifacts, it's just amazing to watch them interact with beautiful smiles and pure faces as they look at the art."

So says the Rev. Mark Pinto, a docent and exhibit coordinator for a spectacular cultural and religious showcase-- "The Vision and Art of Shinjo Ito"--under way at the Chicago Illuminating Co. on the South Side. The exhibit showcases some 100 works by Japan's Shinjo Ito (1906-1989), an artist and revered Buddhist grand master (he founded the Shinnyo-en Buddhist order).

"Children really love this exhibit, especially the 16-foot-long, gold-colored sculpture of a reclining Buddha," said Pinto. "But we wanted to have a special day just for kids, too."

Children's Day will offer youngsters a free box lunch and participation in activities relating to Japanese culture. "They also get to watch a koto player perform. The music it creates is beautiful and peaceful," Pinto said.

Activities include:

- Fish painting: The Japanese art of fish painting was developed as a way for fishermen to record the size and species of their catch. Kids will place a sheet of paper over a faux fish and rub the reliefs with paints.

- Origami: Participants will make simple paper folding art with four to five folds.

- Collage: Youngsters will be given art supplies to create a collage that will become a large mural for the Shinnyo-en Head Temple in Japan.

- Scavenger hunt: The game encourages kids to find six works of art. Everyone is a winner and will receive a special award certificate.

- Do you know Shinjo? The workshop includes coloring with Billy the Squirrel.

Admission to Children's Day and the exhibit is free. The exhibit goes through May 1 at the multiarts rental facility at 19 E. 21st St.

An information center is set up at 102 E. Oak to provide a free trolley to the exhibit and back.

Call (312) 326-9500; www.ShinjoIto.com/events.

Photo: Kids can try origami during Children's Day at the exhibit of Shinjo Ito art under way at the Chicago Illuminating Co. ;

Linda Ronstadt // `Canciones de Mi Padre' // Singer goes back to her roots for an evening in old Mexico

NEW YORK Linda Ronstadt discovered the magic of the mariachi whenshe was just shy of 13 years old. The young man who had hired themusicians to serenade her wasn't shy at all.

"It was in Guadalajara, and he was the son of the guy who ownedthe A&W root beer stand there," reminisced Ronstadt as she relaxed inher hotel suite here with early-afternoon tea. "It must have costhim three or four weeks' salary. He brought the whole mariachi in two taxis. They played for me for about 25 minutes, and then theyset off all these firecrackers and off they went.

"He meant business, because all he had to do was wait aroundfor a couple more years. In Mexico, when you're 15, you're ready toget married."

Ronstadt never married her music-minded suitor - or anyoneelse, for that matter - but she never lost her taste for the romantic music of old Mexico. In fact, her tour insupport of her "Cancionces de Mi Padre" album ("Songs of My Father")carries the subtitle "A Romantic Evening in Old Mexico." Ambitiouslyconceived, impressively staged and beautifully choreographed, thesame show that ran for three weeks on Broadway will play Poplar CreekMusic Theatre in Hoffman Estates next Saturday and Sunday.

Fans shouldn't expect to hear anything from her rock period, orher standards period, or from the traditionally country "Trio"project that she recorded with Dolly Parton and Emmylou Harris. Incostume and in character throughout the two-act revue, Ronstadtdoesn't even speak a word of English. The program sold at mostconcerts is simply a glossy souvenir, but Ronstadt's provides fulltranslations of the songs, a history of the mariachi, and biographiesof the principals within the 21-person cast of singers, dancers andactors.

"It's little pieces of traditional life in Mexico," explainedRonstadt of the staging. It represents an attempt to place themusic in context, from its courtship rituals to its songs ofrevolution, from the traditional "La Bamba" and familiar hat dance tothe heartbreak balladry of the most gorgeous vocal music in LatinAmerica.

"I wanted to bring this music with all the dirt around itsroots," continued Ronstadt, though the production is definitely moreglossy than rootsy. "People have too long associated it withsomething that is background noise in a restaurant, while they'regetting drunk on margaritas. And that's not what it is. InMexico, people live and die by this music; they really feel it.It's in every restaurant, in the street, it's in every wedding, everyfuneral, every baptism, or any other excuse for a party."

As the title of her album indicates, Ronstadt's own associationwith the music is deeply familial. "We sang Mexican music as afamily, together," she explained. Her father's ancestors lived inthe Tucson, Ariz., area, where Ronstadt later was raised, before itbecame part of the United States. "People ask when my family movedfrom Mexico, and I say that we didn't. The border moved. We'vebeen there forever. Tucson was still much more Mexican than Anglountil after World War II."

Ronstadt enjoyed her biggest success in the '70s as acountry-rock singer, but she maintains that Mexican music is more apart of her than rock ever was. While remaining in characterthroughout the "Canciones de Mi Padre" production, she appears farmore comfortable and natural than she did during her rock tours.Her singing style remains distinctively full-voiced, perfectly suitedto the dramatic, romantic narratives of her Mexican selections.

"It's a role, but it's closer to my true identity," she said."I always used to say that I borrowed my mother's personality for theNelson Riddle music (on the three albums of standards that sherecorded), and borrowed my father's personality for the Mexicanmusic, but it really is my very integrated personality that singsthis music.

"Rock 'n' roll was a part of my personality, but it was thatpart of my personality that was a lot more competitive andaggressive. It was a smaller splinter of my personality than thisis, or the Nelson stuff was. And it's a lot healthier for me to dothis than to splinter myself off.

"The character up there is me," she continued, "but she's alsoa character that's based on all the impressions that I received as achild: stories from my grandfather, my grandmother and my father,trips that we took, stories about the revolution that my father andgrandfather personally witnessed, and things about the traditionsthat they taught me."

Whatever her affinity for Mexican tradition, Ronstadt admittedthat it wasn't easy to master these songs on a professional level.Far from fluent in Spanish, she needed to have the materialtranslated and explained, and then she had to memorize it. Toperform with the best mariachi musicians, she had to make herphrasing and timing much tighter than it was for family singalongs.

"I had to spend 15 to 30 hours on each song, just to be able toget through it without stumbling," she said. "When you're singingwith a full mariachi, there's only one right way to do it. Theyknew I was serious, and they really showed me the subtleties. . . .I know what every little article and adjective and tiny littleconjunction means, 'cause otherwise you can't really sing it with theright kind of emotion."

Backing Ronstadt in concert is the 13-member Mariachi Vargas deTecalitan, an orchestra that boasts 90 years of tradition andcontinuity. The band is currently led by violinist Jose "Pepe"Martinez, whose grandfather was part of its original violin sectionin 1898, and whose father was its harp player in the 1940s. Therichness of the group's string arrangements transcends all barriersof language and culture, and the audience response to Mariachi Vargasgenerally rivals the reception accorded Ronstadt herself.

Her supporting cast also includes Danny Valdez - a veteranactor, singer, musician and co-producer of the 1987 film "La Bamba"(directed by his brother, Luis Valdez). Six dancers are featuredprominently, performing traditional dances as well as original dancesby Michael Smuin. The show's director and choreographer, Smuinformerly worked for the San Francisco Ballet.

Though Ronstadt maintains that the production requires notranslation, she admits that audience reponse has been most wildlyenthusiastic in the heavily Mexican areas of the Southwest. "Theyreally understand the songs and the jokes, and they do a lot ofshrieking and carrying on," she said.

"Mexicans are very funny, and there are tons and tons of doubleentendres. In agrarian music, the whole thing is fertility andreproduction, getting the crops to bloom and the animals to reproduceand the people to have babies so you have somebody to work thefields. The songs are charged with spring fever.

"An agrarian culture just has a whole different set ofpriorities, and I'm very attracted to that," she continued. "Becausethis is music of an agrarian society rather than a consumer society,which is what we have here, it is music about the kind of values thatwe're losing here. The idea that if you have something you have tomaintain it, and take care of it, as opposed to throwing it awaybecause it's out of style six months later. The songs are really aliving representation of that, because they've saved the songs overhundreds of years."

