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


1
Healing Groups for People Living with Chronic Pain
  • Mind-Body Medicine at the
  • Full Circle Center for Integrative Medicine

2
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 Trials K 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. . . .

3
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

4
Staff Introductions

5
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

6
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

7
Diaphragmatic Breath Awareness

8
Breathing

9

Diaphragmatic breathing
10


Chest breathing
11

12
Understanding Pain

13
Acute Pain
  • Adaptive
  • Indicates tissue injury
  • Initiates protective behavior

14
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

15
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.

16
Pain Perception the 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.

17
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)

18
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

19
Gate Control Mechanism/Theory

20
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.

21
Gate Control Mechanism/Theory

22
Gate Control Implications Mechanical 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
23
Integrative Pain Management
  • Pain may be mandatory,
  • but suffering is optional

24
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

25
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.

26
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.

27
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

28
Symptom Management Medical Treatment of Pain

WHO's pain ladder - developed for cancer pain,
now applied for nonmalignant chronic pain as well
29
Step 1 Non-Opioid Analgesics
  • Aspirin
  • Tylenol
  • Other NSAIDs

30
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

31
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

32
  • 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

33
The safer anti-inflammatories?
34
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

35
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.

36
Vicious Cycle of NSAID Use Chondrolysis and
Intestinal Injury
Rheum Dis Clin North Am. 1991 May17(2)309-21
37
Adjunctive Medications
  • Topical lidocaine, capsaicin,
    antiinflammatories, other
  • Antidepressants
  • Anticonvulsants
  • Antiarrhythmic drugs
  • Ultram

38
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.

39
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

40
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?

41
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

42
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43
Timing
  • Short-acting/Rescue medications codeine,
    hydrocodone, oxycodone, morphine
  • Drug level
  • time

44
Problems with Short-acting Medications
  • Drug level Loaded
  • In pain
  • Time

45
Long-acting narcotics
  • Drug level
  • Time
  • Fentanyl patches (Duragesic)
  • Methadone
  • MS Contin
  • OxyContin
  • Need to be dosed on a schedule, not prn

46
Making Use of the Mind-Body Connection in
Chronic Pain Management
  • After the break. . . .

47
Stress
  • A Definition

48
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.

49
General Adaptation Syndrome (GAS)
  • The Response to Stress, in 3 Phases
  • Alarm Reaction
  • Stage of Resistance
  • Stage of Exhaustion

50
Alarm Reaction Fight-or-Flight
  • Evolutionary Role escape from predator or acute
    physical danger

51
Alarm Reaction
  • Physiological changes Adrenal hormones
    adrenaline (epinephrine) and norepinephrine
  • Metabolism increases
  • Heart rate increases
  • Blood Pressure increases
  • Breathing Rate increases
  • Muscle Tension increases

52
General Adaptation Syndrome (GAS)
  • The Response to Stress, in 3 Phases
  • Alarm Reaction
  • Stage of Resistance
  • Stage of Exhaustion

53
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

54
General Adaptation Syndrome (GAS)
  • The Response to Stress, in 3 Phases
  • Alarm Reaction
  • Stage of Resistance
  • Stage of Exhaustion

55
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

56
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

57
Maladaptive Symptoms with Acute Stress Hormones
  • Cold Hands and Feet
  • Palpitations
  • Diarrhea or Constipation
  • Decreased sleep

58
Maladaptive Changes with Chronic Stress
  • Worsened blood sugar control/increased insulin
    resistance
  • Increased visceral fat deposition (apple-shaped
    weight gain)
  • Increased inflammation
  • Decreased immunity

59
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)

60
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

61
Mind-Body and Body-Mind Interactions in Chronic
Pain

62
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

63
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

64
Vicious Cycles
65
Vicious Cycles

66
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

67
Benefits of the Relaxation Response
  • Immediate
  • Getting through procedures and short-term stress
  • Long-term
  • Used consistently, there are carry-over effects

68
Program Overview or, How you can learn to manage
stress and maximize joy
  • Relaxation Response
  • Cognitive restructuring, Coping, Stress Hardiness
  • Nutrition
  • Exercise/Body Awareness
  • Spirituality

69
Techniques Which Can Elicit the Relaxation
Response
  • Diaphragmatic Breathing
  • Meditation
  • Body Scan
  • Mindfulness
  • Repetitive exercise
  • Repetitive prayer
  • Progressive muscle relaxation
  • Yoga Stretching
  • Imagery
  • (Music)

70
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

71
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

72
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.

73
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

74
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
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