The Spiritual Aspect of Pain: An Integrative Review

This review was guided by the question “How is the spiritual aspect of pain addressed?”.

A comprehensive literature review was conducted using the electronic databases: PubMed, Scopus, and Web of Science (WOS). A 10-year period for the review period search was carried out, the period between 2012 and 2022, to retrieve the most up-to-date information.

The strategy to follow was elaborated from the MeSH health sciences descriptors: chronic pain, spirituality, spiritual, religion, religions, faith, belief system, religious, religiousness and religiosity; in combination of the Boolean operators AND and OR, whose resulting strategy.

All studies were then reviewed and evaluated to find those that met the established criteria for inclusion in this review. A flowchart was prepared according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols (PRISMA) (Page et al., 2021) (Fig. 1).

A web-based bibliographic manager, Zotero 6.0.20, was used to collect and manage the citations included in the study.

Articles were included if they: (a) whose study design included clinical trials, randomized controlled trials, meta-analyses, reviews, and systematic reviews; (b) were published between 2012 and 2022; (c) were published in peer-reviewed journals; (c) had original data and (d) whose language was English, Spanish, or German.

All documents whose type were books and book chapters, editorials and editorial materials, letters, notes, surveys, biographies, and meetings were excluded; as well as those that were study protocols, opinion articles, instrument validation, autobiographical articles or did not correspond to the objectives of the review.

The methodological quality was assessed using tools that ensure high-quality presentation of clinical trials (i.e., CONSORT), observational studies (i.e., STROBE), systematic reviews (i.e., PRISMA) and qualitative studies (i.e., SRQR guidelines) in order to determinate a sound methodology within the retrieved studies (see supplementary material). Studies scoring low on the appraisals were excluded.

Authors 2 and 3 conducted the searches individually and selected the studies that met the inclusion and exclusion requirements. Duplicate citations were initially manually discarded, titles and abstracts were then reviewed, and any disagreements were resolved by Author 1. The authors 2 and 3 reviewed the full text of selected articles to select those that included a spiritual aspect in pain treatment. Author 1 was responsible for resolving the disputes that arose in this process.

Article data extraction and analysis were performed by Author 4 and verified by Author 1. Any disagreements of these included articles were discussed until the team which reached a consensus, and the authors 2 and 3 independently prepared a results table. Finally, the data extracted included information about the authors, year, country, objective of the study, design, methodology and sample, instruments, results, and quality (Table 1).

Evaluation of the methodological quality of the selected investigations was carried out by using the tools contained in the Equator guidelines. Strobe (von Elm et al., 2014) for observational studies, Consort (Schulz et al., 2010) for clinical trials, and SRQR guidelines (O’Brien et al., 2014) for qualitative studies. This analysis was carried out by two authors (Author 2 and Author 3) and by a third author (Author 4) to resolve discrepancies. The appraisal scores of the studies were summarized in Table 1.

The original search yielded 975 potentially relevant articles. After the first level of screening of articles for titles and abstracts, 402 articles remained for the second level of screening. After data characterization of the full-text articles of 91, a total of 20 studies were included in this review after removing unrelated studies.

Of the total, seven studies are cross-sectional descriptive observational studies, 4 bibliographic reviews, 4 qualitative studies, 3 mixed studies and 2 randomized controlled trials.

A total of 70% of the selected studies were published in the last 5 years. Most of the studies were carried out in the USA (40%), followed by Iran and Switzerland representing 15% of the sample, respectively, and Germany with 10%; while Denmark, England, Lebanon, and the Dominican Republic have a single record, which represents 5% for each of them.

In relation to the size of the sample, a great variety can be observed among the investigations carried out. For example, we found studies like the one by Harris et al. (2018) with 436 veterans with chronic pain, to others such as Booker et al. (2020) with 18 African Americans over 50 years of age, among other, which reflecting the diversity between the different studies.

The main pain disorders addressed by the studies include fibromyalgia (Braun et al., 2022), osteoarthritis (Booker et al., 2020; Yu et al., 2016) along with pain in the chronic back (Hatefi et al., 2019), musculoskeletal (Najem et al., 2021) and head (Feuille & Pargament, 2013). They also include entities that cause pain such as cancer (Büssing et al., 2013). Three of the reviewed papers focus on pain self-efficacy/self-control (Asadi-Piri et al., 2021; Lee et al., 2014; Vasigh et al., 2020) and 2 on interference with life or disability that causes pain (Braun et al., 2022; Harris et al., 2018), while one of them focuses on quality of life (Shropshire et al., 2019).

