Pain Management: More than Just a Pill

1. 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

2. 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.

3. The Nature of Pain The Gate control Theory and Beyond

4. 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

5. 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

6. Pain Perception

7. 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

8. 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

9. 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

10. A multi-modal approach is most effective including medical, psychological, and physical interventions. American Pain Society(2001)

11. Cognitive Behavioral Therapy The role of Thoughts & Emotions on pain

12. Impact of Chronic/Recurrent Pain Proper treatment addresses pain and functioning simultaneously

13. 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

14. 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

15. 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

16. 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).

17. Components of CBT Coping Tools

18. Education Developmentally appropriate explanation of the Gate Control Theory of Pain Rationale for mind-body techniques

19. 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)

20. 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

21. Cognitive Modification Goal = reduce catastrophic thinking about pain

22. 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?”

23. 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

24. Additional Techniques Biofeedback Hypnosis Yoga

25. 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)

26. 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

27. 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

28. 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

29. 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)

30. 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

31. 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