Look Inside Chronic Pain by IASP

Chronic Pain An Integrated Biobehavioral Approach

HERTA FLOR AND DENNIS C. TURK

Mission Statement IASP速 brings together scientists, clinicians, health care providers, and

policy makers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide. IASP Press速 publishes timely, high-quality, and reasonably priced books relating to pain research and treatment.

Chronic Pain: An Integrated Biobehavioral Approach

Herta Flor, PhD Central Institute of Mental Health University of Heidelberg Heidelberg Germany

Dennis C. Turk, PhD Department of Anesthesiology & Pain Medicine University of Washington Seattle, Washington, USA

速

IASP PRESS SEATTLE

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions expressed have not involved any verification of the findings, conclusions, and opinions by IASP . Thus, opinions expressed in Chronic Pain: An Integrated Biobehavioral Approach do not necessarily reflect those of IASP or of the Officers and Councilors.

No responsibility is assumed by IASP for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent veriﬁcation of diagnoses and drug dosages. Library of Congress Cataloging-in-Publication Data Flor, Herta. Chronic pain : an integrated biobehavioral approach / Herta Flor, Dennis C. Turk. p. cm. Includes bibliographical references and index. ISBN 978-0-931092-90-9 (alk. paper) 1. Chronic pain--Treatment. 2. Chronic pain--Psychological aspects. 3. Chronic pain-Physiological aspects. I. Turk, Dennis C. II. Title. RB127.F588 2011 616’.0472--dc23 2011031442

Published by: IASP Press International Association for the Study of Pain 111 Queen Anne Ave N, Suite 501 Seattle, WA 98109-4955, USA Fax: 206-283-9403 www.iasp-pain.org

Printed in the United States of America

Contents Foreword Preface Acknowledgments

xi xiii xvii

Part I Basic Concepts for the Assessment and Treatment of Chronic Pain 1. Basic Concepts of Pain 3 2. Neural Mechanisms of Pain 25 3. The Psychology of Pain 45 4. Psychobiological Mechanisms in Chronic Pain 89 Part II Multiaxial Assessment of Chronic Pain Patients 5. Evaluation of the Patient with Chronic Pain 6. Assessment of Physical Pathology and Physical Functioning 7. Psychophysiological Assessment of Chronic Pain 8. Assessment of Characteristics of Pain and Pain Behaviors: Laboratory and Clinical Methods 9. Psychosocial Assessment 10. Identifying Patient Subgroups and Matching Patients with Treatments

139 177 199 217 253 289

Part III Treatment of Chronic Pain 11. General Principles in the Treatment of Chronic Pain 12. Relaxation and Biofeedback 13. Operant Group Treatment 14. An Introduction to the Cognitive-Behavioral Approach to Chronic Pain Management 15. Applying the Cognitive-Behavioral Approach to Chronic Pain Management 16. The EďŹ&#x192;cacy of Psychological Treatments for Chronic Pain 17. New Vistas on the Behavioral Treatment of Chronic Pain

437 491 509

Glossary Index

529 537 v

321 337 383 413

Contents

Appendices (CD only)

19 Stress Diary

Initial Patient Interaction

20 Stress Diary and Logging of Relaxation

Pain Assessment Interview

Case Example: Chronic Pain Following a Rear-End Collision

Manual Tender Point Survey

Tübingen Pain Behavior Scale

Pain-Related Self-Statements

Pain-Related Self-Statements— Signiﬁcant Other Version

Pain-Related Control Statements

Pain-Related Control Statements— Signiﬁcant Other Version

10 Brief Stress Scale 11 Brief Stress Scale—Signiﬁcant Other Version 12 West Haven-Yale Multidimensional Pain Inventory 13 West Haven-Yale Multidimensional Pain Inventory—Signiﬁcant Other Version 14 Acute Low Back Pain Screening Questionnaire