Regarding the study population, the majority (Asadi-Piri et al., 2021; Booker et al., 2020; Hatefi et al., 2019; Seguin-Fowler et al., 2020; Shropshire et al., 2019) are aimed at older people. Regarding the ethnographic origin, 3 of the investigations were carried out with the Iranian population (Asadi-Piri et al., 2021; Hatefi et al., 2019; Vasigh et al., 2020), 1 with African Americans (Booker et al., 2020) and another with Dominicans (Yu et al., 2016). Likewise, two of the publications dealt with the relationship between health professionals and patients (Andersen et al., 2019; Perrin et al., 2021). It is worth noting that one of the works focused specifically on women (Seguin-Fowler et al., 2020).

The large areas of research detected are, from more general to more specific, non-pharmacological interventions (Shropshire et al., 2019), movement therapies (Lee et al., 2014), yoga (Seguin-Fowler et al., 2020) and mindfulness (Feuille & Pargament, 2013).

Finally, the fields where the analyzes were implemented were university hospitals/health centers (Asadi-Piri et al., 2021; Braun et al., 2022; Hasenfratz et al., 2021; Hatefi et al., 2019; Vasigh et al., 2020; Yu et al., 2016), pain management clinics (Büssing et al., 2013; Harris et al., 2018; Rettke et al., 2021; Snell et al., 2019) and residences (Shropshire et al., 2019).

Regarding the instrument for data collection, 20% of the studies (qualitative) used only questionnaires and interviews not validated ad hoc, although in the other 20% of the studies (reviews of the literature) the use of any instrument. Within the investigations (quantitative and mixed), 60% used validated scales, the most repeated being: Visual Analog Scale (VAS), Spiritual Well-being Scale (FACIT-Sp), the Pain Catastrophizing Scale (PCS), Pain Self-Efficacy Questionnaire (PSEQ), Spiritual and Religious Attitudes in dealing with illness (SpREUK), Graded Chronic Pain Scale (GCPS) and Brief Pain Inventory (BPI).

Related to the vision of patients and health professionals about spiritual care of pain, six studies answered to the question regarding both visions (Andersen et al., 2019; Booker et al., 2020; Hasenfratz et al., 2021; Owens et al., 2016; Perrin et al., 2021; Rettke et al., 2021; Yu et al., 2016). Four studies were qualitative. The other two are a systematic review of the literature (Andersen et al., 2019) and a mixed study (Owens et al., 2016). Most used a descriptive design to explain the different vision between chronic pain patients (CPP) but in healthcare professionals (HCP) there is not too much information about that.

In reference to the barriers of chronic pain self-management, the studies reviewed pointed out that physicians rarely meet the existential, spiritual, and religious needs of their nonmalignant CPP, their dissatisfaction with the physician's attention to these needs is related to increased pain and depression. In contrast, related to the facilitators of chronic pain self-management, the main facilitator was the individual disposition of the doctor to listen with openness and empathy to the existential concerns of his patients. It is a good point to recognize their overall human wholeness, including the spiritual dimension: being seen, recognized and treated as a whole person in all its dimensions is a central aspect of the therapeutic relationship. Those who indicated a desire to include spiritual aspects in the treatment of chronic pain (61.7% wanted spiritual aspects to be considered in their medical treatment) although they should be the ones who could decide whether or not to integrate spiritual issues in their pain management process. They know that they must bear the pain and they can conquer this experience with three actions: adapting to pain, sharing pain with others, and trusting God as a healer. The positive approach to living well with pain enables more communicative pain reporting, provides positive role models for patients and clinicians, and contributes to a broader theoretical perspective on persistent pain. In one qualitative study, the patients had strong religious beliefs that gave them strength to cope with chronic arthritis pain and prepare for acute pain after surgery. In the interviews they showed a lot of trust and hope that God and the doctors would heal their pain through surgery. Patients reported modest use of pain medications and limited knowledge of opioids, and many relied on nonpharmacologic therapies and family support to cope with Yu et al. (2016).