By contrast, contemporary American music seems like an exampleof cultural disposability to Ronstadt. For all of her rock 'n' rollsuccess, she never identified with the music's rebellion againsttradition.

"I grew up in the country, and I grew up with people who valuetradition," she explained. "During the '60s, when everybody hatedtheir parents, I didn't. My dad was a real good singer, and he hadgreat taste in music and he had great ideas. And my mother was anextremely well-educated, nice person, and there was no reason in theworld for me to hate her.

"Rock 'n' roll was a valid expression, when you're in your 20sand you have an identity crisis and you're trying to establishyourself as an independent module from your parents, but I justdidn't fit that mold."

Since her recent projects have been surprisingly successfulcommercially - "Canciones de Mi Padre" earned gold records both inMexico and the States - Ronstadt doesn't feel any pressure torestrict her musical possibilities. With no plans to return to thecontemporary-music mainstream, she plans to follow "Canciones" with acouple of dissimilar musical challenges.

One is "Voces" ("Voices," in English), which is a revue-stylealbum based on Cuban music written by jazz trombonist Barry Rodgers."It's more like a musical, with a cast, and it'll probably eventuallygo onstage," said Ronstadt, who plans to limit her participation torecording the album.

The other project is an album of labor-of-love duets with AaronNeville, the honey-throated warbler of the Neville Brothers. "We'vesung everything from Schubert to Stephen Foster to New Orleans rhythmand blues," she said. "I think he's one of the best singers in thecountry. I love singing with him, and I learn a lot about singingfrom him."

And then?

"Well, I want to do lots more Mexican records, because thereare a lot more songs that I want to do and styles I want to explore,"she said. "As a singer, Mexican music is just so much more satisfyingthan contemporary American music. It's music with melody, ideas,poetry - not a two-note riff that's designed to take up room over theguitar player playing a lot of hot licks.

"You couldn't pry me loose from this stuff with a crowbar," shecontinued. "I don't care if anybody buys it or not. I'm just happyas a pig singing it."

McCain set for 'Saturday Night Live' cameo

My friends, it's John McCain, live from New York, just three days before the election. Aides to the Republican presidential candidate said Friday that McCain will make a detour from battleground states to appear on "Saturday Night Live," the late-night show that has been a must-watch for many during the political season.

Hosting the show this Saturday is actor Ben Affleck, a supporter of Democratic candidate Barack Obama. The musical guest is singer David Cook.

When McCain's running mate, Alaska Gov. Sarah Palin, appeared on the show Oct. 18, "Saturday Night Live" earned its best ratings in 14 years. Former star and head writer Tina Fey, a Palin lookalike, has been at the center of the show's recent parodies of the campaign.

"SNL" regular Darrell Hammond impersonates McCain on the late-night show, now in its 34th season.

McCain last appeared on "Saturday Night Live" in May, after clinching the nomination and while the Democratic primary continued. The 72-year-old Arizona senator joked about his age, saying: "I ask you, what should we be looking for in our next president? Certainly, someone who is very, very, very old."

When McCain hosted "SNL" in 2002, he mocked singer Barbra Streisand's political advocacy by performing a medley of her songs.

Obama appeared on "Saturday Night Live" briefly last season but canceled a return for its season opener in September, citing the devastation brought to parts of the country by Hurricane Ike.

___

On the Net:

"SNL": http://www.nbc.com/Saturday_Night_Live/

BUSH GIVES CHINA A PIECE OF HIS MIND `WE DISAGREE ON BASIC ISSUES,' PRESIDENT SAYS

WASHINGTON Navy crew members returning Thursday from 11 days ofdetention disputed China's account of the collision that brought downtheir surveillance plane, saying a Chinese pilot was at fault.President Bush said "tough questions" would be put to China at aninquiry next week.

His tone stern, Bush said at the White House, "The kind ofincident we have just been through does not advance a constructiverelationship between our countries.

"We disagree on important, basic issues," he said.

Through most of the protracted negotiations that freed the crewbut not their aircraft, Bush had approached Beijing with diplomaticcare, insisting the surveillance was legal but also approvingexpressions of sorrow that the Chinese pilot was lost and theAmerican plane did not seek approval for its emergency landing afterthe April 1 collision.

But after crew members told debriefers they were on a "fixedcourse" and had not swerved into the Chinese jet fighter, as Beijingcontended, Bush stood in the Rose Garden and let loose. He castigatednot only the crew's detention, but also China's record on humanrights and religious freedom.

The crew "did nothing to cause the accident," Bush said. They "didtheir duty with honor and great professionalism."

Details, Pages 6-7

Market Expanding Applications and Territories

Brands Adopt XLA Elastic Fiber in Rapid Succession

Interview with Juan Carlos Cuadrado

Global Business Director

Dow Fiber Solutions

The results reported by Dow Fiber Solutions in the first half of 2006 were positive. The company, a subsidiary of the Dow Chemical Company, is manufacturing and marketing a new stretch fiber, XLA(TM). In addition to achieving growth in revenue, Dow Fiber Solutions also expanded into new sales territories, and increased its presence or entered into new market segments including swimwear, active wear, work wear and intimates. The fact that a number of famous brands in Europe and the U.S. have given the product such a positive reception suggests that XLA meets a long-standing need for a quality, durable stretch fiber. What is the company's present situation and its future outlook? For answers, we interviewed Juan Carlos Cuadrado, Global Business Director of Dow Fiber Solutions.

ATB: Your business performance in the first half of 2006 was very satisfactory. Would you describe the results and topics of interest in detail?

Cuadrado: Dow Fiber Solutions is a subsidiary of the Dow Chemical Company, and we are involved in the manufacturing and marketing of XLA(TM), a revolutionary and premium new stretch fiber that is produced at our manufacturing facility in Tarragona, Spain. Technical and sales staff members throughout the Americas, Europe and Asia support our efforts.

There are a number of reasons for our favorable performance. First, the product itself is fulfilling a clear need for a versatile stretch fiber that can withstand high heat and harsh chemicals - not only in work wear and swimwear, where the benefits to consumers of XLA are clear, but in every major apparel segment and throughout the textile value chain.

For quite some time, textile manufacturers and retail brands have wanted to apply non-iron treatments to stretch fibers, for example, but less sophisticated materials cannot withstand them. XLA can. XLA also removes key steps like heat setting from the manufacturing process, which can dramatically compress the supply chain.

Second, with the Dow Chemical Company, we have a parent company that is committed to investing in and supporting Dow Fiber Solutions for the long-term, both financially and with its expertise in research and business development. We are primed to be a formidable force in the apparel segment, and I think the Dow Chemical Company is a key reason for that.

At Dow Fiber Solutions we've taken that support and created a successful, market-facing business unit. You can see the results in a number of areas.

To begin, in the woven fabric segment, we partnered with Calvin Klein and Brooks Brothers in 2004, while Ann Taylor, Nautica, Talbots and Eddie Bauer embraced XLA in the ready-to-wear segment in 2006.

XLA was also integrated into swimwear products early in 2006. The fiber's ability to withstand chlorine, UV light and even sunscreen were appealing to Nike and Adidas. They were among the first to adopt in Europe. XLA can actually withstand exposure to chlorine for more than 1,000 hours, which is longer than the host fiber. The application of XLA into suits by Brooks Brothers only goes to underscore the versatility of the fiber. XLA is ideal for suit fabrics because it can be blended with host fibers such as wool and cotton without sacrificing their essential appeal, and it is easy to color-match without impairing hand or drape. And a suit featuring XLA will have the durability to keep it looking and feeling good long after purchase.

