No Disclosures

Learning Objectives

1. To understand the impact and characteristics of chronic pain patients.

2. To appreciate the role of brain physiology and processing of chronic pain perception.

3. To appreciate psychosocial influences and the provider’s role in creating/ changing patients’ beliefs about pain.

4. To gain clinical pearls on incorporating psychological strategies into daily pain practice management.

Who Is The Chronic Pain Patient?

• 116 Million American adults with Pain– 20-30% Chronic

• >$635 Billion U.S dollars spent annually– indirect medical costs– lost productivity

• More prevalent than heart disease, diabetes, and cancer combined

Relieving Pain in America: A blueprint for transforming prevention, care, education, and research. From the Institute of Medicine. Washington D.C. The National Academies Press, 6/29/2011.www.iom.edu

• 1 yr chronic pain prevalence– 37% developed countries– 41% developing countriesTsang, 2008

What Do You Do When You See a Chronic Pain Patient Enter the

Office?

What Do You Do When You See a Chronic Pain Patient Enter the

Office?

Chronic Pain Patients Are Challenging

• Mood disorders/ Personality disorders

• Past trauma/ PTSD• Disability/ Worker’s Comp• Substance Abuse disorders• Psychosocial/ socioeconomic

problems• Multiple providers• Numerous failed treatments/

overutilization• Increasingly complex procedures/

technology available to treat complex patients

• Growing aging population

Provider Burn-out?

• Failure to empathize• Loss of interest/

cynicism• Interpersonal distance• Over-objectification• Anger• Fatigue• DepressionEccleston, B Jo of Anaes. 2013.

How Can A Typical Chronic Pain Patient Present?

• Affect• PMH• PSxH

– Excessive procedure history, health care utilization• Medications

– Multiple classes– Long list of adverse effects/ failed medications

• Family History– Positive for chronic pain?

• Social History– Progressive loss of quality of life and normal function– Psychological history

• Obsession with pain and prior treatments• Insistence on further diagnostic testing

– Resistance to previous or alternative explanations.• Low/unrealistic expectations for treatment success

– “You are my last hope.”

Williams, GW, MD, PhD, et. Al. Case 4: Long-Term Management of the Patient With Lower Back Pain [Internet]. New York (NY): Medscape, LLC.; ©1994-2015; [cited 13 August 2015] Available from: http://www.medscape.org/viewarticle/459802_4

Exam Findings

Pain Behaviors– hobbling/ antalgic gait, grimacing, crying/moaning, unnecessary bracing/ adaptive

equipment, poor effort on manual motor testing, limited tolerance to physical exam, avoidance of activity.

Waddell Signs (described in 1980):• Tenderness

– Superficial, diffuse tenderness– non-anatomic tenderness

• Simulation– axial loading– pain on simulated rotation

• Distraction– positive tests are rechecked– straight leg raise test

• Regional distribution– regional weakness– sensory changes

• Overreaction– subjective signs regarding the patient's demeanor and reaction to testing

Pain Is In The Brain

Chronic Pain Is In The Brain

• Molecular imaging studies using PET– cerebral opioid receptor

binding• neuropathic pain, RA, and

fibromyalgia

• Structural changes– grey matter

• cognitive, emotional modulation brain regions• studied in LBP, fibromyalgia, HA, IBS, CRPS, OA

• Altered neurochemistry– glutamate, N-acetyl aspartate

• frontal cortices of chronic back pain, fibromyalgia patients

– DA• forebrain of fibromyalgia patients

Loggia ML, et. Al. Evidence for brain glial activation in chronic pain patients. Brain. 2015 Mar;138(Pt 3):604-15. doi: 10.1093/brain/awu377. Epub 2015 Jan 12. PMID: 25582579

Credit: Marco Loggia/Martinos Center for Biomedical Imaging, MGH

Pain Is In The Brain• Pain is a complex sensory, emotional experience

– activation of multiple sensory, limbic, and associative brain regions• 1°,2° SSC (S1, S2), anterior cingulate cortex, insula, prefrontal cortex, thalamus, nucleus

accumbens, amygdala, periaqueductal gray, and cerebellum

• Connectivity between mPFC and Nac (mesolimbic) circuit predicts pain chronification (Baliki, 2012)– Apkarian et al. showed altered grey matter in CP regions and abnormal circuitry

between mesolimbic (emotional learning) and the prefrontal (memory) network (also

• hallmark of addiction• Brain imaging studies reveal that the

afferent pain pathway is altered by‒ emotional state‒ memory‒ attention‒ empathy‒ placebo

Bushnell, 2013.