In relation with the strategies to work the spiritual dimension of pain, five studies answered to the question: strategies to work the spiritual dimension of pain (Feuille & Pargament, 2013; Lee et al., 2014; Seguin-Fowler et al., 2020; Shropshire et al., 2019; Snell et al., 2019). Yoga is at least as effective as its control or more effective, and reporting of adverse events linked to poor training is relatively frequent but not serious. The findings support the feasibility and potential benefits of regular restorative yoga practice, as intervention participants experienced reductions in pain interference and improvements in energy and social functioning. In addition, mindfulness training leads to a partial reduction in pain-related stress among people with migraine compared to simple relaxation techniques, providing modest support for their use in pain management. Furthermore, the spiritual content integrated into such training improves levels of mindfulness, although this does not correlate with better pain outcomes. And Tai chi practice seems safe with a rare adverse event rate. All included studies demonstrated that tai chi was as effective, or more so, than its control in relieving chronic pain symptoms, which is a slight recommendation in its favors.

Related to other non-pharmacological interventions, older people have used pain relievers had higher perceived comfort scores and lower pain scores than those using pain relievers alone. The most common non-pharmacological interventions were exercise, heat therapy, spiritual/religious activity, and listening to music. And the CREATION Health Model represents a holistic (addresses physiological, psychological, social, and spiritual aspects of care) approach to Biblically based pain management. Three (choice of coping strategies, rest and development of interpersonal relationships) of the eight principles of this model have been selected to improve pain management within the clinic based on the specific needs of their patients.

Finally, related to the relationship between hoping needs, resources spiritual and religious and pain of Patients in clinical practice, eight studies answered to the question: Booker et al. (2020), Braun et al. (2022), Büssing et al. (2013), Closs et al. (2013), Harris et al. (2018), Hatefi et al. (2019), Najem et al. (2021) and Vasigh et al. (2020).

The correlation between pain self-efficacy and religious was stronger than its correlation with the existential dimension; however, this difference was not statistically significant (Asadi-Piri et al., 2021). The degree of religiosity played a role in the choice of coping strategies but had no effect on health and mood (Braun et al., 2022). There is no available evidence on how the beliefs of the world's major religions impact the experience of chronic pain, or how they influence its expression. Furthermore, in most studies, religious identity was confined to Christianity, again with few consistent findings. Those studies that considered positive and negative religious and spiritual coping attempted to explore positive attitudes of love and care toward God (or a higher power) or negative attitudes such as anger and fear toward God, and the impact of these attitudes on experience from pain. The results of these studies were also weak (Closs et al., 2013). The higher the level of CR and attachment to God, the more likely it is that pain will be reduced by increasing its acceptance. Therefore, it is suggested to perform appropriate religious interventions to patients to reduce their pain state in order to improve their quality of life (Hatefi et al., 2019). Religiousness is associated with worse pain-related beliefs, cognitions, and emotions, but with better pain acceptance. However, contradictory results are found between religious beliefs and attitudes and the different domains of pain such as its intensity, disability and self-efficacy (Najem et al., 2021). Spiritual health is a predictor of pain acceptance, so more religious patients were more likely to tolerate chronic pain. For this reason, it is suggested that religious interventions be carried out to reduce this type of pain (Vasigh et al., 2020).

In addition to the above, there are some correlations between some factors that should have taking in account.

First, the correlation between pain self-efficacy and other factors showed that depression and anxiety, coping “reinterpretation,” catastrophizing, and pain intensity have a significant impact on disability due to fibromyalgia syndrome FMS. Depending on the degree of disability, and in combination with other factors such as personal characteristics, stress management and life events; these five factors can increase or decrease resilience or vulnerability (Braun et al., 2022).

Second, the correlation between pain self-efficacy and inner peace, quiet people, and places. The religious and existential needs were of less relevance for the patients than those of inner peace and generation/active generativity. Safety (inner peace) needs include external enablers of intrinsically peaceful states (quiet places in the middle of nature) and internal enablers (finding inner peace, talking to others about fears and worries, turning to someone with a loving attitude) to alleviate the perceived “threat” of disease (Büssing et al., 2013).

Thirdly, related to spiritual distress and depression, spiritual distress is a positive and significant predictor of both catastrophizing and pain interference. Furthermore, depression mediated, partially (in interference) or totally (in catastrophizing), the links between spiritual distress and grief outcomes. Therefore, the results suggest that spiritual distress may exacerbate chronic pain (Harris et al., 2018).

The current review has some limitations that should be taking in account. First, although the search strategy was thorough there may have been studies missed. Exclusion of some important sources such as grey literature could have resulted in the loss of potential important relevant results.

Second, the date limits used in this study have excluded older studies. Although this is a limitation, authors decided to include the most up-to-date evidence in this review, since guidelines, clinical practices and evidence change in a rapid pace.