It is important to understand the value XLA can add for apparel brands and manufacturers. An olefin-based monofilament elastic fiber, it offers excellent resistance to high heat and harsh chemicals while maintaining the stretch characteristics required for new applications and innovations. XLA has freed designers from constraints that have limited them in the past; it allows yarn spinners to improve the efficiency of the manufacturing process and it compresses the supply chain through the removal of the heat setting process.

Today, more than ever, consumers want comfort and ease of care in their clothing. This demand will continuously stimulate growth in the market for apparel that features stretch fibers. Fabrics containing XLA have made it possible to provide ease of care, dimensional stability, durability and comfort, all at the same time. Until now, this combination has been difficult or impossible to achieve.

Intimates featuring XLA can also be washed frequently without losing a gentle stretch, recovery and soft texture.

The introduction of XLA also helps our partners protect their brand image. With its durability, XLA allows clothing to last longer and to maintain its shape, even after repeated washings.

In every segment, XLA offers clear and differentiated value and helps our partners elevate the quality of the apparel they offer consumers.

ATB: How do you view the Japanese and Asian markets?

Cuadrado: From the very beginning, our company has adopted a global approach to marketing, and Japan and Asia are essential to our success. Japan is an innovative and creative center of production that never fails to surprise with the quality and uniqueness of the products it generates. It is a source of constant inspiration.

Throughout 2006, our company has expanded its resources in Asia. We have resident representatives in Tokyo, Shanghai, Taipei, Singapore and Mumbai. We are in the process of expanding our activities in both sales and technological guidance.

The structure of the supply chain is of paramount importance to us. We have sales and technical personnel in Asia who have allowed us to become much closer as an organization to customers from the yarn stage.

Furthermore, in addition to sales and technology, we have placed special emphasis on building our marketing organization in Asia.

Currently, we employ people from as many as 15 countries, all focused on creating unique innovations that benefit our customers.

ATB: What about new products?

Cuadrado: Since our debut at Premiere Vision in September 2002, we have provided marketing support to a handful of carefully selected brands. In the past four years, we have been able to copromote several innovative brand adoptions such as non-iron stretch shirts for men and women with Brooks Brothers and Flexible Fit underwear with Calvin Klein.

With our extensive research and technology capabilities, backed by the Dow Chemical Company, we are working constantly to develop new products and will continue to innovate while responding to our customers needs. In the next six months there should be several exciting new product announcements based on XLA's patented technology.

ATB: What is happening to your marketing within China?

Cuadrado: Our presence in China continues to grow at a rapid pace. Historically, China has been a commoditized market, but it has become far more sophisticated in the past few years: we hear a lot about the demand for high-grade items. We are highly optimistic about our prospects in the country.

To emphasize how important China is to our business, we are even planning to build a new research and development center in Shanghai that will employ 600 engineers.

ATB: What about the situation in the Southeast Asian market?

Cuadrado: In addition to China, India is another market on which we are placing a great deal of focus. We already have - and are looking to grow - an R&D center in India. Also, Dow Fiber Solutions has worked extensively with leading mills to develop innovative applications and treatments for XLA.

Innovations will of course continue to originate from Japan. In addition to Japan, China and India, we have employees in Malaysia, Thailand, Korea and Indonesia.

ATB: Would you describe the priority task for the future?

Cuadrado: We are going to work extremely hard to drive demand with promotions and marketing. We also plan to fully and enthusiastically support the marketing efforts of our partner brands and retailers.

There are a number of ways we can do this. First, we will aggressively participate in exhibitions including Premiere Vision, Lyon Mode for intimates and swimwear, and the Outdoor Retailer Show in the U.S., in addition to developing customized programs with specific retail and brand partners.

Second, we opened a showroom in the heart of Manhattan's garment district in New York City on October 11. This is a space in which our partners from around the world can immerse themselves in the XLA brand; it is very conducive to creative thought, the formation of new innovations and the building of collaborative relationships. The showroom will also be the host venue for continuously updated trend information, which will also be shared with our customers and partners across geographies.

Lastly, we have recently developed an entirely new brand identity and positioning that is resonating well with our partners and consumers. Our new brand positioning frees us to market more effectively in diverse geographies and segments. It is also worth noting that we unveiled our new identity in Shanghai, which demonstrates just how important Asia is to us.

With a striking new identity, aggressive marketing and global public relations campaign and, of course, a great product, we are certainly excited about the prospects for Dow Fiber Solutions in 2007 and beyond.

Police re-bail woman in flats murder probe until January 6 ; In brief

SHENFIELD:A woman arrested on suspicion of murdering a man in hisown home has been rebailed.

Her arrest came after Sean McCann was pronounced dead in a blockof flats in Gordon Road, Shenfield, in August. The 50-year-old hadsuffered a cardiac arrest.

The 43-year-old woman from Wickford who was in the flat whenpolice arrived, has been re-bailed until January 6.

F1 Preview: Spain presents F1 with a new problem that can't be so easily repaired: Racism

Formula One heads into the 2008 season expecting problems like tire blowouts, gearbox failures and spectacular crashes.

Fighting racism wasn't supposed to be on the list.

Governing body FIA announced the launch of an anti-racism campaign _ starting with the Spanish Grand Prix on Apr. 27 _ after British driver Lewis Hamilton endured racist taunts at the same track during F1 testing on Feb. 2.

Widely publicized photographs showed a group of people in the Catalunya Circuit stands wearing dark face paint with T-shirts displaying the slogan "Hamilton's Family."

"I'd really like to meet them when we return to Barcelona for the Spanish GP," F1 boss Bernie Ecclestone told The Associated Press in a telephone interview.

FIA expected F1 to rally around the initiative, but Ecclestone sees the Spanish fans' actions as unsportsmanlike behavior.

"I don't think we should even be talking about racism," he said. "I really think that they are against Hamilton for his ability, not because he is black. I always thought it was a bit of a prank _ they're probably not racist at all."

For many Spaniards, Hamilton shoulders the blame for Fernando Alonso's failure to win a third straight world championship last season. Alonso, who has since left McLaren, is one of Spain's most prominent sporting figures.

"If they wanted to boo Lewis when he comes out of the pits then it's up to them," Ecclestone said. "Let's just hope there are no more problems because it's bad for Spain, the country's promoters, the people, the sport."

The Spanish GP and the European GP _ to be held in Valencia on Aug. 24 _ would not be considered for removal from the F1 calendar due to the incident, according to Ecclestone.

Though FIA isn't revealing what its campaign will entail or the sanctions it could take, Ecclestone isn't worried.

"I don't know what kind of campaign you can create," he said. "A lot of times you create these campaigns without any real idea. I think FIA needed to react and people needed for them to react. I hope it just disappears now."

Catalunya circuit organizers are approaching the GP just as they always do since they have not been made aware of any special schemes to be organized.

"What we're studying is the implementation of more security cameras in the public areas to avoid what happened during testing," circuit spokeswoman Miriam Ramos said, with banners removed only if they are deemed offensive.

Alonso says his countrymen are not racist and that the media has blown the incident out of proportion. Hamilton returned to the Montmelo track for testing the next day to sign autographs and pose for pictures with fans as usual.

Though F1 is an international sport featuring drivers from Brazil to Japan to Australia, Hamilton is the sport's first black driver.

Martin Hines said there was "never a problem, never a question about" race when Hamilton raced karts for him from age 8 to 15.

"Everyone knew he was black and knew that he could become the first black F1 world champion," Hines said.

Bill Sisley _ the managing director at Buckmore Park _ also saw no signs of racial abuse directed at a young Hamilton, who debuted there when he was 8.

"We are racing people _ we're not interested in color, just racing. What happened in Spain never happened here in any instance _ it was absolutely appalling," Sisley said. "I sympathize with the circuit because what can you do to stop three or four people when so many are coming in?"

Though several teams have backed FIA's initiative, some outside the sport point to the sensitive subject of racism in Spain since it's not the first time such incidents have made headlines.

