Healing%20Groups%20for%20People%20Living%20with%20Chronic%20Pain

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Healing Groupsfor People Living with Chronic Pain

• Mind-Body Medicine at the
• Full Circle Center for Integrative Medicine

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A Proven Approach

• Pain. 1992 Mar48(3)339-47. Comparison of
  cognitive-behavioral group treatment and an
  alternative non-psychological treatment for
  chronic low back pain. Nicholas MK, Wilson PH,
  Goyen J. The combined psychological treatment and
  physiotherapy condition displayed significantly
  greater improvement than the attention-control
  and physiotherapy condition at post-treatment on
  measures of other-rated functional impairment,
  use of active coping strategies, self-efficacy
  beliefs, and medication use. These differences
  were maintained at 6 month follow-up.
• Cognitive-Behavioral Therapy for Somatization and
  Symptom Syndromes A Critical Review of
  Controlled Clinical TrialsK Kroenkea, R
  Swindlea, Psychotherapy and Psychosomatics
  200069205-215 (DOI 10.1159/000012395)
• Pain. 1995 Nov63(2)189-98. Relaxation and
  imagery and cognitive-behavioral training reduce
  pain during cancer treatment a controlled
  clinical trial. Syrjala KL, Donaldson GW, Davis
  MW, Kippes ME, Carr JE.
• Arthritis Care Res. 1993 Dec6(4)213-22.
  Cognitive-behavioral treatment of rheumatoid
  arthritis pain maintaining treatment gains.
  Keefe FJ, Van Horn Y.
• Altern Ther Health Med. 1998 Mar4(2)67-70. A
  pilot study of cognitive behavioral therapy in
  fibromyalgia. Singh BB, Berman BM, Hadhazy VA,
  Creamer P.
• J Pediatr. 2002 Jul141(1)135-40. Physical
  therapy and cognitive-behavioral treatment for
  complex regional pain syndromes. Lee BH, Scharff
  L, Sethna NF, McCarthy CF, Scott-Sutherland J,
  Shea AM, Sullivan P, Meier P, Zurakowski D, Masek
  BJ, Berde CB.
• and many others. . . .

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Session 1 Outline

• Staff Introductions
• Review course format, group expectations
• Introduce Diaphragmatic breathing
• Understanding Pain The Physiology of Pain
• Integrative Pain Management
• Diagnosis
• Treatment of underlying causes
• Medical treatment of pain
• Mind/body/spirit medicine for pain management

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Staff Introductions

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Course Format

• Introductory Session didactic (Connie will
  drone on and on)
• Future groups more interactive/experiential
• Relaxation Response Exercise
• Check-in
• Medical Presentation
• CBT exercise
• Med check
• Closure/Relaxation Response

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Course Format

• Homework pain diaries, other
• Comfort issues
• Feel free to stand or move when you need to
• Confidentiality issues
• We will not discuss particulars of your
  medication use or your medical problems with the
  group unless you indicate willingness to do so,
  but we encourage participants to do this

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Diaphragmatic Breath Awareness

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Breathing

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Diaphragmatic breathing
10

Chest breathing
11

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Understanding Pain

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Acute Pain

• Adaptive
• Indicates tissue injury
• Initiates protective behavior

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Chronic Pain

• Maladaptive
• Signal no longer related to
• acute trauma/injury
• Ongoing message is harmful,
• not protective
• Thirty-four million Americans suffer from chronic
  pain

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Effects of Chronic Pain

• Physical stress of chronic pain, interrupted
  sleep, poor wound healing, decreased immunity
• Psychological emotional suffering, depression,
  isolation, self-medication
• Spiritual a reminder of mortality, at times
  perceived as a punishment or evidence of moral
  wrongdoing, causes feelings of powerlessness,
  hopelessness
• Under treatment of CNP often results in suicide.
  In a recent survey, 50 of CNP patients had
  inadequate pain relief and had considered
  suicide to escape the unrelenting agony of their
  pain.

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Pain Perceptionthe plot thickens

• Sensory Nerves
• A-delta Fibers myelinated, 40 mph,
  well-localized and rapid message, respond to
  tissue pressure. Fatigue with repeated
  stimulation.
• C Fibers nonmyelinated, 3 mph, respond to
  noxious thermal, mechanical, or chemical stimuli.
  Slow message, poorly localized. Sensations are
  perceived as dull, aching, burning, and have
  input that does not fatigue or extinguish with
  repeated stimulation.
• Sensitization chemical mediators from
  inflammation or injured tissue can sensitize
  small fibers, so that non-painful stimuli will be
  perceived as painful.

