pain management: more than just a pill · describe pain perception and emotional and lifestyle...
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A N N E L Y N C H - J O R D A N , P H D A S S I S T A N T P R O F E S S O R
P E D I A T R I C S & A N E S T H E S I O L O G Y U N I V E R S I T Y O F C I N C I N N A T I C O L L E G E O F
M E D I C I N E C I N C I N N A T I C H I L D R E N ’ S H O S P I T A L M E D I C A L
C E N T E R
Pain Management: More than Just a Pill
Objectives
Describe pain perception and emotional and lifestyle
factors that can affect pain.
Provide a history of cognitive behavioral therapy
(CBT) and its application to pain management.
Review the components of CBT.
Discuss other mind-body techniques.
T H E G A T E C O N T R O L T H E O R Y A N D B E Y O N D
The Nature of Pain
“ A N U N P L E A S A N T S E N S O R Y A N D E M O T I O N A L E X P E R I E N C E A S S O C I A T E D W I T H A C T U A L O R P O T E N T I A L T I S S U E D A M A G E , O R D E S C R I B E D
I N T E R M S O F S U C H D A M A G E . ”
International Association for the Study of Pain Task Force on Taxonomy, 1994, p. 210
Pain
The Basics
Pain perception is protective
Multiple systems are involved: Peripheral nervous system (sensory nerves & receptors)
Central nervous system (spinal cord & brain)
Sensory nerves receive input from physical stimuli
Receptor input is transmitted to the spinal cord
Further modifications to the input occur
Signals are relayed to brain structures for encoding
Pain Perception
Gate Control Theory of Pain (Melzack & Wall, 1965)
Importance of cognitions and affect on pain experience
Pain is reduced or amplified based on descending pathways from the brain due to characteristics like Pain history
Attention to symptoms
Emotional state
Contributions from genetics, neuroscience, & imaging have refined this theory
Chronic Pain
Central sensitization: “abnormal state of responsiveness to increased gain of the nociceptive (pain) system” (Latremoliere & Woolf, 2009) Hyperarousal of nervous system
Spontaneous occurrence of pain signals
Low levels of stimulation cause high levels of pain
The Role of Stress
Stress (physical or emotional) disturbs body’s homeostasis
Disruption causes internal immune & hormonal reactions to restore balance (Melzack, 2005) Release of substances to fight infection & repair tissue damage
Activation of hypothalamic-pituitary-adrenal (HPA) system
Cortisol release
Prolonged cortisol release may not trigger chronic pain, but may create an internal environment that promotes it
A M E R I C A N P A I N S O C I E T Y ( 2 0 0 1 )
A multi-modal approach is most effective including medical, psychological, and
physical interventions.
T H E R O L E O F T H O U G H T S & E M O T I O N S O N P A I N
Cognitive Behavioral Therapy
Impact of Chronic/Recurrent Pain
Pain affects FUNCTIONING
Physical
Emotional
Social
Proper treatment addresses pain and functioning simultaneously
Cognitive Behavioral Therapy (CBT)
Primary goal = improved coping skills Psychologists have expertise in changing maladaptive
behavior and thoughts (cognitions)
With enhanced coping skills Functioning should improve
Mood should stabilize/improve
Pain and suffering should ease
History of CBT
Behavior Therapy Based upon the principles of operant conditioning (B.F Skinner, 1950s)
and social learning theory (Albert Bandura, 1960s – ’70s)
Goal of therapy is to alter behavior
Cognitive Therapy Based upon principles of information processing and cognitive processes
(Aaron T. Beck, 1970s and 80s)
Goal of therapy is to alter thoughts and beliefs
CBT for Pain Management
Cognitive-behavioral therapy was initially developed for the treatment of depression and anxiety disorders
The potential for CBT was quickly recognized for application in pain management.
Dennis Turk Frank Keefe
CBT for Pain Management
Numerous intervention protocols have been developed for adults with low back pain, fibromyalgia, osteoarthritis, rheumatoid arthritis. Gatchel, RJ, & Okifuji, A. (2006). Evidence-based scientific data documenting
the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. Journal of Pain 7(11), 779-796.
Strong support for chronic pain programs that includes an integrative approach (PT, psychology, & medicine) and focus on functional improvement or rehabilitation
Increased research attention has been devoted to psychological
treatment for youth with chronic pain… Kashikar-Zuck et al., 2012; Palermo et al., 2010; Eccleston et al., 2009;
Huertas-Caballos et al., 2008 Treatment has shown large effect sizes -0.94 (Palermo et al., 2010).
C O P I N G T O O L S
Components of CBT
Education
Developmentally appropriate explanation of the Gate Control Theory of Pain
Rationale for mind-body techniques
Relaxation Training
Diaphragmatic breathing Promotes a parasympathetic response (reduced blood pressure, muscle
tension, heart rate, etc.)