Madrid's image was tarnished in 2004 when spectators directed monkey chants at black England players during an international soccer friendly against Spain at the Santiago Bernabeu stadium. Many believe those actions hurt the Spanish capital's bid for the 2012 Olympics.

Though Spain has a "history of xenophobia," that's no excuse, said Tomas Calvo Buezas, director of the Center for Immigration and Racism department at Madrid's Computense University.

"Spain has one of the lower tolerances to racist behavior in Europe," he said. "In principle, Spain is a leader in terms of allowing equal rights to immigrants in terms of freedom of religious and cultural practices, but when it comes to actually providing them, it's a different story."

High immigration over a short period has fed some feeling of xenophobia in Spanish society. And with the unemployment rate rising and a national election coming on Sunday, the subject is a talking point since immigrants account for about 10 percent of Spain's 45 million population.

The problem is specifically worse in soccer, where ultras _ or fanatical right-wing supporters _ regularly abuse opposing players with racist taunts. Monkey chants have been heard at grounds in Zaragoza and Valencia.

The legislation is there to prosecute, but is rarely used.

"The government has passed strong legislation against racism ... the problem is that the judicial process is very complicated and very expensive," Calvo Buezas said. "So no one goes to court because of this and, subsequently, the police do not prosecute as much as they probably should. The immigrant then has no confidence in the court."

And few public figures are punished either.

Spain soccer coach Luis Aragones once referred to France striker Thierry Henry in racist terms and was fined euro3,000 (US$4,566).

Ecclestone said fans may have blurred the line by jeering Hamilton for his skin color when they meant to taunt him as an opponent. It is the same in Henry's case.

"You don't know whether it's because he's a hell of a player or because he's French," Ecclestone said. "It's just a normal reaction. That's the upside to it."

Report: Doctor being investigated in PED probe

A Canadian doctor who has treated golfer Tiger Woods, swimmer Dara Torres and NFL players is suspected of providing athletes with performance-enhancing drugs, according to a newspaper report.

The New York Times reported on its Web site Monday that Dr. Anthony Galea was found with human growth hormone and Actovegin, a drug extracted from calf's blood, in his bag at the U.S.-Canada border in late September. He was arrested Oct. 15 in Toronto by Canadian police.

Using, selling or importing Actovegin is illegal in the United States.

The FBI has opened an investigation based in part on medical records found on Galea's computer relating to several professional athletes, people briefed on the inquiry told the Times on condition of anonymity because they did not want to be identified discussing a continuing investigation.

The anonymous sources did not disclose the names of the athletes, and Galea told the newspaper "it would be impossible" for investigators to have found material linking his athletes to performance-enhancing drugs.

According to the newspaper, Galea has developed a blood-spinning technique _ platelet-rich plasma therapy _ to help speed post-surgery recovery.

Galea visited Woods' home in Florida at least four times in February and March, the newspaper reported, to provide that platelet therapy after his agents were concerned by his slow recovery from June 2008 knee surgery.

Asked about Woods' involvement with Galea, agent Mark Steinberg told the newspaper in an e-mail: "I would really ask that you guys don't write this? If Tiger is NOT implicated, and won't be, let's please give the kid a break."

Woods announced Friday he is taking an indefinite leave from golf to work on his marriage after allegations of infidelity surfaced in recent weeks.

A message was left by The Associated Press late Monday night seeking comment from Steinberg.

Torres told the newspaper Galea found a previously undiagnosed tear in her quad tendon.

"Excluding draining my knee, he has never treated me, but I did see his chiropractor who did soft-tissue work on my leg," she said in an e-mail to the Times. "That was the extent of my visit with him."

Her agent, Evan Morgenstein, told the AP that Torres was not available for comment Monday night.

Brian H. Greenspan, Galea's criminal defense attorney, said an investigation will vindicate his client.

"Dr. Galea was never engaged in any wrongdoing or any impropriety," Greenspan said. "Not only does he have a reputation that is impeccable, he is a person at the every top of his profession."

Galea, who acknowledged he has used human growth hormone himself for 10 years, told the newspaper he never gave any athletes HGH, which is banned by the World Anti-Doping Agency. And Galea told the Times he has never combined HGH or Actovegin with his platelet treatments.

"All these athletes come see me in Canada cause I fix them, and I think people just assume that I'm giving them stuff," he told the newspaper. "They don't have to come to me to get HGH and steroids. You can walk into your local gym in New York and get HGH."

Galea is also being investigated by the Royal Canadian Mounted Police for smuggling, advertising and selling unapproved drugs as well as criminal conspiracy, the Times reported.

Psychological Approaches in the Treatment of Chronic Pain Patients-When Pills, Scalpels, and Needles Are Not Enough

Background: Chronic pain is a prevalent and costly problem that eludes adequate treatment. Persistent pain affects all domains of people's lives and in the absence of cure, success will greatly depend on adaptation to symptoms and self-management.

Method: We reviewed the psychological models that have been used to conceptualize chronic pain-psychodynamic, behavioural (respondent and operant), and cognitive-behavioural. Treatments based on these models, including insight, external reinforcement, motivational interviewing, relaxation, meditation, biofeedback, guided imagery, and hypnosis are described.

Results: The cognitive-behavioural perspective has the greatest amount of research supports the effectiveness of this approach with chronic pain patients. Importantly, we differentiate the cognitive-behavioural perspective from cognitive and behavioural techniques and suggest that the perspective on the role of patients' beliefs, attitudes, and expectations in the maintenance and exacerbation of symptoms are more important than the specific techniques. The techniques are all geared to fostering self-control and self-management that will encourage a patient to replace their feelings of passivity, dependence, and hopelessness with activity, independence, and resourcefulness.

Conclusions: Psychosocial and behavioural factors play a significant role in the experience, maintenance, and exacerbation of pain. Self-management is an important complement to biomedical approaches. Cognitive-behavioural therapy alone or within the context of an interdisciplinary pain rehabilitation program has the greatest empirical evidence for success. As none of the most commonly prescribed treatment regimens are sufficient to eliminate pain, a more realistic approach will likely combine pharmacological, physical, and psychological components tailored to each patient's needs.

Can J Psychiatry 2008;53(4):213-223

Clinical Implications

* Chronic pain is a complex phenomenon that consists of biological, psychological, and social components.

* Physical and psychological adaptation to chronic pain does not constitute psychopathology, rather it reflects normal processes of the human condition.

* No single treatment for chronic pain will be efficacious alone, rather a combination of treatment modalities will yield the best results.

Limitations

* Literature concerning the numerous relaxation techniques and methods to induce hypnosis are inconsistent as to which are the most effective and (or) they contain discrepancies, which makes evaluation of efficacy difficult.

* Currently, few data are available that are consistent in identifying the characteristics of people who would most likely benefit from any of the pain treatment methods described.

* Studies are needed to determine which treatments delivered in what ways are most effective for people with what set of characteristics with the least iatrogenic complications and adverse events.

Key Words: chronic pain, operant conditioning, psychological treatment, psychological therapies, cognitive-behavioural, psychosocial, respondent conditioning, psychological techniques

Abbreviations used in this article

CBT cognitive-behavioural therapy

RCT randomized-controlled trial

Chronic pain is prevalent and affects about 20% to 30% of the adult population in Western countries. ' By definition, chronic pain persists for extended periods of time. Although therapeutic approaches have resulted in significant improvements, the most potent drugs only reduce pain by 30% to 40% in fewer than 50% of patients.2 Similarly, sophisticated surgical techniques, such as implantation of artificial discs in the spine3 and implantable drug delivery systems,4 provide limited pain reduction in only a subset of patients.

