Pain Management: More than just a pill

Report
Pain Management:
More than Just a Pill
ANNE LYNCH-JORDAN, PHD
ASSISTANT PROFESSOR
PEDIATRICS & ANESTHESIOLOGY
UNIVERSITY OF CINCINNATI COLLEGE OF
MEDICINE
CINCINNATI CHILDREN’S HOSPITAL MEDICAL
CENTER
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 Nature of Pain
THE GATE CONTROL THEORY AND BEYOND
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
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
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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)


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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)

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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 multi-modal approach is most effective
including medical, psychological, and
physical interventions.
AMERICAN PAIN SOCIETY
(2001)
Cognitive Behavioral Therapy
THE ROLE OF THOUGHTS & EMOTIONS ON
PAIN
Impact of Chronic/Recurrent Pain
Physical
Pain affects
FUNCTIONING
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


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Functioning should improve
Mood should stabilize/improve
Pain and suffering should ease
History of CBT
 Behavior Therapy

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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…

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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).
Components of CBT
COPING TOOLS
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

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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
Emotions
Thoughts
Actions
Physical
Symptoms
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
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“My flare up won’t last forever.”
“I can get through this.”
“There are still good things in life.”
 Examine worries
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“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

Additional Techniques
BIOFEEDBACK
HYPNOSIS
YOGA
Biofeedback
 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)
Evidence for Biofeedback
 Most commonly used for migraine or tension-type
headaches, with reviews focused on this problem
 Evidence based summary:
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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
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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
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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

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