871 Notes
871 Notes
871 Notes
of Cognitive Behavioral Therapy
for Chronic Pain Management
John D. Otis, Ph.D.
Research &
Spinal Cord Injury Service
VA Boston Healthcare System
Who is on the call today?
• Psychologists
• Nurses
• Social Workers
• Physicians
• Physical Therapists
• Students
• Other
Presentation Overview
A Historical look at Pain Management
The Problem of Chronic Pain
Cognitive Behavioral Therapy for Chronic Pain
Key Elements of Treatment and Examples
Research:
• An Integrated treatment for Pain and PTSD
Early humans related pain to evil,
magic, and demons. Relief of pain was
the responsibility of sorcerers,
shamans, priests, and priestesses,
who used herbs, rites, and
ceremonies as their treatments.
Early 19th Century
Pain Relief
• Most pain relievers were made
from plants and could be deadly
when taken in overdose. One of
the most commonly used
substances was opium derived
from the poppy flower. Other
substances used included alcohol
or wine, mandrake, belladonna,
and marijuana.
Potions that
included these
substances were
commonly
available around
the turn of the
century and
promised to cure
a variety of
afflictions.
• Touted as a cure for Rheumatism, Sprains, Bruises, Lame Back, Frost Bites,
Diarrhea, Burns and Scalds.
• Contents = 50%‐70% alcohol, camphor, ammonia, chloroform, sassafras,
cloves, and turpentine.
• Wizard Oil could also be used on horses and cattle.
Coca-Cola was originally
sold as a medicine. It
contained stimulating
extracts from coca leaves
and kola nuts. It was
available in carbonated form
at the pharmacy and as a
concentrated syrup. From
1886 until 1903 the formula
for Coca-Cola included
approximately 9 milligrams
of cocaine per serving.
Mrs. Winslow's Soothing Syrup was an indispensable aid to
mothers and child‐care workers. Containing one grain (65 mg)
of morphine per fluid ounce, it effectively quieted restless
infants and small children.
What is the true impact
of PAIN?
What is Chronic Pain?
• Pain is defined as an unpleasant sensory and
emotional experience associated with actual
or potential tissue damage, or described in
terms of such damage (IASP, 1994).
Chronic pain = Pain with a
duration of 3 months or
greater that is often
associated with
functional, psychological
and social problems that
can negatively impact a
persons life.
Prevalence of Chronic Pain in Veterans
Pain is one of the most common complaints
made by patients to primary care providers in
the VA healthcare system (approximately 50% of
patients).
Kerns, R. D., Otis, J. D., Rosenberg, R., & Reid C. (2003). Veterans’ concerns about pain
and their associations with ratings of health, health risk behaviors, affective distress,
and use of the healthcare system. Journal of Rehabilitation, Research and
Development, 40(5), 371‐380. (PMID: 15080222)
The Problem of Pain
Pain is typically an adaptive reaction to an injury
and gradually decreases over time with
conservative treatment.
However, for some people pain persists past the
point where it is considered adaptive and
contributes to …
Negative Mood (depression)
Disability
Increased use of healthcare system resources.
The Role of Thoughts and Emotions
Henry Knowles Beecher: WWII Soldiers & Pain
• Observed that soldiers with serious wounds complained
of less pain than did his postoperative patients at
Massachusetts General Hospital.
Hypothesis: => The soldier's pain was alleviated by his survival
of combat and the knowledge that he could now spend
weeks or months in safety and relative comfort while he
recovered. The hospital patient, however, had been
removed from his home environment and now faced an
extended period of illness and the fear of possible
complications.
The Pain Cycle
Muscle atrophy &
weakness
Weight loss/gain
Pain Disability
Negative self-talk
Poor sleep
Missing work Less active
Decreased motivation
Distress Increased isolation
The Challenge of Pain
Over time, negative thoughts and beliefs about
pain, and behaviors related to pain can become
very resistant to change.
Thoughts Behaviors
• CBT has been found to be effective for a number of
chronic pain conditions, including headache,
rheumatic diseases, chronic pain syndrome, chronic
low‐back pain, and irritable bowl syndrome.