Even when medications and invasive procedures effectively reduce pain, they often do not produce concomitant improvements in physical and emotional functioning. Moreover, many prescribed treatments can result in significant complications or side effects. For example, more than 40% of patients who are implanted with pain-alleviating devices will experience significant adverse events4 and premature termination rates from drug clinical trials often exceed 30%.2 Further, opioids, the most potent and frequently prescribed class of drugs to control pain, carry significant risk of misuse and abuse that may exceed 40%.5-7

The mean duration of pain in patients seeking treatment and treatment from chronic pain treatment facilities is about 7 years.8 Consequently, all domains of their lives are compromised for a significant amount of time. Further, the average age of patients treated at multidisciplinary pain rehabilitation facilities is 44 years.8 Thus, prior to pain onset, these people have histories spanning 37 years; therefore, their prior histories are important in understanding how people respond to their symptoms and plight. Moreover, most people live a social context. Significant people in patients' lives likely influence their adaptation (see Figure 1).

After patients receive appropriate treatment, because chronic pain is incurable, they are left to manage their residual symptoms on their own. In the preface to "The Management of Pain," first edition,9 and repeated 36 years later in the second edition,10 Bonica observed that:

The crucial role of psychological and environmental factors in causing pain in a significant number of patients only recently received attention. As a consequence, there has emerged a sketch plan of pain apparatus with its receptors, conducting fibers, and its standard function which [sic] is to be applicable to all circumstances. But... in so doing, medicine has overlooked the fact that the activity of this apparatus is subject to a constantly changing influence of the mind.p12

Based on the evidence presented, 2 conclusions are obvious: psychosocial and behavioural factors play a significant role in the experience, maintenance, and exacerbation of pain; and because some level of pain persists in most people with chronic pain, regardless of treatment, self-management is an important complement to biomedical approaches.

There are numerous psychological approaches to facilitate adaptation and self-management of patients' symptoms. The most common approaches include insight-oriented therapies, behavioural treatments, and CBT. In addition, several techniques based on these models have been efficacious (that is, motivational interviewing, biofeedback, relaxation, guided imagery, hypnosis, and meditation) independently or as part of comprehensive rehabilitation. In this review, we provide an overview of psychological approaches and techniques for the treatment of patients with chronic pain. We emphasize the cognitive-behavioural perspective for conceptualization and treatment within an interdisciplinary framework because it has the greatest empirical support.11-13

Insight-Oriented Approaches

Insight-oriented approaches are predicated on the belief that chronic physical pain may be somatic presentations of emotional distress, and nonconscious factors will influence both the onset and the maintenance of symptoms. As one set of evidence to support this assumption, insight-oriented practitioners often cite the data on the prevalence of childhood physical and sexual abuse acknowledged by people reporting chronic pain.14,15

Psychodynamically-oriented therapy and insight-oriented approaches primarily focus on early relationship experiences that are reconstructed within the therapeutic relationship. The therapeutic relationship reintegrates emotions into symbolic and available mental processes, resulting in improved emotional regulation.16 Although insight-oriented psychotherapy may be useful with select individuals,16 to our knowledge, no RCTs have been published demonstrating its efficacy for people with chronic pain problems.

The Role of Reinforcement in Maintenance of Pain Behaviours

Pain is subjective; the only way we know about someone's pain is to ask, observe, and make inferences about their behaviour. When patients are asked about their pain, they may provide numerous descriptors that convey information; however, there is no objective criterion. Observation of behaviour, for example, limping or grimacing, may indicate something about subjective states. However, this inference can only be confirmed by self-report because the association between objective evidence of pathology is only weakly associated with reported pain.17 Self-report or other behaviours are merely surrogates for the subjective experience of pain. Furthermore, persistent noxious symptoms will take a toll among others living with or in close contact with the patient.18

Behaviour is communication that elicits responses from observers. Consider a woman who is rubbing her neck and moaning. Her husband observes these behaviours and infers his wife's neck pain is flaring up. If he acknowledges her pain, brings her medication, rubs her neck, and spends time talking with her, assuming these are desired responses, they will serve as positive reinforcement. What the patient has learned is that her pain-related behaviours communicated a message to her husband. This learning process may increase the likelihood that she will increase these behaviours as a way of obtaining desired responses from others in the future.

Behavioural principles work in another way. Avoidance of undesirable activity and or behaviours that reduce distress is negatively reinforcing. Negative reinforcement strengthens a behaviour because the negative condition is terminated or avoided as a consequence of the behaviour. Consider a patient in physical therapy who reports that whenever he performs certain exercises his pain increases. The physical therapist may tell him to stop the activity ("If it hurts, don't do it"). Assuming his pain is reduced by termination of the activity, the patient will learn that avoidance of activity has a positive effect. Avoidance is a positive outcome and may negatively reinforce similar behaviours when the circumstance arises again. This has the unintended consequence of increasing physical deconditioning. Although this may be an appropriate response for acute pain, it may not be in the context of chronic pain and the attainment of corrective feedback-activity may not increase pain. Corrective feedback is necessary to learn that hurt and harm are not the same thing.

Physicians and patients also demonstrate a potent reciprocal relationship of reinforcement that influences each others' behaviours. Studies have shown that physicians prescribe treatment for pain patients based on observations of patients' behaviours, including emotional distress, compared with physical pathology or pain severity.19'20 Conversely, patients observe the responses of their physicians. If they note (learning might not be a conscious process) that either the physician increases their analgesic medication when they are more demonstrative-pain behaviours, complain more, appear more distressed-the next time they visit the physician, they may present as more extreme to obtain attention and further treatment.

Failure to positively reinforce well behaviours, such as activity, will influence behaviour. Behaviour that is not positively reinforced will be reduced or even extinguished. The behavioural principles related to reinforcement are outlined in Table 1.

Two treatment approaches have been developed based on behavioural principles of reinforcement and conditioning. These are described briefly in the next section.

Respondent Conditioning

If a nociceptive stimulus is repeatedly paired with a neutral stimulus in close temporal proximity, the neutral stimulus will elicit a pain response. This is referred to as classical or respondent conditioning. In chronic pain, many neutral or pleasurable activities may elicit or exacerbate pain. Thus, over time, numerous stimuli (for example, activities) may be expected to elicit or exacerbate pain and will be avoided (that is, stimulus generalization). The anticipatory fear of pain and restriction of activity, and not just the actual nociception, may contribute to disability. Anticipatory fear can also elicit physiological reactivity that can aggravate pain. Thus, conditioning can directly increase nociceptive stimulation and pain.

The longer inactivity prevails the more difficult it is to modify people's convictions and behaviours. Treatment of pain from the respondent conditioning model includes repeatedly engaging in behaviours that produce progressively less pain than was predicted (corrective feedback)-exposure that is then followed by reductions in anticipatory fear and anxiety associated with the activity. Such transformations lend support to the importance of quota-based exercise programs, with participants progressively increasing their activity despite fear of injury and discomfort associated with use of deconditioned muscles.

Operant Conditioning

Operant approaches focus on the extinction of pain behaviours. Therapists withdraw positive attention for pain behaviours while increasing reinforcement of well behaviours. The op�rant paradigm does not seek to uncover the etiology of symptoms but focuses on the maintenance of pain behaviours and deficiency of well behaviours. Pain behaviours are identified, as are their controlling antecedents and consequent reinforcers or punishments,12 such as overly solicitous behaviours by a spouse.21

Reduction, and ultimately elimination of the connection between pain behaviours and their positive or negative consequences, is used to increase and maintain desired behaviours and decrease pain-compatible behaviours. With operant behavioural treatment, individuals are expected to be active in setting treatment goals and follow-through with recommendations.12 The efficacy of operant treatment was demonstrated in several studies of individuals with various chronic pain disorders, including low back pain22 and fibromyalgia syndrome.23

Cognitive-Behavioural Perspective and Therapies

Perhaps the most commonly adopted treatment approach for chronic pain patients is CBT.11 It is important to make a distinction between the cognitive-behavioural perspective and cognitive and behavioural techniques.24 The cognitivebehavioural perspective is predicated on the assumption that people hold the belief that they are unable to function because of their pain and helpless to improve their situation (see Table 2). Treatment goals focus on helping people with pain to realize that they can, in fact, manage their problems, and provide them with skills to respond in more adaptive ways that can be maintained after treatment is terminated. The techniques used can be drawn from among those described in this article.