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Pain Perception

• Spinal Cord
• Modulation Transmitting cells are influenced by
  multiple signals coming in from periphery as well
  as inhibitory messages coming down from the brain
  (serotonin, norepinephrine, endorphin)

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Pain perception

• Brain
• Can tonically amplify or suppress the messages
  coming in from the periphery
• Gives meaning to the pain experience
• Differences in pain levels of victims of
  automobile accidents vs. those responsible for
  the accident
• Carolyn Myss insights, etc.
• John Sarno and repressed anger

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Gate Control Mechanism/Theory

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Imagine. . .

• The brain has messages coming in and has caller
  ID.
• It can screen calls
• Some callers are filtered out altogether
• Some callers are amplified
• The messages reaching the brain depend not just
  on what is happening in the outside world, but
  also on how the messages are transmitted.

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Gate Control Mechanism/Theory

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Gate Control ImplicationsMechanical Stimuli Can
Decrease Pain Sensation
Chronically firing pain neurons can be silenced
by intense mechanical stimuli.
Boal RW, Gillette RG. Central neuronal
plasticity, low back pain and spinal manipulative
therapy. J Manipulative Physiol Ther. 2004
Jun27(5)314-26
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Integrative Pain Management

• Pain may be mandatory,
• but suffering is optional

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Pain Diary Instructions

• Physical sensation
• Aching Sharp Burning Penetrating
• Throbbing Tender Shooting Nagging
• Dull Numb Stabbing Gnawing
• vs.
• Emotional Response
• Frustration Anger Anxiety Sadness
• Fear Hopelessness Helplessness

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Numerical Ratings

• Rating Physical Sensation/activities Emotional
  Response
• 0 No painful physical sensation No negative
  emotional response
• 1-4 Mild intensity of physical pain,
  Minimal/low level of negative Minimal effect on
  activities emotions
• 5-6 Moderately intense physical Moderate
  negative emotions
• Sensation, increased body tension,
• Moderate restriction of activities
• 7-8 Significant pain sensation,
  difficulty Significant negative emotions
• Moving, decreased activities
• 10 Severe pain sensation associated Severe
  depression, anxiety, with inability to move
  or despair.

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The Rules of Tacks

• If you are sitting on a tack, it takes a lot of
  aspirin to make the pain go away.
• If you are sitting on 2 tacks, removing one does
  not lead to a 50 improvement in symptoms.
• -Syd Baker, M.D.

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Corollaries to the Rule of Tacks

• Accurate diagnosis is important
• Do not rush to control symptoms and ignore the
  message about an underlying health problem
• Remove tacks where possible, i.e. treat
  underlying causes
• Surgical treatment
• Physical therapies
• Specific medical treatment for neuropathy,
  systemic inflammation related to gut
  disturbances, etc.
• Sleep, hormonal influences on tissue healing
• Counseling - History of trauma

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Symptom Management Medical Treatment of Pain

WHO's pain ladder- developed for cancer pain,
now applied for nonmalignant chronic pain as well
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Step 1 Non-Opioid Analgesics

• Aspirin
• Tylenol
• Other NSAIDs

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Tylenol toxicity

• Chronic tylenol ingestion of 4 g per day (8
  vicodin) can produce liver damage
• Lesser doses can be toxic when fasting/not eating
  well or when consumed in conjunction with alcohol

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Adverse effects of NSAIDs

• Gastrointestinal bleeding and gastric ulceration
• Increased intestinal permeability
• Promotion of bone necrosis and cartilage
  destruction
• Inhibition of cartilage synthesis
• Promotion of hepatic and renal injury and failure
  
• Death

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• Conservative calculations estimate that
  approximately 107,000 patients are hospitalized
  annually for nonsteroidal anti-inflammatory drug
  (NSAID)-related gastrointestinal (GI)
  complications and at least 16,500 NSAID-related
  deaths occur each year among arthritis patients
  alone. The figures for all NSAID users would be
  overwhelming, yet the scope of this problem is
  generally under-appreciated.
• Am J Med. 1998 Jul 27 105(1B) 31S-38S

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The safer anti-inflammatories?
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NSAIDs Impair Joint Repair

• In vivo studies with NSAIDs at physiologic
  concentrations have shown that several NSAIDs
  reduce glycosaminoglycan synthesis.
• Salicylate
• Acetylsalicylic acid
• Fenoprofen
• Isoxicam
• Tolmetin
• Ibuprofen
• femoral head collapse and acceleration of
  osteoarthritis have been well documented in
  association with the NSAIDs Lancet. 1985 Jul
  6 2(8445) 11-4

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Downsides of NSAIDs

• Suppression of COX robs cartilage of the
  prostaglandins that are necessary for the
  production of glycosaminoglycans
• PGD(2) and PGF(2)alpha enhanced chondrogenic
  differentiation and hyaline cartilage matrix
  deposition. Rheumatology. 2004 43 852-857
• Suppression of COX robs bone of the
  prostaglandins that are necessary for bone
  remodelling
• COX-2 inhibitors currently taken for arthritis
  and other conditions may potentially delay
  fracture healing and bone ingrowth. J Orthop
  Res. 2002 Nov20(6)1164-9
• Suppression of COX shunts arachidonate into
  leukotrienes, which promote painless silent
  inflammation.