• Significant evidence base supporting the use of CBT
for chronic pain management
Hoffman, Papas, Chatkoff, & Kerns, (2007)
Otis, Sanderson, Hardway, Pincus, Tun, & Soumekh (2013)
Buhrman, Syk, Burvall, Hartig, Gordh, & Anderson (2014)
CBT for Chronic Pain
• Components of CBT for pain include:
– Encourage increasing activity by setting goals.
– Identify and challenge inaccurate beliefs about
pain
– Teach cognitive and behavioral coping skills (e.g.,
restructuring negative thoughts, activity pacing)
– Practice and consolidation of coping skills and
reinforcement of their appropriate use
CBT for Chronic Pain
Session 1 Rationale for Treatment
Session 2 Theories of Pain, Breathing
Session 3 Relaxation Training
Session 4 Cognitive Errors
Session 5 Cognitive Restructuring
Session 6 Stress Management
Session 7 Time‐Based Activity Pacing
Session 8 Pleasant Activity Scheduling
Session 9 Anger Management
Session 10 Sleep Hygiene
Session 11 Relapse prevention
• Children’s pain is more plastic than that of adults, such that
psychosocial factors may exert an even more powerful
influence (McGrath & Hillier, 2002).
• Parents’ response to children’s expression of pain can either
further exacerbate or reduce the child’s perception or
expression of pain.
The ultimate goal of cognitive‐behavioral strategies is to help
children have concrete tools to cope with their experience of
pain so that developmentally appropriate activities can
resume.
Children and Pain
Techniques:
– Distraction techniques (such as counting) during painful
medical procedures, or thinking about a favorite holiday.
– Relaxation techniques are helpful for coping with painful
procedures.
– Cognitive coping ‐ Children have found it helpful to
“throw away” negative thoughts and instead use positive
coping thoughts such as “I can cope with anything that
comes my way; I am very strong and brave.”
Older Adults and Pain
Beliefs and expectations about pain
– Pain is an expected part of growing older (e.g., losing a
tooth or hair)
Previous experience with pain
– A history of successfully coping with a pain problem
(e.g., older adults and knee surgery)
Older Adults and Pain
Pain Intensity
25
Disability
20
Depression
15
10
Pre Post
13 Residents (Ages 65-92)
Pre to Post-treatment (p<.01) Assessment
Present a Convincing Treatment Rationale
Treatment only works if patients are engaged
• TIPS:
1. Providers:
• Use MI to help patient arrive at their own decision to
try CBT
2. Therapists:
• Patients will drop out if they don’t think you have
something to offer them
• Read key articles and chapters related to pain
management but deliver content in your own words
Critical Element of Treatment
• Relaxation Training
– Learning to breathe correctly is one of the easiest
methods of learning how to relax and help reduce
pain.
• Other techniques:
– Progressive Muscle Relaxation, Visual Imagery
– Tai Chi, Yoga, Meditation, etc.
– The Advantage: It is a concrete skill
– Early success with this skill sets the patient up for
success on future goals.
Critical Element of Treatment
• Cognitive Restructuring
– Goals:
• Recognize cognitive errors and maladaptive thoughts,
challenge those thoughts, and substitute more adaptive ones.
• Create a more balanced way of thinking in order to reduce
negative emotions that contribute to the experience of pain.
– Tips:
• Not all thoughts are accurate
• You can control the way you think
• Ask them to be a “detective”
Cognitive Restructuring
Alternate Format Cognitive Restructuring
AUTOMATIC THOUGHTS
1. Identify a situation you found unpleasant.
2. Write down the emotion you were feeling.
3. Try to figure out the automatic thoughts that led to the emotion
4. Write down alternative thoughts you could have about the situation, and challenge your automatic
thoughts.
Automatic
Situation Emotion Alternative Thoughts
Thought
Sample: It may be true that the city engineers are
I’m stuck in traffic Anger, frustration The city incompetent, but tomorrow I’ll take
engineers are another route. I’ll catch up on my
incompetent reading by listening to a book on tape.
I’m really only delayed by 10 minutes,
I’d waste that amount of time if I were at
home.
Critical Element of Treatment
• Time‐based Activity Pacing
– Activity breaks are based on time intervals, not on
how much of the job is completed
– Ideal for the patient who tends to over‐do it
• The weekend warrior
• “This is the way I was trained”
– The Professional Athlete example.
• How do they perform at their best?
