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