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 FUNCTIONIN

G

Physical

Emotional

Social

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

Thoughts

Emotions

Physical Symptom

s

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

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