Critical Element of Treatment
• Sleep Hygiene
Suggestions for Therapists
• Join forces with Primary Care
• Create a pain group
• (e.g., therapist led – peer led – multidisciplinary)
• Set treatment goals:
• Goals should be measurable/behavioral
• Work towards goals each week
• When available, incorporate rehab medicine goals
• Don’t focus on “pain”, … get them moving.
• Monitor homework completion
• Tailor the treatment to your patient
Otis, J.D., & Hughes, D. (2010). Psychiatry and Pain: Integration and Coordination with Primary
Care. Psychiatric Times. http://www.psychiatrictimes.com/display/article/10168/1759170
CVT Pain Management
Research
Pain and Trauma
• Pain can result from a number of sources
including occupational injuries, motor vehicle
accidents, or injury related to military combat.
• This has led to a growing interest in the
interaction between pain and PTSD, as research
and clinical practice indicate that they frequently
co‐occur and can interact in such a way to
negatively impact the course of treatment for
either disorder.
Chronic Pain, PTSD, and TBI in OEF/OIF
Veterans
Medical record review of 340 OEF/OIF Veterans referred to
the VA Polytrauma Network Site (PNS) at VA Boston
following a positive TBI screen.
Data were based on the second level TBI clinical evaluation
by the Physiatrist of the PNS.
Prevalence of Chronic Pain, PTSD and
TBI in a Sample of 340 OEF/OIF Veterans
Chronic
PTSD
Pain
16.5% N=232
N=277
2.9% 68.2%
10.3%
81.5%
42.1%
12.6% 6.8%
TBI 5.3%
N=227
66.8%
Lew, H., Otis, J. D., Tun, C., Kerns, R. D., Clark, M. E., & Cifu, D. X. (2009). Prevalence of Chronic Pain,
Posttraumatic Stress Disorder and Persistent Post-concussive Symptoms in OEF/OIF Veterans: The
Polytrauma Clinical Triad. Journal of Rehabilitation, Research and Development. 46(6)
Pain and PTSD Co‐morbidity
Alschuler & Otis (2012) – 194 veterans participating
in a VA pain management program
– Analyses indicated that 47% of the sample endorsed
symptoms consistent with PTSD.
– Veterans with pain and PTSD endorsed significantly higher
levels of maladaptive coping strategies and beliefs about
pain (i.e., greater catastrophizing and emotional impact on
pain; less control over pain) when compared to veterans
with chronic pain alone.
Alschuler, K., & Otis, J.D. (2012). Coping Strategies and Beliefs about Pain in Veterans with Comorbid
Chronic Pain and Significant Levels of Posttraumatic Stress Disorder Symptoms. European Journal of
Pain
Clinical Presentation
• “When ever I'm laying in bed at night and my shoulder
starts hurting, I start having thoughts of when I was shot.”
• “When I think about the day our humvee was hit I can feel
the pain in my back flare up right where I was hurt.”
• “Pain is like a barnacle on my hull – it keeps reminding me
of what I went through.”
• “I tried my PT exercises but the pain started increasing and I
started thinking about what I saw and heard in Iraq so I just
said the heck with it and called it quits for the day.”
Clinical Presentation
• For one veteran, pain was the “price” or a “penance” he paid
for surviving while some friends did not.
• Another veteran reported he was experiencing pain for a
reason, so that he would never “forget.”
• Other veterans reported using pain and PTSD symptoms as a
distraction. For example, one veteran reported that he would
intentionally bring on pain by physically over‐exerting himself
in order to take his mind away from his PTSD.
• Another veteran reported that he would intentionally expose
himself to trauma‐related cues that would elicit anger in
order to feel “alive” and forget his pain.
Treatment Components
• High rates of comorbidity between pain and PTSD
• Pain and PTSD seem to interact with one another
• Cognitive‐behavioral treatments for both have
similar components
• Question: Is there a more efficient and effective way
of providing treatment?
Efficacy of An Integrated CBT Approach to
Treating Chronic Pain and PTSD
John D. Otis, Ph.D. and Terence M. Keane Ph.D.
A VA Merit Review funded by the VA Rehabilitation,
Research & Development Service
• Purpose: Evaluate the efficacy of an integrated CBT
approach to the treatment of co‐morbid Chronic Pain
and PTSD
• A 12‐session integrated treatment that contains
elements of evidence‐based treatments for chronic pain
and PTSD.