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Vicious Cycle of NSAID Use Chondrolysis and
Intestinal Injury
Rheum Dis Clin North Am. 1991 May17(2)309-21
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Adjunctive Medications

• Topical lidocaine, capsaicin,
  antiinflammatories, other
• Antidepressants
• Anticonvulsants
• Antiarrhythmic drugs
• Ultram

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Antidepressants for Pain

• Work by affecting neurotransmitters
• Do not only work for treating pain by improving
  depression.
• Work as well in non-depressed people as in people
  with depression
• Effectiveness for pain does not correlate with
  effectiveness for depression
• Do not work for all types of pain.

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Opioids in Chronic Pain Management

• Benefits and Risks
• Side effects constipation, sleep disruption,
  altered mental status, itching, nausea,
  respiratory depression
• Addiction vs. Dependence
• Assessing whether medication improves quality of
  life and participation in life or diminishes
  them

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Questions to Ask

• Is the persons day centered around taking
  medication?
• Does the person take pain medication only on
  occasion, perhaps three or four pills per week?
• Have there been any other chemical (alcohol or
  drug) abuse problems in the persons life?
• Does the person in pain spend most of the day
  resting, avoiding activity, or feeling depressed?
  
• Is the pain person able to function (work,
  household chores, and play) with pain medication
  in a way that is clearly better than without?

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Signs Someone is Being Harmed more than Helped by
Pain Medication

• Sleeping too much or having days and nights
  confused
• Decrease in appetite
• Inability to concentrate or short attention span
• Mood swings (especially irritability)
• Lack of involvement with others
• Difficulty functioning due to drug effects
• Use of drugs to regress rather than to facilitate
  involvement in life
• Lack of attention to appearance and hygiene

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Timing

• Short-acting/Rescue medications codeine,
  hydrocodone, oxycodone, morphine
• Drug level
• time

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Problems with Short-acting Medications

• Drug level Loaded
• In pain
• Time

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Long-acting narcotics

• Drug level
• Time
• Fentanyl patches (Duragesic)
• Methadone
• MS Contin
• OxyContin
• Need to be dosed on a schedule, not prn

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Making Use of the Mind-Body Connection in
Chronic Pain Management

• After the break. . . .

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Stress

• A Definition

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Stress

• Homeostasis based definition stress is the
  compromise of homeostasis an imbalance that can
  lead to changes over time (as the physiological
  adaptation occurs) or dysfunction.
• Adrenal-based definition. The state of adrenal
  activation stimulated by the influence or
  detection of an environmental challenge to the
  body's homeostatic mechanisms that cannot be
  accommodated within the normal metabolic scope of
  the animal. Rooted in the observations of
  adrenal hypertrophy (due to overactivity)
  in chronically stressed animals.

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General Adaptation Syndrome (GAS)

• The Response to Stress, in 3 Phases
• Alarm Reaction
• Stage of Resistance
• Stage of Exhaustion

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Alarm Reaction Fight-or-Flight

• Evolutionary Role escape from predator or acute
  physical danger

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Alarm Reaction

• Physiological changes Adrenal hormones
  adrenaline (epinephrine) and norepinephrine
• Metabolism increases
• Heart rate increases
• Blood Pressure increases
• Breathing Rate increases
• Muscle Tension increases

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General Adaptation Syndrome (GAS)

• The Response to Stress, in 3 Phases
• Alarm Reaction
• Stage of Resistance
• Stage of Exhaustion

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Stage of Resistance

• HPA (hypothalamo-pituitary-adrenal axis Cortisol
  increases when stress becomes chronic
• Block energy storage and help mobilize energy
  from storage sites
• Increase cardiovascular tone
• Inhibit anabolic processes such as growth,
  repair, reproduction and immunity

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General Adaptation Syndrome (GAS)

• The Response to Stress, in 3 Phases
• Alarm Reaction
• Stage of Resistance
• Stage of Exhaustion

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Adrenal Exhaustion

• Coping responses cannot sustain their response if
  stressor is sufficiently severe and prolonged
• Diseases of adaptation" may arise
• Hypertension
• Ulcers
• Heart disease
• Symptoms that disappeared during the stage of
  resistance may reappear
• Death possible

