Pain Management: More than Just a Pill
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Transcript of Pain Management: More than Just a Pill
ANNE LYNCH- JORDAN, PHDASSISTANT PROFESSOR
PEDIATRICS & ANESTHESIOLOGYUNIVERSITY OF CINCINNATI COLLEGE OF
MEDICINECINCINNATI CHILDREN’S HOSPITAL
MEDICAL CENTER
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.
THE GATE CONTROL THEORY AND BEYOND
The Nature of Pain
“AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE
DAMAGE, OR DESCRIBED IN TERMS OF SUCH DAMAGE.”
International Association for the Study of Pain Task Force on Taxonomy, 1994, p. 210
Pain
The Basics
Pain perception is protectiveMultiple 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
cordFurther modifications to the input occurSignals 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
AMERICAN PAIN SOCIETY(2001)
A multi-modal approach is most effective including medical, psychological, and physical
interventions.
THE ROLE OF THOUGHTS & EMOTIONS ON PAIN
Cognitive Behavioral Therapy
Impact of Chronic/Recurrent Pain
Pain affects FUNCTIONING
Proper treatment addresses pain and functioning simultaneously
Cognitive Behavioral Therapy (CBT)
Primary goal = improved coping skillsPsychologists 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).
COPING TOOLS
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 awarenessAutogenic relaxation
Parallels meditation techniques and focuses on desired autogenic responses
“My arms are warm and heavy” said repeatedlyImagery/Visualization
Pleasant mental images aimed to distract away from pain or distressMindfulness 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
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
BIOFEEDBACKHYPNOSIS
YOGA
Additional Techniques
Developed in 1960sPreviously 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 flowMost 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 exerciseAdult 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.orgAssociation for Applied Psychophysiology and
Biofeedback: www.aapb.orgAmerican Psychological Association (APA):
www.apa.orgAssociation for Behavioral and Cognitive
Therapies (ABCT): www.abct.orgAmerican 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