EMDR Therapy's Efficacy in the Treatment of Pain

Summary of the Randomized Controlled Trials

The efficacy of EMDR in the treatment of chronic pain has so far been investigated in a total of six randomized controlled trials. One of the first randomized trials investigated the effect of a modified EMDR short-term intervention on the course of acute migraine attacks (Marcus, 2008). For this purpose, the influence of an “integrated EMDR” treatment intervention was compared with standard medication. While the EMDR intervention group (N = 26) was not allowed to take any pain medication during the observation period, the comparison group (N = 26) received its individual acute medication to cope with the migraine attack. Instead of medication, the EMDR intervention group received a single EMDR short-term intervention, which consisted of a combination of diaphragmatic breathing, external rhythmic head compressions, and bilateral eye movements. All participants were treated during the mid to late stages of a migraine attack, and pain conditions were assessed by an independent evaluator before, after, 24 hours, 48 hours, and 7 days after treatment. Both the standard medication and the integrated EMDR treatment groups showed a reduction in migraine pain immediately after treatment and 7 days later. However, the integrated EMDR treatment reduced or eliminated migraine pain more rapidly and showed significantly greater improvements compared to conventional medication. No adverse events were reported. A limitation of this study, which makes comparison with other EMDR studies difficult, is certainly the modified form of EMDR intervention used in this study. This began with the participant's use of diaphragmatic breathing in conjunction with rhythmic head compression carried out by the therapist. After this introductory phase, the therapist stopped the rhythmic head compressions and started a set of bilateral stimulation in the form of slow and fast eye movements in a figure of eight for 30–90 seconds. The entire session usually lasted between 12 and 30 minutes. In this respect, this intervention differs significantly from a classical EMDR therapy, and it remains questionable to what extent these results generalize to classical EMDR therapy.

Another interesting randomized trial is described in the doctoral thesis of the American psychologist Linda Estergard (2009), which examined the effectiveness of a classical EMDR intervention on pain symptoms in pain patients for the first time. In this thesis, which unfortunately has not yet been published in a peer-reviewed journal, the efficacy of six sessions of EMDR was compared with a treatment as usual wait-list control in a coordinated two-group design. The participants were matched to their baseline pain levels and randomized to EMDR or a waiting list group with delayed treatment. The experimental group received six 90-minute EMDR sessions over a period of 6 weeks, and the control group waited. The patient population and EMDR treatment are unfortunately not described in more detail in the article. The results showed that EMDR was significantly superior to the waiting list in terms of reducing pain and improving dysphoria. This study is of particular importance for two reasons: Firstly, this study showed the efficacy of the classic EMDR protocol in pain patients for the first time, and secondly, the effects with an effect size of hedges g = 1.12 [-1.82, -0.42] can be considered as clinically significant. One weakness is certainly that the work has not yet been formally published, and therefore relevant information (such as type of pain, age of patients, or therapy targets) remains unclear.

In the authors' own study, patients with non-specific chronic back pain who reported previous experiences with psychological trauma were randomized to standardized pain-focused EMDR in addition to routine care or routine care alone (control; Gerhardt et al., 2016). The results of this RCT showed that pain intensity decreased significantly after EMDR treatment and effects remained stable at 6-month follow-up. On an individual patient basis, the analysis showed that about 50% of the patients in the intervention group had clinically relevant improvements and assessed their situation as clinically satisfactory compared to no patients in the control group. Notably, secondary analyses of the healthcare utilization behavior during the study period showed that patients in the control group had on average twice as many additional appointments with healthcare providers than patients in the EMDR intervention group, indicating significant cost effectiveness. However, it must also be mentioned that this study was designed as a feasibility study with small sample size, and was therefore not sufficiently powered for confirmatory decisions about efficacy of EMDR. Furthermore, EMDR was not compared to other psychotherapeutic treatments in this study but compared to a wait-list control group. It has been noted that such designs may overestimate intervention effects, thus results might be biased.

To avoid this limitation, Nia et al. (2018) conducted a three-arm study in patients with chronic musculoskeletal pain due to rheumatoid arthritis. In this randomized controlled trial, 75 pain patients were allocated into two intervention groups and one treatment-as-usual control group. EMDR and guided imagery were provided in an intensive manner, with six daily sessions of 45–90 minutes. Results showed that EMDR (in addition to multimodal rehabilitation treatment) was significantly superior not only to multimodal rehabilitation treatment alone, but also to guided imagery. Guided imagery and EMDR both reduced pain in rheumatoid arthritis over and above the multimodal rehabilitation treatment, but pain reduction was larger following EMDR than guided imagery.

