Dr Julie ZarifehSenior Clinical Psychologist

Professional Practise Fellow

CDHB

University of Otago

Dr Chris HoffmanOrthopaedic Surgeon

Auckland

14:00 - 16:00 WS #12: Pain Symposium

16:30 - 18:30 WS #17: Pain Symposium (Repeated)

Mr Chris GreggPhysiotherapist

TBI Health

Wellington

The Place of Evidence-Based Psychological Pain Management@

TBIHEALTH

Julie Zarifeh

Consultant Clinical Psychologist

• In the absence of cure, the most appropriate treatment is one that addresses the cognitive, affective, and behavioural factors associated with chronic pain and not solely physical ones ( Turk,2002)

• There is good evidence for the efficacy of cognitive behavioural therapy ( CBT) programmes as a package, compared with either no treatment or treatment as usual ( TAU) in improving pain experience, mood, coping, negative outlook on pain and activity levels.

( Morley et al, 1999;Guzman et al, 2001; European Guidelines 2004; Koes et al, 2006; Hoffman et al, 2007; Williams et al, 2012)

The primary focus of pain-oriented CBT is on improving functioning without assuming that a change in pain is necessary to improve that functioning.

Pain relief or reduction in other symptoms is typically not a primary aim of treatment, although improvements in pain can be reported.(British Pain Society, 2013)

CBT for chronic pain: Basic assumptions

• Human beings are unique in their ability to be active processors, rather than passive reactors, to stimuli (Including pain)

• Cognition (e.g. beliefs, appraisals, attributions, expectancies) can elicit or modulate the emotional, physiological, and behavioural reaction to pain-related stimuli.

• People should be considered active agents of change of maladaptive patterns of response to pain.

The CBT model

Traditional psychological assessment..

• Reason for referral

• Relevant presenting personal and social history

• Current and past psychological history

• Co-morbid health diagnoses

• Family psychological and medical history

• Substance use/abuse

• Current and past experience of pain – management of

• Psychological insight/ understanding of multi-faceted nature of ‘pain.’

What is pain? ( to specific patient)

• Pain sensations – what does it feel like?

• Pain location- where does it hurt?

• What do YOU think is going on?

• What comes into your mind when you feel your pain?

• What feelings come up for you when you’re sore?

• What is pain getting in the way of?

• What are people telling you about your pain and what you should do?

• What happens when you do things when you’re sore?

• What are you most worried about?

Biopsychosocial Framework

• An assessment based on ‘clinical reasoning skills’ is more likely to identify the necessary education targets rather than an approach using algorithms and a reliance on questionnaires.

• Want to know how patient’s pain has had a negative effect on their life in these spheres.

The Four P’s

THE FOUR P’s MODEL

• Case conceptualization equals a method of a patient and a therapist coming to a shared understanding of a difficulty.

• Formulation ‘contextualizes’ the difficulty, making its origin and maintenance understandable

• Best completed collaboratively with clients positioned as the ‘experts’ in themselves..

• Predisposing factors

( what may have made person vulnerable to the problem)

• Precipitating factors

(what may have triggered the problem)

• Perpetuating factors

(mechanisms which might keep a problem going)

• Protective factors

A case formulation ( case conceptualization) can be thought of as a way of helping a client understand what their difficulties are, where/how they originated, what keeps them going.

TBI Pain Management

• Early access to comprehensive assessment and interdisciplinary treatment

• Ambulance at top of cliff, ideally

• Targeting of psychosocial barriers to improvement of pain ‘experience.’

How Chronic Pain has changed me?

Before Chronic Pain vs Now

• Physical activity?

• Leisure/recreation?

• Employment/productivity?

• Socially/friends?

• Family?

• Mood?

