Presentation for Veteran’s Affairs

1. Presentation for Veteran’s Affairs Spring 2014 Dr. Jeffrey Ennis

2. Victoria Cross Recipients There have been 1351 VC’s given with 96 going to Canadians

3. Ties to the Military

7. Argyll and Sutherland Highlanders of Canada

8. Lieutenant Alexander Roberts Dunn • 1st recipient of the VC in Canada • Was in the ‘Charge of the Light Brigade’ in the Crimean War, October 25, 1854 • For having in the Light Cavalry charge on the 25th October, 1854, saved the life of Serjeant Bentley, 11th Hussars, by cutting down two or three Russian Lancers who were attacking him from the rear, and afterwards cutting down a Russian Hussar, who was attacking Private Levett, 11th Hussars.” • - Victoria Cross citation, The London Gazette, February 24, 1857.

9. Who Am I?

10. My Physician Qualifications • Masters in Social Work • MD (McMaster University) • FRCP(C) Psychiatry (McMaster University) • Two Years additional training (working under supervision) in the management of chronic noncancer pain

11. Before

12. My Patient Qualifications • Guillain-BarréSyndrome • Chronic IdeopathicPolyradiculoneuropathy • Connective Tissue Disorder • Ehler-Danlos Syndrome • 18 Musculoskeletal surgeries • 6 to the back including 2 fusions • 6 to the knee • 6 to the hands

13. Qualifications

19. Magic

23. Epidemiology of Chronic Pain

24. Chronic Pain-Epidemiology • 38% of institutionalized elderly have chronic noncancer pain (CNCP) compared to 27% who live independently • OA affects 1:3 Canadians or 3 million people • 8.2% or 1 million Canadians have neuropathic pain • Telephone research finds about 25% of the population reports chronic pain (poor response rates) • In the US, 15% have LBP on most days for at least a month (no Canadian studies) • UK reports 46.5%

25. Impact of CNCP • Physiologic changes • Sleep • Cognitive function • Sexual function • Mood • Cardiovascular function • Quality of Life • Loss of work capacity • Loss of role function as parent/spouse/friend • Loss of social/recreational activities Fine PG.. Long-term consequences of chronic pain: mounting evidence for pain as a neurological disease and parallels with other chronic disease states. Pain Med. 2011 Jul;12(7):996-1004.

26. CNCP-Co-morbidities • Addiction • About 10% will abuse opioids • Alcohol • About 12% overlap between patients using opioids and ETOH abuse • Psychiatric Issues • Mood disorder (4 x more prevalent) • Anxiety disorders • Somaform Disorders

27. The Military Experience • Now a Less than 10 % died from wound rate • Increase in survival • Significant increase in wounded with chronic pain

28. Hampden Zane Churchill Cockburn Born in Toronto, Cockburn served with the Royal Canadian Dragoons in South Africa during the Boer War. Lieutenant Cockburn, with a handful of men, at a most critical moment held off the Boers to allow the guns to get away; to do so he had to sacrifice himself and his party, all of whom were killed, wounded, or taken prisoners, he himself being slightly wounded. (London Gazette, no.27307, 23 April 1901)

29. Program Elements

30. Treatment • Manage Pain • Surgery • Intervention • Analgesics • Other Medication • TCA, Anticonvulsant, Gabapentinoids • Other Strategies • Acupuncture • Marijuana • Herbal • Manage Coping • Multidisciplinary Programs • Individual Therapy • Pharmacotherapy • Manage Function • Occupational Therapy • Multidisciplinary Pain Program • Individual Therapy

31. Reduce Pain When Possible • A good physical assessment as well as psychiatric assessment are required • Based on assessment, determine what physical treatments can lead to pain reduction • Disease management • Surgery • Medication management • Intervention • Other modalities • acupuncture Dr. Jeff Ennis -September 2008

32. Management of CNCP • Management is the last option of treatment when sensory discriminative types of treatment have failed. • Patients who require rehabilitation have been failed by the medical model • Always treat co-morbid psychiatric issues Dr. Jeff Ennis -September 2008

33. Operant Conditioning • Classical conditioning forms an association between two stimuli. • Operant conditioning forms an association between a behavior and a consequence. • Operant conditioning is distinguished from classical conditioning in that operant conditioning deals with the modification of "voluntary behavior" or operant behavior rather than reflex behaviour. • Operant behavior "operates" on the environment and is maintained by its consequences Dr. Jeff Ennis -September 2008

34. Cognitive Behavioural Therapy (CBT) • CBT incorporates principles associated with operant conditioning, information processing and learning theories. • A basic assumption of CBT is the recognition that there is a reciprocal relationship between a patient’s cognitive processes, affect, physiology, and behaviour. • CBT emphasizes the importance of changing cognitions, affect and behaviors as a way of reducing symptoms and improving the functioning of the affected person. • The therapist and the client are active participants in the therapy. The treatment is not driven by an exploration of past events. Dr. Jeff Ennis -September 2008

35. CBT • It is based on the assumption that people believe they cannot function because of their pain and they are helpless to improve their situation. They become depressed and they avoid activity. • It is much more than Hurt vs Harm • Treatment goals focus on: • Examining thoughts (cognitions) and challenging ‘faulty’ thinking • Learning alternative behavioural responses (eg relaxation) • Altering negative affect • Dealing with ‘helplessness’ • Develop new skills (behaviours) to respond to one’s circumstances in a more adaptive way. Can J Psych.2008;53(4):213-223 Dr. Jeff Ennis -September 2008