21 Instruction on Biofeedback 22 Brief Relaxation with Diaphragmatic Breathing 23 Biofeedback Training Manual 24 Sample Assessment Discussion 25 Sample Treatment Agreement 26 Operant Group Treatment: Course of Therapy 27 The Relationship of Pain and Learning 28 Determination of Activity Goals 29 Deﬁnition of Activity Goals for Homework 30 Homework Sheet Activity Curve 31 Pleasant Events Schedule 32 Sample Role-Play of Pain and Well Behaviors and Their Reinforcement 33 Sample Letter to the Referring Physician 34 Preparation by a Referral Source

15 Training in Progressive Muscle Relaxation

35 Introduction to CognitiveBehavioral Treatment

16 Example of a Discussion with the Patient about Homework

36 Introducing a Multidimensional Model of Pain to the Patient

17 Patient Information about Autogenic Training

37 Homework Exercise for the Gate Control Model

18 Patient Information about Biofeedback and Chronic Back Pain

38 Homework: Treatment Goals and Goal Attainment Rating

Contents 39 Information Sheet: Information for the Patient about Treatment 40 Patient Diary 41 Challenging Maladaptive Negative Thinking 42 Problem Solving: Questions— Actions—Self-Monitoring 43 Exercise Sheet for Problem Solving and Positive Communication 44 Questions about Coping Strategies 45 Deep Relaxation with Pleasant Imagery

46 Stress Symptoms and Responses to Stress

vii 52 Distraction of Attention 53 Body Focus 54 Homework Sheet: List of Methods for Diversion from Pain 55 Two Exercises to Divert the Patient’s Attention from Pain 56 Examples of Imagery 57 Information on Pain Medication 58 Medication Reduction Plan 59 Determining a Target Pulse and Selecting a Physical Activity 60 Exercise Sheet: Daily Activities 61 Mutual Goal Planning

47 Exercise: The Role of Thoughts in Stress and Pain Situations

62 Questions about Pain for the Patient and Signiﬁcant Other

48 List of Stress and Coping Thoughts

63 Joint Activities

49 The A-B-C Model

64 Outline of a Cognitive-Behavioral Treatment Program

50 Exercise: Coping Thoughts 51 Exercise: Recognition of PainEnhancing and Pain-Reducing Self-Talk

65 Ten Problems with Physical Exercises and Their Solutions

Herta Flor, PhD, studied psychology at the Universities of Würzburg, Tübingen, and Yale and obtained her PhD at the University of Tübingen in 1984. She is a licensed clinical psychologist with a specialization in behavior therapy. She has held positions as visiting professor at the University of Pittsburgh (1985–87) and as professor of clinical psychology at Humboldt University, Berlin (1993– 2000). Since 2000 she has served as Scientific Director of the Department of Neuropsychology and Clinical Psychology at the Central Institute of Mental Health and as a full professor at the University of Heidelberg. She has made important discoveries in the field of pain and phantom phenomena, including the cortical processing of pain-related information in humans. Her research focuses on the interaction of brain and behavior, in particular the question of how behavior and experience influence neural processes and how neural processes alter behavior and experience. A special interest is in the role of implicit learning and memory processes in the development and maintenance of chronic pain, tinnitus, anxiety disorders, addiction, and depression. The methods she has used range from experimental psychology to non-invasive brain imaging and peripheral psychophysiology. She is also actively involved in the development of new behavioral approaches to pain and other mental disorders and teaches and supervises clinical psychologists in cognitive-behavioral methods. She has published more than 300 scholarly articles and has received several awards and honors, which include the Award for Basic Research of the State of Baden-Württemberg (2004), the German Psychology Award (2002), the Muscle Pain Research Award (2001), the Max-Planck-Award for International Cooperation (2000), and the German Pain Research Prize (1992 and 2000). She is also a fellow of the German National Academy of Science Leopoldina and the Academia Europaea.