Progressive muscle relaxation Reduces muscle tension and promotes body awareness
Autogenic relaxation Parallels meditation techniques and focuses on desired autogenic responses “My arms are warm and heavy” said repeatedly
Imagery/Visualization Pleasant mental images aimed to distract away from pain or distress
Mindfulness meditation Meditation with a focus on a calm awareness of the present moment and
acceptance without judgment of bodily sensations and emotions (Bishop et al., 2006)
Behavioral Activation and Regulation
Two types of activity patterns are common but equally problematic
Cycle 1: Under-exertion Fear of pain, avoidance, disuse & deconditioning, disability
Cycle 2: Over-exertion Unhealthy high levels of activity, task persistence, disability
4 types of activity patterns (McCracken et al., 2007) Avoiders Doers Medium Cyclers Extreme Cyclers
Cognitive Modification
Goal = reduce catastrophic thinking about pain
Thoughts
Emotions
Physical
Symptoms Actions
Methods of Cognitive Modification
Identify negative beliefs & attitudes Black-and-white thinking; fortune telling
“I cannot function when I’m in pain.” “My health is hopeless.” “I’m never going to be able to cope with pain.”
Create calm, supportive self-statements “My flare up won’t last forever.” “I can get through this.” “There are still good things in life.”
Examine worries “In 5 years, will I remember (or care) about this worry?” “Do I know for sure it will be as bad as I anticipate? “What is the worst that can happen?”
Rehearsal & Maintenance
Regular practice of techniques Promotes continued re-training of physiology
Serves as a preventive mechanism
Prepares for effective use during flare ups
Relapse prevention Important to prepare for potential flare ups
Engage problem solving skills in anticipation so disability does not become extreme
Kashikar-Zuck et al. (2012): CBT for juvenile fibromyalgia Included two booster sessions post-treatment
At 6 months post-treatment, CBT group showed ongoing improvements (disability), even better than immediately post-txt
B I O F E E D B A C K
H Y P N O S I S
Y O G A
Additional Techniques
Developed in 1960s Previously believed that people were unable to gain
voluntary control of certain body processes Began investigating the “average” person’s ability to
control autonomic responses Heart rate, respiration, blood pressure, muscle tension,
peripheral blood flow
Most people do not have interoceptive awareness Not adaptive to be consciously aware of these processes (i.e.
pulse, breathing)
Biofeedback
Evidence for Biofeedback
Most commonly used for migraine or tension-type headaches, with reviews focused on this problem
Evidence based summary: Biofeedback can facilitate the pace of progress, especially when
used with therapy vs. biofeedback alone (Yip, 2006; Asfour, 1990)
In many studies, biofeedback alone had no direct effect on pain intensity compared to control groups (Bush 1985; Asfour, 1990)
Best effects were found as part of combination therapy (either with relaxation training alone or CBT packages). (Bucklew, 1998)
Orlando, 2007 for review
Issues with Biofeedback
No evidence for purely physiological model of biofeedback success
Difficult to clearly establish criteria for “acquired
physiological control” Psychological factors Self efficacy Perceive symptom control
Hypnosis
Hypnotic Process: Induction: initial suggestions for changes in behavior or
perception (e.g., for focused attention and/or relaxation);
Specific suggestions for alterations in how pain is viewed or experienced,
Post-hypnotic suggestions
Jensen & Patterson (2006) meta-analysis 19 studies compared to wait list, standard care, relaxation
Hypnosis > no treatment for pain control
Hypnosis > medication, physical therapy, or education
Hypnosis = similar relaxation-based treatments
Yoga
Several randomized control trials for yoga Limitations: poor ability to construct a placebo yoga group that takes
into account interpersonal attention and exercise
Adult research in migraine/back pain Intervention: weekly session, home practice, 3-4 months duration Compared to self-care education, yoga improved:
Functional disability Pain intensity Medication use Also had positive effects on anxiety and depression John et al. 2007, Williams et al. 2005
Children: effective for reducing disability, mood problems for kids with IBS (Kuttner et al., 2006)
Resources
National Center for Complementary and Alternative Medicine (NCCAM): www.nccam.nih.gov
American Pain Society (APS): www.ampainsoc.org Association for Applied Psychophysiology and
Biofeedback: www.aapb.org American Psychological Association (APA):
www.apa.org Association for Behavioral and Cognitive Therapies
(ABCT): www.abct.org American Society of Clinical Hypnosis (ASCH):
www.asch.net
Resources
References: Conquering your child’s chronic pain. Lonnie Zeltzer
The pain survival guide: how to reclaim your life. Turk & Winter
Mindfulness meditation for pain relief: guided practices for reclaiming your body and your life. (CD) Jon Kabat-Zinn