The CBT approach typically combines stress management, problem solving, goal setting, pacing of activities, and assertiveness. These skills can be integrated within a rehabilitation approach. Cognitive and behavioural techniques are woven into the fabric of treatment in an effort to enhance patients' sense of self-control. Biofeedback, relaxation, meditation, guided imagery, and hypnosis (described below) can all be incorporated within CBT to facilitate perceptions of selfcontrol. The objective is to help patients acquire a sense of hopefulness, resourcefulness, and action to replace their more typical feelings of hopelessness, stress reactivity, and passivity.

In CBT, therapists assist patients with their concerns about the future, returning to work, and physical limitations. They help people build their communication skills, gain a sense of control over their pain, and cope with fear of pain, reinjury, or frustrations owing to the responses of others. Patients are taught positive coping strategies and are encouraged to increase their activities in a graded fashion. The expectation is that patients will gain mastery over their pain, resulting in improved mood.23

The 4 key components of CBT have been described as: education, skills acquisition, skills consolidation, and generalization and maintenance.24 The education component focuses on helping patients challenge their negative perceptions regarding their abilities, and to manage pain by making them aware of the role that thoughts and emotions play in potentiating and maintaining stress and physical symptoms-in effect, cognitive restructuring. Cognitive restructuring includes identifying maladaptive thoughts during problematic situations (such as during pain exacerbations and stressful events), introduction and practice of coping thoughts and behaviours, shifting from self-defeating to coping thoughts, practice of positive thoughts, home practice, and follow-up. The therapist encourages patients to test the adaptiveness of their thoughts, beliefs, expectations, and predictions. The crucial element is bringing about a shift in the patient's repertoire, from well-established, habitual, and automatic but ineffective responses toward systematic problem solving and planning, control of affect, behavioural persistence, or disengagement from self-defeating situations when appropriate.23

The goal of skills acquisition and consolidation is to help people learn and, importantly, practice new pain management behaviours and cognitions, including relaxation, problem solving, distraction methods, activity pacing, and communication. Therapists use education, didactic instruction, Socratic questioning, and role-playing techniques among others. However, the techniques are less important than the general message of self-management that is derived from experience using various techniques (some of which are described below). Patients may learn best from observing the outcomes of their own efforts rather than by instruction alone. Often CBT is carried out in a group context where the therapist can use the support of other patients and also have patients interact with each other to assist in providing alternative ways of thinking and behaving.

Finally, generalization and maintenance is geared toward solidifying skills and preventing relapse. Homework is an essential ingredient of CBT. Once patients have been taught and have practiced self-management skills within the therapeutic context, it is essential that they practice these in their home environment where the therapist is not present to guide and support them. The difficulties that will inevitably arise when attempts are made at patients' homes become important topics for discussion and further problem solving during therapeutic encounters. Problems that arise during home practice are viewed as opportunities to assist patients to learn how to handle setbacks and lapses that will likely occur following treatment. In this phase, therapists assist patients to anticipate future problems and high-risk situations so that they can think about and practice the behavioural responses that may be necessary for adaptive coping.

The goal during the latter phase, then, is to enable patients to develop a problem-solving perspective where they believe that they have the skills and competencies to respond in appropriate ways to problems as they arise. In this manner, attempts are made to help patients learn to anticipate future difficulties, develop plans for adaptive responding, and adjust their behaviour accordingly.

The efficacy of CBT in treating various chronic pain disorders has been demonstrated in numerous studies and has been reviewed in numerous reviews and metaanalyses.11,25-27 There is a wealth of evidence that CBT can help restore function as well as reduce pain and disability-related behaviours.11'25 Although CBT was found to be helpful for numerous individuals, there are some for whom CBT is not beneficial. Investigators are just beginning to explore different aspects of CBT to answer the question, what works for whom?28-30

With this overview of the cognitive-behavioural perspective, we now discuss specific techniques that can be incorporated with CBT when treating chronic pain patients. The primary objective of these techniques is enhancement of patients' sense of self-efficacy by increasing a sense of control to combat the feelings of helplessness and demoralization often felt by people with chronic pain.

Motivational Interviewing

Motivational interviewing was initially developed for substance abusers31; however, it has been adapted to chronic pain patients.32 Tasks are tailored to specific postulated stages of change. Learning and accepting self-management requires a significant cognitive shift by chronic pain patients; thus, a clinician needs to be aware of an individual's readiness to undertake the necessary steps. Most pain patients adhere to a biomedical model where their symptoms are closely aligned with physical pathology. However, as pain persists, some people become aware of how factors such as emotional stress impact their pain33; therefore, they might entertain the possibility that they can learn and use self-management techniques to help them adapt to life with a chronic pain condition. Other people with chronic pain have difficulty acknowledging the role of psychological factors. The stage of acceptance of self-management is important, as those unready for the use of psychological techniques will tend to avoid and dismiss such methods.

In the precontemplation stage, people with chronic pain have not yet begun to consider changing, owing to a purely physical view of pain. They assume a passive role and rely on the health care provider to provide the appropriate treatment. The clinician's role is fostering acknowledgement of risks and problems owing to passivity and inactivity-problems such as increased pain and physical deconditioning.31

In the contemplation stage, people with chronic pain acknowledge the risks associated with inactivity and passivity. The clinical goal at this stage is to assist the patient to realize that the risks of inactivity outweigh the perceived benefits.

When the patient is ready to become more active (preparation stage), the clinician helps the patient outline appropriate structured physical activities in which the individual is willing to participate. Finally, in the action stage, the clinician helps the individual increase activity. This is followed by maintenance, geared toward the individual's ongoing motivation and commitment.31

Clinicians can encourage transition to different stages by providing motivational statements, listening with empathy, asking open-ended questions, providing feedback and affirmation, and handling resistance.31 Motivational interviewing should be thought of not as a treatment itself but as a general framework for preparing individuals for treatment and for adhering within the cognitive-behavioural perspective, which can be readily used with CBT. Motivational interviewing is one means of fostering motivation for self-control. Success using various techniques will directly reinforce feelings of self-efficacy.34 Thus it is of central importance to direct practice and attention to the usefulness of these methods in improving quality of life in people with chronic pain despite the presence of noxious symptoms that cannot be totally eliminated. The assessment process35 should help the therapist determine an individual's motivation for the use of biomedical approaches.

Relaxation

There are numerous relaxation techniques. The literature is inconsistent as to which techniques are the most effective. Moreover, the different components may be synergistic. The important message to the patient is that there is a broad spectrum of approaches available and no one method is more efficacious. It is most important to help patients learn which technique(s) are most helpful for them by trying a variety. Clinicians may also note that no one technique is effective for all people all of the time; hence, knowledge of a range of methods may be the best approach. It is important to acknowledge that these methods are skills that require practice to become more proficient. In this section, we provide a brief overview of some of the most popular methods.

Meditation

Meditation is defined as the "intentional self-regulation of attention,"36'1"456 a systematic inner focus on particular aspects of inner and outer experience.37 Meditation was originally developed within a religious or spiritual context and held as the ultimate goal of spiritual growth, ending suffering, personal transformation, or transcendental experience.38 However, as a health care intervention, it has been taught effectively regardless of patients' cultural or religious backgrounds.39,40

There are many forms of meditation. We will describe 2 extensively researched general approaches: transcendental meditation and Zen or mindfulness meditation.41 Transcendental meditation requires concentration; it involves focus on any one of the senses, like a zoom lens, on a specific object. For example, the individual often repeats a silent word or phrase (mantra) with the goal of transcending the ordinary stream of thought.38,42 Mindfulness meditation is the opposite of transcendental meditation in that its goal is attempting awareness of the whole perceptual field, like a wide-angle lens. Thus it incorporates focused attention and whole field awareness in the present moment. For example, the individual observes, without judgment, thoughts, emotions, sensations, and perceptions as they arise moment by moment.39,43 Banadonna44 proposed that individuals with chronic illness have an altered ability to concentrate; therefore, transcendental meditation may be less useful than mindfulness meditation when one is sick.