Dennis C. Turk, PhD, is the John and Emma Bonica Professor of Anesthesiology and Pain Research and Director of the Center for Pain Research on Impact, Measurement, & Effectiveness (C-PRIME) at the University of Washington. A charter member of the International Association for the Study of Pain and a founding member of the American Pain Society, Dr. Turk is a fellow of the Academy of Behavioral Medicine Research, the Society of Behavioral Medicine, and the American Psychological Association. Dr. Turk is Past-President of the American Pain Society. He is a Special Government Employee of the United States Food and Drug Administration. Dr. Turk has received a number of awards, including the Award for Outstanding Scientific Contributions to Health Psychology from the American Psychological Association and the Wilbert E. Fordyce Clinical Investigator Award from the American Pain Society, which recognizes “individual excellence and achievements in clinical pain scholarship and is given to a pain professional whose total career research achievements have contributed significantly to clinical practice.” Dr. Turk is currently Editor-in-Chief of The Clinical Journal of Pain, Co-Chair of the Initiative on Methods, Measurement, & Pain Assessment in Clinical Trials (IMMPACT), and Co-Director of the Executive Committee for the Analgesic Clinical Trials Translations, Innovations, Opportunities, & Networks (ACTTION) initiative—a public-private partnership with the U.S. Food & Drug Administration. He was a member of the Institute of Medicine’s Committee on Advancing Pain Research, Care, and Education. Dr. Turk has contributed over 500 publications to the health care literature. He has authored or edited 16 volumes, most recently The Pain Survival Guide: How to Reclaim Your Life (with Frits Winter) and the third edition of the Handbook of Pain Assessment (with R. Melzack).

To my teacher and friend Niels Birbaumer, with gratitude In memory of Irmela Florin (1938–1998), the pioneer of behavioral medicine and behavior modiﬁcation in Germany Herta Flor

To my great friend Robert H. Dworkin, who continues to pique my interest in issues related to clinical trial design, the IMMPACT we could have, and the ACTTION we could inspire by collaborating together. His enthusiasm and energy are infectious and a continuing inspiration. And to my loving and sharing wife, Lorraine, who has encouraged me and sacriﬁced for me throughout our marriage. My career would not have been half as successful without her enduring support. Dennis C. Turk

Foreword To be in physical pain is to find yourself in a different realm—a state of being unlike any other, a magic mountain as far removed from the familiar world as a dreamscape. Usually, pain subsides, one wakes from it as from a nightmare, trying to forget it as quickly as possible. But what of pain that persists? The longer it endures, the more excruciating the exile becomes. Will you ever go home? you begin to wonder, home to your normal body, thoughts, life? Melanie Thernstrom, The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing and the Science of Suffering (New York: Farrar, Straus and Giroux; 2010, p. 3)

According to the recently published report from the Institute of Medicine, “Relieving pain: a blueprint for transforming pain prevention, care, education and research” (2011), as many as 116 million adult Americans suffer from common chronic pain conditions at an estimated cost of between $560 and $630 billion annually for health care expenses and lost productivity. Pain affects everyone, and the toll of chronic pain on one’s sense of self and wellbeing, on physical functioning, and on overall quality of life can be devastating. The IOM report integrates the voices of persons living with chronic pain to highlight the anguish of unremitting pain, helplessness and hopelessness, and the travails of the unsuccessful search for relief. The quote above from author Melanie Thernstrom, a member of the IOM Committee that prepared the report and herself a person with chronic pain, provides a glimpse of the personal horrors of life with persistent pain, particularly the prospect of pain without end. Advances in understanding of the mechanisms that promote the development of chronic pain and that sustain it have been rapid in the past several decades, and an increasing array of effective therapies have been identified. These therapies span pharmacological, interventional, behavioral, and rehabilitation strategies, as well as a growing number of evidence-based complementary and alternative approaches. Yet millions continue to suffer due to a limited response to therapy or because of barriers to accessing appropriate care. The IOM report calls for a comprehensive approach to meet the moral imperative to eliminate these barriers xi