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Physical and Psychological Side Effects of Stress

• The body cannot distinguish physical danger from
  psychological threat
• For most modern stressors, the value of
  increased heart rate, increased muscle tone, etc.
  is less, and those changes are not utilized for
  physical exertion, leaving the organism aroused
  without a release

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Maladaptive Symptoms with Acute Stress Hormones

• Cold Hands and Feet
• Palpitations
• Diarrhea or Constipation
• Decreased sleep

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Maladaptive Changes with Chronic Stress

• Worsened blood sugar control/increased insulin
  resistance
• Increased visceral fat deposition (apple-shaped
  weight gain)
• Increased inflammation
• Decreased immunity

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Documented Relationship of Illness to Chronic
Stress

• Susceptibility to the common cold correlates with
  psychological stress
• Psychological stress and susceptibility to the
  common cold S Cohen, DA Tyrrell, and AP Smith
  NEJM Volume 325606-612 August 29, 1991. Number 9
  
• Several potential stress-illness mediators,
  including smoking, alcohol consumption, exercise,
  diet, quality of sleep, white-cell counts, and
  total immunoglobulin levels, did not explain the
  association between stress and illness. Controls
  for personality variables (self-esteem, personal
  control, and introversion-extraversion) failed to
  alter findings.
• Timing of heart attacks
• Many studies have shown an excess of
  cardiovascular events on Mondays. A relative
  trough has been seen on Saturdays and Sundays
  compared with the expected number of cases.
  Highest incidence is within the first three hours
  of waking on Monday morning.
• New Insights into the Mechanisms of Temporal
  Variation in the Incidence of Acute Coronary
  Syndromes Strike PC, Steptoe A, Clin. Cardiol.
  26, 495499 (2003)

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Blaming or Taking Responsibility

• Understanding the importance of stress in our
  medical conditions gives us the power to use
  stress management to decrease illness and change
  our experience of it
• This concept should not be used to blame people
  for their illnesses

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Mind-Body and Body-Mind Interactions in Chronic
Pain

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How Emotions and Stress Affect Chronic Pain

• Chronic muscle tension in response to stress can
  cause pain in a non-injured body part
• Neurogenic inflammatory response the nervous
  system can actually cause tissue damage in
  response to pain messages
• Altered sleep can cause chronic pain, as can
  depression

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How Chronic Pain Affects Emotions and Stress

• Body tension is perceived as emotional by the
  brain
• Secondary effects on
• Sleep
• Disability and financial fall-out
• Side effects of treatments

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Vicious Cycles
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Vicious Cycles

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The Relaxation Response

• Counterbalancing mechanism to the Fight-or-Flight
  Response
• Metabolism decreases
• Heart rate decreases
• Blood Pressure decreases
• Breathing Rate decreases
• Muscle Tension decreases
• May be consciously elicited
• Generally needs to be practiced

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Benefits of the Relaxation Response

• Immediate
• Getting through procedures and short-term stress
• Long-term
• Used consistently, there are carry-over effects

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Program Overviewor, How you can learn to manage
stress and maximize joy

• Relaxation Response
• Cognitive restructuring, Coping, Stress Hardiness
• Nutrition
• Exercise/Body Awareness
• Spirituality

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Techniques Which Can Elicit the Relaxation
Response

• Diaphragmatic Breathing
• Meditation
• Body Scan
• Mindfulness
• Repetitive exercise

• Repetitive prayer
• Progressive muscle relaxation
• Yoga Stretching
• Imagery
• (Music)

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Common Elements of Techniques Used to Elicit the
Relaxation Response

• Focusing of attention through repetition of words
  or physical activity
• Passive disregard of everyday thoughts when they
  occur, and return to the repetition

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Common Problems

• No time
• Restlessness
• Falling Asleep
• Noises
• Thoughts
• Anxiety

• Old Stuff surfacing
• Insomnia
• Increase in Dreaming
• Doing it right perfectionism
• Changes in bodily perceptions

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Feeling Worse

• Common when beginning to identify what you are
  experiencing, both physically and emotionally.
• Remember this for the future changing your
  awareness changes the pain experience.

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Homework for the First Session

• Pain diary, Bimonthly feedback form
• Practice Relaxation Response 20 minutes per day
  (in 1 or 2 sessions)
• Read chapters 1 and 2
• Self-portrait exercise

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Self Portrait Exercise

• Draw a picture of you and your pain, using
  crayons or colored pencils, or describe this in
  words
• Then draw or describe yourself as you intend to
  be in the future