Mindfulness meditation reframes the experience of discomfort in that physical pain or suffering becomes the object of meditation. Attention and awareness of discomfort or suffering is another part of human experience; rather than to be avoided, it is to be experienced and explored.44 Studies have found that mindfulness-based interventions have decreased pain symptoms, increased healing speed, improved mood, decreased stress, contained health care costs, and decreased visits to primary care.38,45

Meditation has captured the attention of medicine, psychology, and neurocognitive sciences. In part, this is due to experienced meditators demonstrating reduced arousal to daily stress, better performance of tasks that require focused attention, and other health benefits.46,47 Lazar et al46 found that long-term meditation in Western practitioners showed increased cortical thickness in areas related to somatosensory, auditory, visual, and interoceptive processing. They found thickening in right Broadman's Areas 9 and 10, which has been shown to be involved in the integration of cognition and emotion. Meditation may be useful for chronic pain patients owing to the reciprocal relation between stress and pain symptoms. Higher alpha brainwave activity was found to have beneficial health effects as well as to promote a general sense of well-being.48-50 Furthermore, gamma wave activity is the synchrony of areas of the brain communicating with each other, and research on the effects of meditation on gamma wave activity47 demonstrates meditation can be beneficial for people with chronic pain owing to dysregulation within the hypothalamo-pituitary-adreanal axis and autonomie nervous system.

Biofeedback

Biofeedback is a self-regulatory technique. The assumption regarding biofeedback treatment is that the level of pain is maintained or exacerbated by autonomie nervous system dysregulation, which is believed to be associated with the production of nociceptive stimulation. The objective of biofeedback is to teach people to exert control over their physiological processes to assist in reregulating the autonomie nervous system. When people are treated with biofeedback, they are attached by surface electrodes to equipment that is linked to a computer that transforms and records physiological responses. These monitored physiological processes can include skin conductance, respiration, heart rate, heart rate variability, skin temperature, brainwave activity, and muscle tension. The biofeedback equipment conveys physiological responses as visual or auditory signals that the individual can observe on a computer monitor. In this way, the physiological information is fed back. With practice, individuals learn to control and change their physiological responses by learning to manipulate the auditory or visual signals by their own efforts. In addition to the physiological changes accompanying biofeedback, patients are provided with a sense of control over their bodies. Given the high levels of helplessness observed in people with chronic pain problems, the perception of control may be as important as the actual physiological changes observed.

Biofeedback has been used successfully to treat numerous chronic pain states such as headaches, back pain, chronic myofascial pain, temporomandibular disorders, irritable bowel syndrome, and fibromyalgia, either as primary treatment or within the broader context of CBT integrated within rehabilitation programs.38'51 Examples of prominent forms of biofeedback include electromyographic biofeedback, in which patients, for example with tension headaches, are provided with information feedback to them from the physiological recordings and taught to manipulate the tension in their frontalis muscle (or other muscles, for example splenius captitis). Patients with migraine are provided with thermal feedback. They are instructed to warm their hands using visual or auditory temperature biofeedback cues. Also, heart rate variability biofeedback demonstrated some preliminary results in improving depression, pain, and functioning in fibromyalgia patients.52

Recently, real-time functional magnetic resonance imaging has been used as a sophisticated source of biofeedback to train participants to control activation in the rostral anterior cingulate cortex. This brain region is reputedly involved in pain perception and regulation. When the participants deliberately induced changes in the rostral anterior cingulate cortex, there was a corresponding change in the perception of pain.53

The actual mechanisms involved in the success of biofeedback are still unknown; however, a general sense of relaxation is an important feature of biofeedback. It is not clear whether the alteration of specific physiological parameters putatively associated with pain is the most important ingredient of biofeedback, compared with the broader relaxation and sense of control created.

Guided Imagery

Guided imagery can be a useful method for helping people with pain to relax, achieve a sense of control, and distract themselves from pain and accompanying symptoms. This modality involves the generation of different mental images, evoked either by oneself or with the help of the practitioner. It overlaps with different relaxation techniques and hypnosis. Although guided imagery has been advocated as a stand-alone intervention to reduce presurgical anxiety and postsurgical pain, and to accelerate healing,54 it is most often used in conjunction with other treatment interventions such as relaxation and within the context of CBT.

With guided imagery, using the capacities of visualization or imagination, individuals are asked to evoke specific images that they find pleasant and engaging. In this way, a detailed representation that is tailored to the individual can then be created. When patients with chronic pain are feeling pain or are experiencing pain exacerbation, they can use imagery with the goals to redirect their attention away from their pain and achieve a psychophysiological state of relaxation.

The most successful images involve all of the senses (vision, sound, touch, smell, and taste). However, some people can have difficulty generating images and may find it helpful to listen to a taped description or purchase a poster that they can focus their attention on to assist their imagination.

Hypnosis

Hypnosis has been defined as a natural state of aroused attentive focal concentration coupled with a relative suspension of peripheral awareness. There are 3 central components in hypnosis: absorption, or the intense involvement in the central object of concentration; dissociation, where experiences that would commonly be experienced consciously occur outside of conscious awareness; and suggestibility, in which individuals are more likely to accept outside input without cognitive censoring or criticism.55

Hypnosis has been used as a treatment intervention for pain control at least since the 1850s. It has been shown to be beneficial in relieving pain for people with headache, burn injury, arthritis, cancer, and chronic back pain.56"58 As with relaxation techniques, imagery, and biofeedback, hypnosis is rarely used alone in chronic pain, although it has been used as a solo psychological model with some success with cancer patients59; practitioners often use it concurrently with other treatment interventions.

A metaanalysis57 suggests an overall benefit of the addition of hypnosis to nonhypnotic pain management strategies, although this may be mediated by an individual 's level of hypnotic suggestibility. Further, there are discrepancies in the literature regarding the methods used to induce hypnosis, making it difficult to accurately evaluate the efficacy of this intervention.59 Based on systematic reviews, Patterson and Jensen56,58 suggested that hypnosis has more utility in the treatment of acute pain than chronic pain. Thus the degree to which hypnosis is effective, above and beyond other interventions and for which populations, is yet to be determined.

The techniques and modalities described can be readily integrated with more comprehensive rehabilitation programs. They can be useful complements to physical therapy, medication management, and rehabilitation by providing patients with something they can do when pain flares up as well as being a routine part of a self-management program. They convey a sense of hopefulness as an antidote to the more common feelings of helplessness and dependency.

Efficacy of Psychological Approaches

The first reported trial of behavioural treatment for chronic pain was published in 1968 by Fordyce et al.60 Since that initial publication, there have been numerous clinical trials evaluating the efficacy of various psychological treatment approaches and modalities (such as cognitive-behavioural therapy, biofeedback, and hypnosis) for chronic pain. Psychoeducational and multidisciplinary pain management programs approaches often or usually incorporate some combination of psychological treatments based on behavioural principles within comprehensive rehabilitation programs.