36. CBT in Brief • A person behaves in a particular way because of what they think and how they feel. • A person feels a particular way, because of how they think and behave. • A person thinks in a particular way because of how they feel and behave. • Thinking, feeling and behaviour are intimately intertwined. By changing one of these variables, the others are affected. Dr. Jeff Ennis -September 2008

37. The Nuts and Bolts • Change the cognition (thinking) • restructuring • Identify the patient’s schema • Self monitoring • Change the affect • Medication management (severe mood disorder MUST be treated with medication-this is a standard of practice) • psychotherapy • Change the behaviour • Behavioural Experiments • Activation (exercise, socializing, hobbies) • Relaxation Skills (do not send patients home with a CD and assume they know how to ‘relax’ • CHANGE THE OPERANT…THE OUTCOME OF BEHAVIOUR, AFFECT AND COGNITIONS • This changes everything Dr. Jeff Ennis -September 2008

38. Operant Conditioning and CBT • Examine the system for reinforcers of the ‘sick role’/illness behaviours/pain behaviours. Use and ABC chart. Dr. Jeff Ennis -September 2008

39. Thomas William Holmes • Holmes was born in Montreal in 1897, dying in Toronto in 1950. he served with the 4th Canadian Mounted Rifles, Canadian Expeditionary Force. • For most conspicuous bravery and resource when the right flank of our attack was held up by heavy machine-gun and rifle fire from a ‘pill-box’ strong point. Heavy casualties were producing a critical situation when Pte. Holmes, on his own initiative and single-handed, ran forward and threw two bombs, killing and wounding the crews of two machine guns. He then returned to his comrades, secured another bomb, and again rushed forward alone under heavy fire and threw the bomb into the entrance of the ‘pill-box,’ causing the nineteen occupants to surrender. • By this act of valour at a very critical moment Pte. Holmes undoubtedly cleared the way for the advance of our troops and saved the lives of many of his comrades.” • (London Gazette, no.30471, 11 January 1918)

40. The Four Steps of CBT • 1 Education • 2 Skill Acquisition • (3 Activation) • 4 Generalization • 5 Maintenance Can J Psych.2008;53(4):213-223 Dr. Jeff Ennis -September 2008

41. Education • Provide new information about pain and pain management. The hypothesis is that with new information, patients will change their thinking and therefore affect/behaviour. • The concept of ‘hurt versus harm’ is an oversimplification of a complex problem and most patients do not buy it. The usual response to this is ‘how would you know’. • Topics include: • The physiology of pain and chronic pain • Medication management • Sleep • Managing medications • Human sexuality • productivity Dr. Jeff Ennis -September 2008

42. Skills • Relaxation training is the most common skill • Tai Chi • Acupressure • Self Monitoring and analysis-this is critical • Self Hypnosis • Remember relaxation skills are important because they provide the patient with an alternative response to pain that is more functional. Dr. Jeff Ennis -September 2008

43. Skills • Help patients develop skills to identify their cognitions (thoughts and beliefs-ABC charting) • Help them recognize the relationship between cognition/behaviour/affect/consequence. • Help them develop self-monitoring skills • Help patients examine their cognitions/develop alternative thoughts and responses Dr. Jeff Ennis -September 2008

44. Skills • Self monitoring is a significant and most difficult skill for patients to develop in Goal attainment scaling. Often, it is their cognitions that are the barriers to goal attainment. Dr. Jeff Ennis -September 2008

45. Physical Activation • Fitness • Fitness can reduce deconditioning and pain from weakened muscles. There is no evidence that fitness is a method of pain reduction • Fitness is a behavioural experiment. • Activity Sessions • Cooking • Hardware Store • Aquatherapy • Tai Chi • Painting Dr. Jeff Ennis -September 2008

46. Physical Activation • Pacing skills are an integral part of physical activation. • Pacing does not mean doing less • Pacing does not mean stopping when you have pain • Pacing is learning to make activity not contingent on pain (changing the consequences of pain) • Break up an activity into time dependent, do-able components with planned breaks. Dr. Jeff Ennis -September 2008

47. Physical Activation • Gives patients the opportunity to identify limitations to activity other than pain and develop solutions to these limitations • Physical activity can be viewed as behavioural experiments • Physical activity provides an opportunity to practice pacing • The activity should be easily available and can be tailored to a specific patients capacity • Physical activity is gradually increased in a planned way while examining cognition, affect and consequences. Dr. Jeff Ennis -September 2008

48. Thomas Ricketts “For most conspicuous bravery and devotion to duty on the 14th October, 1918, during the advance from Ledeghem, when the attack was temporarily held up by heavy hostile fire and the platoon to which he belonged suffered severe casualties from the fire of a battery at point-blank range. Pte. Ricketts at once volunteered to go forward with his section commander and a Lewis gun to attempt to outflank the battery. Advancing by short rushes under heavy fire from enemy machine guns with the hostile battery, their ammunition was exhausted when still 300 yards from the battery. The enemy, seeing an opportunity to get their field guns away, began to bring up their gun teams. Pte. Ricketts, at once realising the situation, doubled back 100 yards under the heaviest machine-gun fire, procured further ammunition, and dashed back again to the Lewis gun, and by very accurate fire drove the enemy and the gun teams into a farm. His platoon then advanced without casualties, and captured the four field guns, four machine guns, and eight prisoners. A fifth field gun was subsequently intercepted by fire and captured. By his presence of mind in anticipating the enemy intention and his utter disregard of personal safety, Pte. Ricketts secured the further supply of ammunition which directly resulted in these important captures and undoubtedly saved many lives.” “ (London Gazette, no.31108, 6 January 1919)

49. Dr. Jeff Ennis -September 2008

50. Dr. Jeff Ennis -September 2008