xii

Foreword

through substantial investments in prevention, novel therapies, education for health care professionals and the public, and research. A major challenge facing the field of pain management is the need to expand efforts to educate and train health care providers in the use of evidence-based clinical assessment and therapeutic approaches. This is a tough challenge as the science of pain and pain management continues to expand at an enormous rate, making it difficult for educators and future providers to maintain an up-to-date knowledge of these advances and to build and maintain clinical competencies. Expansion of formal education and training programs in pain management is clearly needed, and opportunities for continuing education need to be increased in number and scope. Chronic Pain: An Integrated Biobehavioral Approach, by Herta Flor and Dennis C. Turk, two of the leading scientists and scholars in our field, offers in a single volume the most comprehensive and in-depth view of the field currently available. Drs. Flor and Turk share their collective knowledge and professional insights accumulated over three decades of extraordinary contributions to the field. The book provides a compelling case in support of an integrative approach to clinical assessment and management of chronic pain that draws upon the state-of-the-science from the diverse field of pain management that extends from clinical neuroscience to translational behavioral medicine science. The first section provides an up-to-date and highly digestible review of the foundational principles of the multidimensional experience of chronic pain and is followed by two sections on clinical assessment and treatment, concluding with a glimpse at future innovations in pain care. These later sections are simply extraordinary in integrating theory, science, and practical information that will be equally useful to novice and experienced clinicians, investigators, and policy makers. Ultimately, this text promises to stand alone as the single best source for educators and for those seeking to expand their knowledge of the field of chronic pain management. I applaud this exciting addition to our armamentarium in meeting the challenges of the IOM and furthering our collective efforts to help relieve unnecessary pain and suffering. Robert D. Kerns, PhD National Program Director for Pain Management, Veterans Health Administration; Director, Pain Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System; Professor of Psychiatry, Neurology and Psychology, Yale University

Preface This volume provides a psychobiological perspective on people who experience chronic pain and describes a comprehensive approach to their treatment. The text focuses on the interaction of psychosocial (psychological, behavioral, and social) and physiological processes in people with chronic pain and the implications that follow. In recent years, there has been growing recognition that neither purely somatic nor completely psychological models by themselves are adequate to explain the subjective experience of chronic pain and associated disability. Our basic hypothesis is that chronic pain is a learned response, whereby “pain memories” rather than current nociceptive input determine much of the pain experienced. Moreover, interdisciplinary approaches that integrate psychological principles and approaches with traditional biomedical knowledge in the assessment and treatment of people with chronic pain are more fruitful than any single modalities, be they physical (surgery, medication, regional anesthesia, or neuroaugmentive interventions) or psychological (biofeedback, counseling, or psychotherapy). Integration of current psychological information and principles with existing biomedical knowledge will increase our understanding of people with various chronic pain syndromes and should lead to more eﬀective treatment outcomes and improved quality of life for those with persistent pain. Although our emphasis is on the role of psychological and social factors in chronic pain states, we attempt to integrate these aspects with the current biological understanding of the neurophysiology of nociception. In the introductory section we provide a theoretical framework that is essential for understanding, evaluating, and successfully treating the person with chronic pain and not just the pain. We give special emphasis to learning and cognitive processes (beliefs, anticipation, subjective meaning, and memory) that determine how pain is experienced. In the second section, we focus on a comprehensive approach to assessment. We outline our concept of multiaxial assessment and guide xiii