Genetic Predisposition Of Chronic Pain

• 100% accuracy in predicting pain persistence over the next year– validated in a second cohort– no further alterations over a

1-year period

Ali R. Mansoura, et al. Brain white matter structural properties predict transition to chronic pain PAIN®Volume 154, Issue 10, October 2013, Pages 2160–2168

• MRI studies on patients with subacute LBP‒ n = 24 SBP patients studied over 1 yr“‒ SBPp = 12, SBPr = 12

• Significant white matter (fractional anisotropy) abnormalities found

Psychosocial Factors And Pain Chronification

• Chronic pain is related to– emotional distress– perceived life control– attention– prior learning/ cultural and educational background– socioeconomic support

• Psychosocial factors are clearly involved in– Etiology– Severity– Exacerbation– maintenance of suffering and disability

• Attitudes and behaviors of health professionals affect patients’ beliefs. (Crisson & Keefe, 1988)– Patients who believe health is controlled by chance

• more likely depressed and anxious

Why Is The Chronic Pain PatientImportant To The Physiatrist?

• Pain is #1 cause of disability/ lost productivity• Chronic pain has no easy cure

– We need to think comprehensively about patient quality of life, function (not only alleviating symptoms)

• Physical therapy/ exercise– KEY in restoring FUNCTION– reduces disability, suffering

• Treatment means long-term management– MULTIDISCIPLINARY TEAM APPROACH

• medical provider, pain specialist, PT/ OT, social worker, and ideally, the pain psychologist and/or psychiatrist.

Do We Add To The Problem?

Chronic Pain

- Unnecessary Diagnostic

Testing

- Repeated Failed

Therapies- Excessive Referrals

Lack of Good Evidence for Treatments

- Rising Healthcare

Costs- Overutilization

Chronic Post Surgical Pain• >20% of pain clinic patients trace pain onset to surgery

Reddi D., Curran N., 2015

• Predictive factors– younger age, female, lower income, less education, anxiety, depression,

catastrophizing, stress, solicitous spouseDeLeon, 2014

-------------------------------------------------------------------------------------------------------------------

• Most useful predictors of poor surgical outcome‒ Pre-surgical somatization‒ Depression ‒ Anxiety‒ Poor coping

• Minimally predictive factors‒ Pretreatment physical findings‒ Activity interference‒ Pre-surgical pain intensity

Celestin J, Edwards R, Jamison R (2009). Pretreatment Psychosocial Variables as Predictors of Outcomes Following Lumbar Surgery and Spinal Cord Stimulation: A Systematic Review and Literature Synthesis. Pain Medicine 10(4): 639-653.

Catastrophizing

• Involves– Rumination– Magnification– perceived helplessness

• Strong predictor of pain, disability– predicts outcomes

• Enhances pain behavior• Increases pain

awareness/attention• Reinforces fear-avoidance• Exacerbates pain

• Exaggerating pain symptoms• Believing in the worst possible outcome

‒ based on actual or anticipated pain experience

What Do You Do When PT, Meds, Injections, And Surgical Referrals Are Not The Answer?

• REFER TO pain specialist pain psychologist/ psychiatrist multidisciplinary care setting

BUT

• Access to multidisciplinary treatment centers– tricky/ not always practical

• Psychological referrals– may cause patient anger/distrust/fear of abandonment

– “The pain is not in my head, it’s in my back!!!”• Long-term follow up

– still a problem

What Is Our Role?

“Beliefs about the cause, meaning, and consequence of pain are often at stake in any consultation. The pain doctor is a powerful co-creator of beliefs about pain, which can endure and drive disability behavior.”

C. Eccleston, S.J. Morley and A.C. de C. Williams, Psychological approaches to chronic pain management: evidence and challenges (2013). Br Jo of Anaes. 111 (1) 59-63.

Psychological Factors And Pain

• Perceived Disability– 555 LBP patients in primary care followed X 6 months followed 6 mos– Baseline fear of movement/ re-injury predicted future disability

Swinkels-Meewisse, I.E. et al (2006). Fear of movement/ (re)injury predicting chronic disabling low back pain: a prospective inception cohort study. Spine, 32 (6), 658-64.

• In chronic LBP, pain-related fear significantly associated with restricted physical performanceVlaeyen et al., 1995, Crombez et al., 1999, Geisser and Al Obaidi 2000.