• Confidence

• Plans/goals? – revoked/revised by above answers! Plus new goals……

CBT for chronic pain: Treatment

1. Education and reconceptualization

2. Acceptance and motivational enhancement

3. Collaborative goal-setting

4. Coping skill acquisition

5. Coping skill consolidation and generalisation

1. Pain education and reconceptualization

Benefits of returning to full function or as close to it as possible

- Normal routine- Recover a sense of self- Improved self esteem and satisfaction- Social contact- Decrease pain focus- Restore independence- Find a balance between level of the quality of life and level of pain

Target concepts of Education(from ‘Explain Pain,’ ( Butler and Mosley).

1. Pain is normal, personal and always real

2. There are danger sensors, not pain sensors

3. Pain and tissue damage rarely relate

4. Pain depends on the balance of danger and safety

5. Pain involves distributed pain activity

1. Pain relies on context2. Pain is one of many protective

outputs3. We are bioplastic4. Learning about pain can help the

individual and society5. Active treatment strategies

promote recovery

2. Acceptance and motivational enhancement

One of the primary strategies is to shift participant behaviour from struggling ineffectively with pain and to focus their behaviour on more worthwhile individual goals (British Pain Society, 2013)

But the patient wants the pain “cured”, “fixed”, or at least subdued.

How do we shift the patient from a “cure” to a “self management” model?

Demonstrate the futility of pursuing a purely biomedical cure: • Education• Metaphor and analogy (e.g. trying to dig yourself out of a hole with a spade)• Analyse the “workability” of pursuing biomedical ‘cure’ in terms of the

patient’s overall quality of life

3. Collaborative goal-setting

4. Coping skill acquisition

• Education and instruction is provided in the clinical setting.

• It is imperative that the patient practises outside of sessions (skills consolidation and generalisation).

• Homework (e.g. guided audio, handouts and worksheets, behavioural experiments and exposure) should be provided to facilitate home practice.

CBT for chronic pain usually incorporates….

• Relaxation-based methods• Distraction and other attention-regulation

strategies • Cognitive restructuring • Graded exposure and behavioural experiments • Activity pacing• Problem solving• Other areas: Communication and assertiveness

skills, sleep

Coping skill acquisition: RELAXATION

Rationale:Reduce muscle hypertonicity and spasm, reduce anxiety and stress system reactivity, improve sleep and fatigue, increase sense of control over impact of pain on self.

Methods:• Progressive muscle relaxation• Autogenic training • Diaphragmatic breathing • Yoga• Tai Chi

Coping skill acquisition: ATTENTION REGULATION

Rationale:Patients in pain are often preoccupied with their bodily symptoms. This can lead to increased awareness, hypervigilance, and overestimation of sensory information.

Attention regulation training aims to reduce the role of attentional fixation on the pain and associated distress.

Methods:• Distraction• Some forms of Meditation (e.g. concentration-focused methods)• Imagery• Visualisation

Coping skill acquisition: COGNITIVE RESTRUCTURING

Rationale:Thoughts, beliefs, and other cognitive content can influence potently influence mood, behaviour, and some physiological processes. Conversely, mood, behaviour,and physiological activity can influence an individual’s thoughts. Thus, it is important for pain sufferers to become aware of the thoughts and feelings associated with theirpain episodes. Cognitive restructuring is a method that encourages people to identify and modulate stress-inducing thoughts and feelings associated with the experience of pain.

Methods:• Thought monitoring • Education on common pain-related Thinking Errors• Instruction in challenging and modifying maladaptive thoughts• Developing Coping Statements

From Cognitive Therapy for Chronic Pain: A Step-by-Step Guide, Second Edition, by Beverly E. Thorn. Copyright © 2017

Thought monitoring

From Cognitive Therapy for Chronic Pain: A Step-by-Step Guide, Second Edition, by Beverly E. Thorn. Copyright © 2017

Education on common pain-related Thinking Errors

Challenging maladaptive thinking

What is the evidence? What is the evidence to support these thoughts, assumptions, or conclusions?

What are alternative views? How might someone else view this situation?If this were happening to someone else, how would

I view it?

Is the thinking distorted? Are you only attending to the dark side of things?

Are you assuming that you can do nothing to change things?