xiv

Preface

the reader through the process of achieving a differential diagnosis that serves as the basis for decision making and treatment planning. We provide a detailed discussion of the rationale behind and the components of comprehensive assessment. We include specific recommendations for using a set of assessment procedures, including interviews, self-report questionnaires, behavioral observation schemes, and psychophysiological methods. We provide a general assessment algorithm and recommend specific methods that will form the basis for a comprehensive evaluation of the chronic pain patient. In the final section, we outline three well-validated treatment approaches that have received the greatest amount of empirical support in pain management: biofeedback and relaxation training, operant group treatment, and cognitive-behavioral pain management. We also focus on newer treatment methods that are based on findings of learning-related maladaptive plastic reorganization of the brain secondary to the experience of pain. These insights open the avenue to innovative approaches that may be incorporated in the treatment of chronic pain patients. We will not provide an exhaustive review of the vast pain literature, but rather emphasize our own empirically based view of the best evidence-based approaches to the treatment of chronic pain patients. In our discussion of treatments, we describe the rationale behind each approach, provide detailed guidelines describing how and when to implement each of the treatments, and summarize outcome research supporting these methods. We include an appendix on CD that incorporates many assessment instruments as well as detailed outlines of treatment protocols to help clinicians understand important features and nuances that can lead to successful outcomes for many patients. This volume has five primary objectives: 1) Provide the reader with a thorough understanding of an integrated psychobiological model that emphasizes the crucial role of learning, memory processes, cognitive processes, and contextual factors as the basis for understanding people with chronic pain. 2) Present a rationale for our belief that the “pain-patient uniformity myth” is wrong. That is, not all people with the same medical diagnosis will benefit from the identical treatment. We believe that matching both

Preface

physical and psychological interventions to specific patient characteristics will enhance successful treatment outcome. 3) Provide the reader with a specific rationale indicating how treatment decisions should follow from a comprehensive assessment. 4) Demonstrate the synergy between research and clinical practice. 5) Provide the reader with sufficient detail regarding our comprehensive, multiaxial approach to assessment and treatment so that it can be integrated into clinical practice. We include extensive details on assessment and treatment methods, because we believe not only that better outcomes can be achieved but that more meaningful research can be conducted when we focus on specific treatments rather tan relying on vague descriptions and treatment titles such as “operant (behavioral) therapy,” ”cognitive-behavioral therapy,” “extinction training,” ”biofeedback,” and “multidisciplinary/interdisciplinary treatment,” all of which have idiosyncratic meanings and treatment elements. We include our e-mail addresses below and welcome readers’ comments. We hope that readers will let us know how well we have succeeded in accomplishing our objectives. Herta Flor, PhD herta.flor@zi-mannheim.de Dennis C. Turk, PhD turkdc@u.washington.edu

Basic Concepts of Pain

the person experiencing pain and his or her significant other. (We use the phrase “significant other” throughout this text to refer to a spouse, partner, family member, friend, coworker, or employer. Moreover, “significant others” also include the health care providers with whom the person with pain is in frequent contact.) Despite significant advances in anatomy, neurophysiology, biochemistry, and medicine, pain—especially pain that has persisted beyond the expected period of healing, which is not the result of a progressive disease, or for which there is no identifiable physical pathology—has remained an enigma for clinicians and scientists, as well as for pain sufferers. These pain syndromes, including many chronic and recurrent conditions, have proven particularly recalcitrant to even the most advanced medical, surgical, and pharmacological methods of treatment [25]. In this chapter, we will review the magnitude of the problem of pain, introduce a number of key definitions, and describe the classification of pain syndromes. This foundation is essential for clinicians who want to appreciate the current state of knowledge, understand the basis for assessment and treatment approaches, and communicate effectively with patients, patient’s significant others, other health care providers, and third-party payers about the nature and scope of pain problems, treatment planning, interventions, rehabilitation, and disability.

Foundations of Current Understanding of Pain and Pain Management Pain only became a focus of systematic research and clinical interest within the past 50 years. Prior to the 1960s, pain was relegated primarily to the domain of sensory physiology. Clinical medicine tended to view pain as an epiphenomenon of disease or injury—a response, and therefore of secondary importance. The emphasis was on eliminating the cause of the pain and ﬁnding a cure. The assumption was that once the physical cause of the pain was eliminated, pain would subside and no longer represent a signiﬁcant problem. Thus, pain was not viewed as something worthy of consideration or treatment in its own right; it was only important because it provided information about physical pathology. Otherwise, pain was just a nuisance.

