Managemen komprehensif nyeri

Azimatul Karimah([email protected])

Konferensi Nasional I CLPYogyakarta, 8-10 Maret 2013

Complex subjective experience

Emosi(kecemasan,

takut, depresi, marah)

Perilaku(peran sakit, sbg

hukuman, perilaku menghindar,

perilaku belajar)

Kognitif(makna nyeri, beliefs, harapan,

perhatian, distraction, labelling, proses belajar)

Somatic damage

Pain

Goal (Sellinger et.al, 2011)

1. Pain Assessment from multiple source persons (patient, family, nurses etc)

2. Keep “aware” of biopsychosocial approach

3. Treatment plan4. Outcome measurement identification

5. Education

Multidicipline Pain Assessment

Multidicipline Pain Assessment

( Sellinger, 2011)

Biopsychososial model of Pain Management

Insight Oriented Approach

Chronic pain is somatic presentations of emotional distress, and non-conscious factors

Focus on : early relationship experiences that are reconstructed within the therapeutic relationship

No controlled trial efficacy ???

Turk, Wilson, Swanson, 2011

Reinforcement in maintenanceof pain behavior

Ask, observe, and make inferences of behavior. “pain-related” behaviors communicated a message Avoidance of activity has a positive effect (negatively

reinforcing) Corrective feedback “hurt” “harm”

Respondent Conditioning Opperant Conditioning


Reinforcement in maintenanceof pain behavior (2)

Respondent Conditioning

• corrective feedback• exposure• quota-based exercise

programs

Opperant Conditioning

• withdraw positive attention for pain behaviors, reinforcement of well behaviors.

• active in setting treatment goals and follow through with recommendations

• Efficacy goodTurk, Wilson, Swanson, 2011

• Which behavioral technique was more effective ?? • Weak evidence that they were more effective when

compared to usual care • Van Tulder et al. behavioral treatments, as compared

to placebo or wait-list control, were moderately effective for low back pain intensity in over half of the studies they reviewed(van Tulder MW, Ostelo RWJG, Vlaeyen JWS, et al. , 2002 Behavioral treatment for chronic low back pain )

• Eccleston, et al. Determined: behavioral treatments were effective in reducing severity and frequency of chronic headache pain (Eccleston C, et.al. Pain 2002;99:157–65)

Reinforcement in maintenanceof pain behavior (3)


CBT

Stephen Morley (2011) Efficacy and effectiveness of cognitive behaviour therapy for chronic pain:Progress and some challenges .PAIN 152 : S99–S106

CBT

• Most common• Beliefs : unable to function because of pain, and

helpless to improve the situation• Goals : realize that they can manage their problems,

and provide them with skills to respond in more adaptive ways that can be maintained after treatment is terminated.

• stress management + problem-solving, goal-setting + pacing of activities + assertiveness

• Homework• Efficacy vs not beneficial


4 Component of CBT

Maladaptive thought to coping thoughts and behavior

learn and practice newpain management behaviors and cognitions

solidifying skills and preventing relapse

Ex : Pain Diary

Motivational intreviewing

Stage TargetContemplation acknowledge the risks associated with inactivity and

passivityGoal : realize that the risks of inactivity outweigh the perceived benefits.

Preparation helps the patient outline appropriate structured physical activities

Action increase activity

Maintenance Motivation and commitment


Motivational intreviewing (2)

• Providing motivational statements,

• Listening with empathy,

• Asking open-ended questions,

• Providing feedback and affirmation,

• Handling resistance

Relaxation

Jensen, 2011; Turk, Wilson, Swanson, 2011

Meditation

Trancendental meditation Mindfulness meditation

Focus, concentration reframes the experience of discomfort

~ zoom lens ~ wide lens

transcending the ordinary stream of thought

attempting awareness of the whole perceptual field

Less useful More useful

Biofeedback

• pain is maintained or exacerbated by ANS dysregulation ~ the production of nociceptive stimulation

• Objective : teach people to control over their physiological processes

• Monitored : (Tan, Jensen, 2007; Turk, Wilson, Swanson, 2011)

• skin conductance, • respiration, • heart rate variability for depression and pain,

fibromyalgia• skin temperature for migraine• brain wave activity,• muscle tension for TTH

Biofeedback (2)

• Mechanism ?? General sense of relaxation ?? Sense of control ???

• Nestoruic and Martin: all biofeedback methods were effective for chronic headaches (Nestoruic Y, Martin A. Efficacy of biofeedback for migraine:meta-analysis. Pain 2007; 128:111–27)

Using rtfMRI to control activation in the rostral anterior cingulate cortex (rACC) ~ pain perception and regulation

Guided Imagery

• To relax, achieve sense of control and distract from pains

• Stand alone or used in conjunction with other treatment• Visualization or imagination• The most successful images involve all of the

senses(vision, sound, touch, smell, and taste).

Hypnosis

Three central component :1. Absorption; involvement in central object of

concentration2. Dissociation ; experience be experienced consciously

occur outside of conscious awareness

3. Sugesstibitily ; accept outside input without cognitive censoring or criticism

• Patterson and Jensen, hypnosis has more utility in the treatment of acute pain than chronic pain(Jensen MP, Patterson DR. Hypnotic treatment of chronic pain. J Behav Med 2006; 29:95–124)

Hypnosis

• The evidence for hypnosis was incomplete (Turk, Wilson, Swanson, 2011)

• Hypnosis + CBT treatments = enhances the efficacy of the latter, arguing for combining hypnosis with CBT to improve clinical outcomes (Jensen, 2011)

Other Modalities

• Education and Group Therapy• Anger Management• Assertive Communication• Perfectionism and Unrealistic Expectations• Cycle of Chronic Pain• Planning for Difficult Days• Personal Responsibility• Relationships and Chronic Pain• Physical Therapy• Occupational Therapy• Sleep hygiene• Lifestyle management

Conclussion

• Meta-analyses, psychological treatments have modest benefits on improving pain, physical, and emotional functioning

• A multidisciplinary program would be maximally effective, all of the above treatment-component team members need to be working collaboratively on a daily basis

Managemen komprehensif nyeri

Health & Medicine

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