• Interventions aimed at reducing pain related fear in acute stages– may prevent activity restriction– increase participation in normal activity and exercise – may prevent pain chronification

Psychological Models For Chronic Pain

Model:• Operant Model (W. Fordyce)• Physiological Models

• Cognitive coping Models

• Central neurophysiological Models

From “Contributions of Psychology to the Understanding and Treatment of People with Chronic Pain,” Mark P. Jensen and Dennis C. Turk, 2014.

Treatments Associated:• Contingency management• Relaxation training and Biofeedback-

assisted relaxation• Cognitive therapy and restructuring• Motivational interviewing• CBT: coping skills, problem-solving,

stress management, communication skills, graded exposure, mindfulness-based stress reduction, acceptance therapy

• EMG and fMRI biofeedback• Hypnosis• Imagery• Mirror visual feedback• Sensory discrimination training

Evidence For CBT And Psychological Interventions

I. Self-Management Education‒ Lambeek, Van Mechelen, Knol, Loisel, Anema (2010)‒ Buchner, Zahlten-Hinguranage, Schiltenwolf, Neubauer (2006)‒ Linton and Ryberg (2001)‒ Flor, Fydrich, Turk (1992)

II. Cognitive Behavioral Therapy– Most well-known, studied

• 2 meta-analyses– Cognitive-behavioral and behavioral therapies most effective when integrated within rehabilitation programs (Flor

’92 and Morley ‘99)• Bernardy K. et al, 2010. Cochrane Review (14/27 RCTs of CBT in Fibromyalgia)

– CBT reduced depressed mood and health-care seeking behavior• decreased # physician visits

• Linton and Andersson, 2000– CBT decreases medical utilization, lessens pain, improves activity and quality of life

• Eccleston et al 2012 (Cochrane Database Syst Rev)– CBT effective in reducing disability immediately after treatment– reduces anxious thinking about pain and future pain– Mood and disability status are improved.

• Eccleston, Palermo, 2012: CBT in pediatric chronic pain– 50% pain reduction with “brief psych interventions.”

• CBT effects on pain are overall modest– no good evidence for long-term effect, and the exact content, structure, and components are variable (needs

more study).

Expertise about the brain, behavior, and their interaction is at the heart

of both the problem of and the solution to chronic pain.

Jensen and Turk, Contributions of Psychology to the Understanding and Treatment of People with Chronic Pain.

Can We All Become Better Caregivers Through Psychological

Approaches?• Effective listening, empathy• Appreciate psychosocial/ genetic factors

playing a role in treatment failures– avoid redundant, unnecessary diagnostic testing

• Educate patients– negative, maladaptive, inaccurate thoughts about pain– Changing over-rehearsed thoughts, behaviors

• Fear, catastrophization• HURT ≠ HARM

– Reward positive behaviors• Promote the goals of maximizing function, independence

Maladaptive Adaptive Thoughts

• Pain always harmful; should be avoided

• All treatments have failed; doctors must be missing something…

• I have degenerative ____ disease and will have to live with this forever; it will only get worse over time.

• I injured myself doing ____, therefore I need to continue avoiding it; exercise will worsen pain.

• This is just going to mask the pain

• I can’t do anything

• I cannot live with this pain anymore

• HURT ≠ HARM

• I am glad that more serious conditions have been ruled out.

• My diagnoses are common; “degenerative” is the medical term for normal aging, not necessary foreboding. Many medical conditions are managed over time.

• It may not hurt me. Movement and activity will make me stronger; I feel good from exercise.

• Recommended treatments may help modify my pain and allow me to function better

• I am capable of helping myself more than I think; I can function despite pain; I’ve been successful before…

• This moment will pass

Psychological Counseling Tips

• Engage Support of partners• Suggest

– resources– support groups– appropriate referrals

• Stress Management• Flare contingency planning• Avoid “prn” med dosing

– taper pain medications with goal-oriented strategies• Encourage

– self-efficacy– helpful lifestyle strategies.

• Do not give up! – Long-term follow up/relationships are required.

Improving patients’ ability for independent action in the context of persistent pain, and

giving freedom from the fear of future disability and loss, can be rewarding medical practice.

Eccleston, Morley, and Williams, Psychological approaches to chronic pain management: evidence and challenges (2013).

Patient Online Resources

• www.theacpa.org offers support and education to patients living with chronic pain, as well as their families.

• www.USPainFoundation.org support and advocacy for chronic pain patients, educating and empowering people living with pain

• www.abct.org Association for CBT• www.bcia.org biofeedback specialists by zipcode• www.acufinder.com licensed acupuncturists by

zipcode

Thank You