Particularly remarkable results were reported from a randomized controlled trial on the efficacy of EMDR on phantom limb pain in patients after limb amputations (Rostaminejad et al., 2017). In this study, a total of 60 patients with amputations were allocated randomly into experimental or control group. Control group patients were allocated to routine care, whereas the EMDR group received 12 1-hour sessions distributed over a period of 1 month. The mean pain intensity decreased in the experimental group between the first and last session, whereas the control group tended to experience an increase in pain. The differences were statistically significant and clinically highly relevant. In the 2-year follow-up period, over 86% of patients in the EMDR intervention group reported a complete or almost complete pain relief with just 12 sessions of EMDR therapy—compared to 0% in the control group. These impressive results are impaired by several methodological biases, that is, a lack of information on statistical, procedural, and therapeutic details, which make it hard to evaluate the quality of the data.

Interestingly, there is also preliminary evidence that EMDR is effective in acute pain conditions. Maroufi et al. (2016) explored the effect of a single session of EMDR for acute postoperative pain management in adolescents. The majority of patients reported at least moderate levels of pain postsurgery, despite being on medication. In this randomized controlled study, 56 adolescent surgical patients were allocated to EMDR treatment or a non-EMDR (control) procedure in which patients underwent a 60-minute “neutral” interview. Following EMDR treatment, there was a significant decrease in pain intensity, while the control group reported slightly higher (though nonsignificant) levels of pain on average. The fact that a rather relaxing (EMDR) and a potentially stressful (60-minute interview) procedure were compared makes it difficult to evaluate the results in respect to the natural course of postsurgical pain. These results suggest that EMDR may be an effective treatment modality for postoperative pain.

Types of Pain Treated With EMDR and Treatment Targets

It is astonishing that EMDR appears to be effective for a wide variety of pain disorders, regardless of the underlying cause. For specific pain syndromes such as phantom, postoperative, or inflammatory pain, good efficacy of EMDR has been demonstrated as well as for nonspecific pain conditions. Similarly, there is preliminary evidence for the efficacy of EMDR in both chronic pain and acute pain. These results suggest that it is not so much the original origin of the pain that is important for the treatment response as the association of pain symptoms with stressful memories, thoughts, or feelings.

Much more important than the question of the type of pain seems to be the question of whether the pain must be related to psychological traumatization or whether the pain itself is not a kind of “trauma” that can be processed “trauma-therapeutically” with the help of EMDR. The current state of studies seems to indicate that both is possible. Most studies used the standard EMDR protocol to focus on the processing of traumatic memories associated with pain (De Roos et al., 2010; Gerhardt et al., 2016; Grant & Threlfo, 2002; Konuk et al., 2011; Maroufi et al., 2016; Mazzola et al., 2008; Wilensky, 2006) or traumatic memories completely independent of the pain (Gerhardt et al., 2016), or on possible pain triggers (Gerhardt et al., 2016; Maroufi et al., 2016; Schneider et al., 2008). In addition, numerous studies (De Roos et al., 2010; Grant & Threlfo, 2002; Kavakci, Semiz, Kaptanoglu, & Ozer, 2012; Marcus, 2008; Mazzola et al., 2008) have reported that the pain itself can be targeted and processed by using modified “pain-specific” protocols. In such protocols, special attention is often paid to the processing of pain-associated fears, as well as to enabling changes in pain sensations and developing new coping strategies based on these changes. Overall, however, the current data situation does not allow any conclusions to be drawn as to whether one approach is superior to another. However, it can be assumed that different patient groups will benefit from different approaches, and it will be the challenge of future studies to test which approach is best for which patient group.

Clinical Implications and Outlook for Future Research

Despite increasing scientific evidence, many questions remain regarding the practical use of EMDR in patients with pain. This concerns in particular the question of the selection and modification of “special EMDR pain protocols.” At present no clear statements can be made regarding the most favorable approach in the selection of protocols. Preliminary evidence suggests that EMDR in the treatment of chronic pain may require a greater variety of goals and more flexibility in protocol application than the treatment of posttraumatic stress disorder. In addition, the exploratory description of the course of most studies suggests that the goals for desensitization and reprocessing should not be limited to pain or traumatic life events in advance, but should be adapted to the individual as needed. It will be the task of future studies to create more clarity in this area and thus perhaps to make the therapy protocols even more efficient and patient-centered.