Are Thinking Errors affecting your thoughts?

What action can you take? Where does thinking like this get you?What can you do to change the situation or how

you feel?

Developing Coping Statements

Coping skill acquisition: GRADED EXPOSURE AND BEHAVIOURAL EXPERIMENTS

Rationale:Through Pavlovian conditioning processes, pain sufferers associate particular activities with pain. Operant conditioning processes reinforce the avoidance of these activities. Graded exposure involves structuring a series of practice activities in ways that are specifically designed to confront and reduce pain-related fear and behavioural avoidance, and thereby increase activity.

Methods:• Education on the fear-avoidance model • Identification of activities avoided due to pain-related fear• Graded exposure to feared activities • Exposure can incorporate behavioural experiments

(testing fear-related predictive hypotheses)

Coping skill acquisition: PROBLEM-SOLVING

Rationale:Pain patients frequently feel overwhelmed and helpless. They perceive that the problems that they face are insurmountable. This deflates their sense of control and self-efficacy, and entrenches disability.

Methods:• Instruction in practical problem-solving:

Problem identification “What is the concern?”Goal selection “What do I want?”Generation of alternatives “What can I do?”Decision making “What is my decision?”Implementation “Do it!”Evaluation “Did it work? If not, recycle.”

Coping skill acquisition: ACTIVITY REGULATION (PACING)

Rationale:Many pain sufferers fall into a “boom-bust” activity cycle. Informed by socio-normative beliefs such as “no pain, no gain” individuals push themselves hard until their pain levels precipitate a rapid reduction in activity. When the pain level recedes the individual again pushes themselves to the pain of pain-reactive immobility. This approach tends to increase pain system sensitivity and is associated with negative emotional and physical functioning.

Activity pacing is a preferable approach. This has been defined as:

an active self-management strategy whereby individuals learn to balance time spent on activity and rest for the purpose of achieving increased function and participation in meaningful activities.(Jaimeson-Lega et al., 2012).

Methods:• Education• Interdisciplinary communication and collaboration

CBT strategies -recap

• Relaxation and visualization

• Activity scheduling / GMI ( graded motor imagery)

• Pleasant event scheduling

• Distraction

• Graded exposure therapy

• Identification of negative automatic thinking errors

• Cognitive restructuring techniques.

• Mindfulness and elements of ACT ( acceptance and commitment therapy).

• Explicit methods for generalising and integrating new skills and behaviour change into daily life and maintaining these over the longer term.

• Patients are helped to set goals, make explicit plans and commitments, and then to practice these in their home and other environments, monitoring what they do.

• Setbacks and flare up preparation should also be addressed.

5. Consolidation and Generalisation

Methods:

• Discuss the importance of adherence to home practice throughout treatment.

• Address patient’s understanding of recommendations.• Be proactive, help patient to anticipate problems (e.g., identify high-risk

situations that may undermine efforts).• Teach how to deal with problems, setbacks, flare-ups, side effects, and

lapses in effort.• Encourage self-reinforcement and use of charts to self-monitor behaviour

and progress.• Provide explanation of need and importance of recommendations and

home practice with significant others if necessary.

Anticipated outcomes

• Prevention/halting or reversal of a decline to a sedentary lifestyle

• Increased participation in progressive goal setting and re-integration into aspects of life before pain , plus new goals.

• Inspire and engender realistic hope for improved pain outcomes, through reconceptualization of pain ( Explain Pain).

• Improved pain ‘literacy.’

• Case example if time…. P.B

CBT service delivery

• Individual and group treatment.

• Well suited to interdisciplinary teams (e.g. CBT-informed physical rehabilitation)

• Psychologists and non-psychologists.

• Primary, secondary and tertiary settings.

• Telehealth.

• Self-help.

Questions??

All referrals can be sent to

tbireferrals@tbihealth.co.nz

TBI Health76 Peterborough Street

ChCh Central

Also @

Sports Doctors9 Humphreys Dr

Ferrymead

tbireferrals@tbihealth.co.nz