The Psychology of Pain

The Operant Conditioning Model of Chronic Pain As noted in Chapter 1, the operant conditioning formulation proposed by Fordyce [49] has substantially contributed to our understanding of chronic pain and has had a significant impact on treatment and rehabilitation. In Chapter 1, we mentioned that the operant model distinguishes between the private pain experience and observable and quantifiable pain behaviors, which are overt communications of pain, distress, and suffering such as moaning, grimacing, or taking medication. It is these behaviors, rather than pain itself, that are assumed to be amenable to behavioral assessment and treatment. The operant conditioning model proposes that acute pain behaviors may come under the control of (be maintained by) external contingencies of reinforcement and thus develop into a chronic pain problem. Pain behaviors may be positively reinforced, for example, by attention from a spouse or from health care providers [128]. Pain behaviors may also be maintained by the termination of unpleasant states, such as a reduction in pain level by analgesic medication or inactivity or the avoidance of undesirable activities such as work or unwanted sexual activity (negative reinforcement). Also, well behaviors (functional activities including working, home-making activities, and self-care) may not be sufficiently reinforcing, and so the more rewarding pain behaviors may be maintained (see Fig. 6).

S+

(moaning)

(attention)

S-

(medication intake)

(pain reduction)

S+

(well behavior)

(lack of positive reinforcement)

positive reinforcement of pain behavior

negative reinforcement of pain behavior

extinction of well behavior

Fig. 6. Operant conditioning model of chronic pain (R = response, S = stimulus).

H. Flor and D.C. Turk

pain memories on all levels of the nervous system that may, over time, maintain pain even in the absence of peripheral nociceptive input. We propose that in chronic pain, the extinction rather than the acquisition of these learning processes may be especially disturbed. We have summarized the main factors that we believe contribute to the development and maintenance of chronic pain in Fig. 1. We will describe these factors and their potential interactions in more detail in the following sections. It is important, however, to acknowledge that although we have isolated these four components to simplify discussion, they all interact and are not mutually exclusive, nor intended to connote a linear sequence.

Eliciting stimuli •

aversive external and/or internal stimuli

Predisposing factors

Psychophysiological response stereotypy y y

•

genetic determination

•

learning

e.g., symptomspecific EMG increase

•

occupational f t factors

Pain response

Maintaining processes

•

verbal subjective

•

nonassociative learning

•

behavioral

•

physiological organic i

associative learning

•

explicit li it learning

Eliciting responses

•

lack of coping skills, e.g., catastrophizing

•

inadequate perception and interpretation of physiological h i l i l processes and db bodily dil symptoms t

•

anticipatory anxiety

•

memory of pain

•

lack of self-efficacy

Fig. 1. Psychobiological model of chronic pain.

Evaluation of the Patient with Chronic Pain

163

The Pain Assessment Interview The clinical interview is an integral part of the assessment of every person with persistent pain. The interview serves to establish a positive, therapeutic relationship, to determine the treatment motivation of the patient, and to obtain a comprehensive history of the pain problem. In addition, the interview will focus on the identification of psychosocial aspects that may cause or maintain the pain, on the history of previous treatments, and on the patient’s attitudes toward the pain (for preparation for referral for a psychological evaluation, see Table IV). Thus, the interview is an important part of the behavioral analysis. When conducting an interview with chronic pain patients, the health care professional should focus not simply on factual information but on specific thoughts and feelings of the patient and his or her significant others (spouse or partner, family, or friends). The professional should observe specific behaviors by the patient as well as the interaction between the patient and significant others. During an interview, it is important to adopt the patient’s perspective. Patients’ and significant others’ beliefs about the cause of symptoms, their trajectory, and beneficial treatments will have important influences on emotional adjustment and compliance with therapeutic interventions. A habitual pattern of maladaptive thoughts may contribute to a sense of hopelessness, dysphoria, and unwillingness to engage in activity. The interviewer should determine both the patient’s and significant others’ expectancies and goals for treatment and address misconceptions or expectations of outcomes that are excessively optimistic and are destined to cause distress when these expectations are not realized. Attention should focus on the patient’s reports of specific thoughts, behaviors, emotions, and physiological responses that precede, accompany, and follow pain episodes or exacerbations, as well as on the environmental conditions and consequences associated with cognitive, emotional, and behavioral responses in these situations. During the interview, the health care provider should attend to the temporal association of these cognitive, affective, and behavioral events and consider their specificity versus generality across situations, as well as the frequency of their occurrence. These details will help to establish salient features of the target situations, including the controlling variables. The interviewer should seek