Treatment Development
• GOALS:
– Create a treatment that amounted to more than
the sum of its parts.
– Create a treatment that was effective and
transportable so that it would be considered
clinically practical to use by therapists.
– It had to be easy to understand for therapist and
patient and not too time intensive.
Study Observations
• Study drop out rate was above 20%
• Challenge to engage patients in treatment
• Problems gaining therapeutic momentum
• Veterans did not want to be in the VA for 12
weeks or longer ‐ they want to get on with
their lives.
Pilot Study: Intensive Treatment of Pain
and PTSD for OEF/OIF Veterans
John D. Otis, Ph.D. and Terence M. Keane Ph.D.
funded by VA RR&D
• Purpose: Develop and Pilot an Intensive (3‐week 6‐
session) integrated Pain and PTSD treatment program
specifically for OEF/OIF Veterans
• Advantages of this approach:
• More time efficient = more acceptable to veterans
• Less costly to administer
• Quicker re‐establishment of adaptive functioning (military or
civilian)
Intensive Treatment
• Participants:
– 8 veterans with comorbid chronic pain and
PTSD were recruited for participation in this
pilot study.
• Assessment:
– Participants were assessed by an independent
evaluator at pre and post treatment. (e.g., Pain,
PTSD, Distress).
Treatment Development
• Session content and sequence
– Therapist feedback
– Patient feedback
• Deciding on the number of sessions
• The timing of sessions
– Building momentum
– Behavioral goals
• Pilot testing
Intensive Treatment Outline
• Session 1
Making The Connection Between Pain and PTSD
• Session 2
Cognitive Restructuring
• Session 3
Focused Cognitive Restructuring
• Anger Management
• Power/Control
• Trust/Safety
• Session 4
Sleep and Relaxation Training
• Session 5
Activity Pacing and Pleasant Activities
• Session 6
Social Support and Integrating Skills into Everyday
Life
Additional Information
• Total Time to conduct pilot study = 3 months
• Treatment often took place after “normal” working hours
• There were no treatment dropouts
• If found to be effective, this treatment could be a “first
step” to engaging OEF/OIF/OND veterans in programs to
help them maintain the skills they have learned, or
strengthen their skills to effectively cope with pain and
PTSD.
Results
Paired Comparison t-tests on Mean Pre to Post-treatment Outcome
Measure Scores
Clinician Administered
72.13 59.13 .03
Assessment of PTSD (CAPS)
• “I’m doing things I haven’t done in a long time, I needed this.”
• “Dr. Otis and his staff have a great project going. It helped me
to sort things out and manage my pain and PTSD.”
• “It probably should be made required for ALL Vets returning
from combat/overseas situations, as a ‘down‐time’ adjusting
period.”
Current Research
• A VA Merit Review Grant for the Intensive Treatment
of Chronic Pain and PTSD for OEF/OIF Veterans was
funded by VA Rehabilitation Research and
Development. • Study N = 102
PT Integrated treatment • Multisite
Recruitment
A1 A2 A3
SC
W0 W1 W2 W3 W4 W5 W41
----------M1-M4 ---------
• Integrative treatment approaches that address
multiple problems simultaneously show promise
• There is a need to develop innovative methods for
disseminating these treatments to the people who
need them most
• Mobile applications delivering evidence‐based
treatments may be an alternative for some
individuals.
Things to Keep in Mind
• Substance use/abuse:
– Drug and alcohol use may be common among their peers
– Pain medications and other substances may be used as a
way to avoid and detach from the world
• Look for Red Flags:
– Relationship problems (parents/spouse/authority)
– Difficulty concentrating
– Anger/Irritability – may be directed at you
• Social Support:
– Support from others is a protective factor. Involve the
spouse and family
Things to Keep in Mind
• They all have chronic pain, they have all seen specialists,
and they are probably not happy with the results.
• Acknowledge frustrations with the system (military and
VA) and problems with previous pain treatments.
• Make a commitment to work with them on finding a
solution to their problems (Pain, PTSD, or other issues).
• Integrating mental and physical healthcare is going to be
essential.
QUESTIONS & DISCUSSION