In early studies, the questions that most interested researchers and practitioners were whether behavioural approaches were effective and if the efficacy of these treatments were comparable to other therapeutic options. Although there was at first a lack of well-controlled RCTs, or dismantling studies, and the metaanalytic techniques used needed refinement, the clinical outcomes always tended to support the use of psychological approaches and treatment modalities usually included in comprehensive rehabilitation programs.61'62 Although only modest improvements in pain-related outcomes were observed, analgesic medication use, physical incapacity, health care use, and disability rates showed marked reductions.63-67

With the basic questions of efficacy addressed, increased availability of RCTs, and refined metaanalytic techniques, research began focusing on variables that influence outcomes or that change with treatment. Several metaanalyses68-70 reviewed the evidence of the effectiveness of the psychological treatments with samples of chronic pain patients with diverse patient samples. The results of these metaanalyses with adult patients came to somewhat similar conclusions-as a group, psychological treatments have modest benefits on improving pain, physical, and emotional functioning. For example, van Tulder et al70 concluded that behavioural treatments, compared with placebo or wait-list control, were moderately effective for low back pain intensity hi more than one-half of the studies they reviewed; however, the evidence was inconclusive regarding which behavioural technique was more effective, compared with another, and there was weak evidence that they were more effective, compared with usual care.

In the case of migraines, Campbell et al71 concluded that all behavioural treatments (except hypnosis) were effective in the prevention of migrames and if used concomitantly with medications to augment relief. The authors concluded that the evidence for hypnosis was incomplete. Nestoruic and Martin72 also found that all biofeedback methods were effective for chronic headaches. Moderators (factors that affect outcome but are not part of the treatment process) for follow-up outcomes included headache years, study validity, and treatment setting. Based on the outcomes of published studies of treatment of children and adolescents with chronic headache, Eccleston73 determined that there was strong evidence that behavioural treatments were effective in reducing severity and frequency of chronic headache pain; however, the data was insufficient regarding mood, function, or disability, and there was a nonsignificant trend in favour of behavioural treatments used for abdominal pain.

Recently, Turner et al74 found that the mediators of improvement in pain and activity one year following CBT were cognitive variables including patients' perceptions of control, disability, self-efficacy, harm, catastrophizing, and rumination. They also found moderators that predicted therapeutic change were number of pain sites, depression, somatization, rumination, catastrophizing, and stress existing before treatment. These data confirm the need to address psychosocial as well as physical aspects of the chronic pain experience to obtain positive results, even in the absence of cure.

It is important to acknowledge that the modest reduction in pain severity obtained with psychological interventions and with comprehensive rehabilitation studies observed in the various metaanalyses were comparable to those observed with more traditional pharmacological and procedural treatment modalities.2 This observation suggests that none of the most commonly prescribed treatment regimens, by themselves, are sufficient to eliminate pain and to have a major impact on physical and emotional functioning. This is hardly surprising given the complexity of chronic pain. A more realistic approach will likely be one that combines pharmacological, physical, and psychological components, with the balance among these tailored to each patient's needs. As one author opined in an editorial regarding combinations of treatment for chronic pain, "Sometimes 1 + 1 does = 3."75

Concluding Remarks

For the individual experiencing chronic pain, there is a quest for relief that remains elusive, leading to feelings of helplessness, hopelessness, demoralization, and depression. Chronic pain confronts the individual, not only with the stress created by pain but also with a cascade of ongoing Stressors that compromise all aspects of the sufferer's life. Living with chronic pain requires considerable emotional resilience and tends to deplete emotional reserve, taxing not only the pain sufferer but also the significant others' capacity to provide support.

There is much evidence to demonstrate that psychological factors can interfere with or hinder an individual's ability to cope with the pain experience. As a result, psychological assessment and intervention are becoming standard in chronic pain treatment. Psychological treatments focus on the emotional distress and maladaptive behaviours accompanying chronic pain, and provide education and training in the use of cognitive and behavioural techniques that may reduce perceptions of pain and related disability. Psychological principles have played a major role in the understanding and treatment of people with pain, and mental health professionals have an important function in interdisciplinary pain rehabilitation programs as clinicians and researchers.

None of the treatments described are successful in eliminating pain; consequently, most people have to adapt to the presence of chronic pain and learn self-management in the face of persistent pain and accompanying symptoms. The various psychological interventions described provide a general overview of different treatment strategies. Treatment with cognitive-behavioural therapy alone or within the context of an interdisciplinary pain rehabilitation program has the greatest empirical evidence for success. At this point, it seems prudent to use psychological treatments in combination with traditional medical interventions.

Currently, few data are available that are consistent in identifying the characteristics of people who would most likely benefit from any of the pain treatment methods described, although some studies suggest that tailored treatments are associated with more improved symptoms than standard treatment.76-78 Studies are needed that answer the question, What treatments delivered in what ways are most effective for people with what set of characteristics with the least iatrogenic complications and adverse events?27 Answers to this question will permit more clinically effective and more cost effective ways to treat the difficult problem of chronic pain.

Funding and Support

Preparation of this manuscript was provided in part by grant AR44724 from the National Institutes of Health. This work was supported by an honorarium to authors.

[Sidebar]

R�sum� : Les approches psychologiques du traitement des patients souffrant de douleur chronique - quand pilules, scalpels et aiguilles ne suffisent pas

Arri�re-plan : La douleur chronique est un probl�me pr�valent et co�teux qui d�passe le traitement ad�quat. La douleur persistante affecte tous les domaines de la vie des gens et en l'absence d'un rem�de, le succ�s reposera lourdement sur l'adaptation aux sympt�mes et l'auto-prise en charge.

Methode : Nous examinons les mod�les psychologiques qui ont �t� utilis�s pour conceptualiser la douleur chronique - psychodynamique, comportemental (r�pondant et op�rant), et cognitivo-comportemental. Les traitements bas�s sur ces mod�les, dont la compr�hension de soi, le renforcement ext�rieur, la technique d'entrevue motivationnelle, la relaxation, la m�ditation, la r�troaction biologique, l'imagerie dirig�e, et l'hypnose sont d�crits.

Resultats : Sur la perspective cognitivo-comportementale car la majeure partie de la recherche soutient l'efficacit� de cette approche aupr�s des patients souffrant de douleur chronique. Surtout, nous diff�rencions la perspective cognitivo-comportementale des techniques cognitives et comportementales, et nous sugg�rons que la perspective sur le r�le des croyances, attitudes et attentes des patients dans le maintien et l'exacerbation des sympt�mes est plus importante que les techniques sp�cifiques. Les techniques sont toutes ax�es sur l'incitation � la ma�trise de soi et � l'auto-prise en charge qui encourageront le patient � remplacer ses sentiments de passivit�, de d�pendance et d'impuissance par l'activit�, l'ind�pendance et l'esprit d'initiative.

Conclusions : Les facteurs psychosociaux et comportementaux jouent un r�le significatif dans l'exp�rience, le maintien et l'exacerbation de la douleur. L'auto-prise en charge est un compl�ment important des approches biom�dicales. La th�rapie cognitivo-comportementale seule ou dans le contexte d'un programme interdisciplinaire de r�habilitation de la douleur pr�sente les meilleures donn�es probantes empiriques de r�ussite. Puisqu'aucun des r�gimes de traitement les plus fr�quemment prescrits ne suffit � �liminer la douleur, une approche plus r�aliste combinera vraisemblablement des composantes pharmacologiques, physiques et psychologiques adapt�es aux besoins de chaque patient.

[Reference]

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[Author Affiliation]

Dennis C Turk, PhD1; Kimberly S Swanson, PhD2; Eldon R Tunks, MD, PhD3

[Author Affiliation]

Manuscript received and accepted September 2007.

1 John and Emma Bonica Professor of Anesthesiology and Pain Research, University of Washington School of Medicine, Department of Anesthesiology, Seattle, Washington.

2 Senior Fellow, University of Washington School of Medicine, Department of Anesthesiology, Seattle, Washington.

3 Emeritus Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario; Consultant, Department of Physical Medicine and Rehabilitation, Hamilton Health Sciences, Chedoke Rehabilitation Centre, Hamilton, Ontario.

Address for correspondence: Dr DC Turk, Department of Anesthesiology, 1959 NE Pacific Street, Box 36540, University of Washington School of Medicine, Seattle, WA 98195-6540; turkdc@u.washington.edu