Relaxation and Biofeedback

343

their homework plan—perhaps they are too tired, the environment is not conducive, they have a high level of pain, they are having interpersonal conﬂicts, or they may simply forget. We help patients to proactively problem-solve as to what they would do when these types of impediments arise. It is useful to involve the patient as much as possible in developing the homework plan. It is essential to review homework with the patient at the beginning of the next therapeutic session. Appendix 16 includes an illustration of how to discuss and plan homework. Table I provides a sample homework sheet for relaxation exercises that provides a way to keep detailed records of the exercises and the problems patients may have encountered, along with the eﬀects of these problems. Notice that the therapist encourages the patient to suggest the best times to practice and to plan how to deal with any problems that might arise. Charts are helpful because they serve as a reminder to practice. Information about feelings of relaxation before and after practice sessions can be a helpful reinforcement for the patient to keep practicing. Charts

Table I Homework sheet for relaxation exercises Name: __________________________________ Date: ______________________ Please make an entry on this sheet every time you perform a relaxation exercise. Indicate the exact date and time and estimate how tense you are today and how much pain you are feeling. Use a scale ranging from 0 = no tension and no pain to 10 = extreme tension and extreme pain. Rate your tension and your pain before and after doing the relaxation exercise, and in the last column, describe any problems or difficulties that occurred during the exercise. Tension Date and Time

Before (0–10)

After (0–10)

Pain Before (0–10)

After (0–10)

Notes (Successes, Problems, Difficulties)

Operant Group Treatment

391

Table II Topics addressed in operant group treatment How to deal with medication How to increase physical activity and use correct body posture How to decrease the ways pain interferes with: • Family interactions • Work or housework • Leisure time • Everyday activities • Social activities How to deal with the health care system

the respective type of behavior. As described below, the group can obtain valued reinforcers by completely eliminating red cards. An introduction to operant theory should be part of the treatment program (an abbreviated version should be provided during the overview of treatment before the patient agrees to participate in operant group treatment). To reiterate the previous brief overview, the introduction includes the following components: • • • •

The relationship between bodily processes and learning; The automaticity or unconscious nature of learning; The fact that conscious unlearning or relearning is possible; The concept that chronic pain is a behavior and can be learned and unlearned.

The treatment goals—reduction of excessive disability, improvement of everyday functioning, and better handling of any pain that may persist—need to be emphasized. Appendix 27 gives a sample introduction to operant thinking and operant treatment goals.

Goals and Techniques of Operant Treatment Reducing Pain Behaviors and Enhancing Well Behaviors An important goal of operant treatment is that patients (and therapists) learn to identify pain behaviors and well behaviors. Several exercises involve the identiﬁcation of pain and well behaviors in the group setting. The therapist explains the concept of pain behaviors as “all behaviors that tell

Introduction to the Cognitive-Behavioral Approach

425

The overriding message of the CBT approach, one that begins with the initial contact and is woven throughout the fabric of treatment, is that people are not helpless in dealing with their pain, nor do they need to view pain as an all-encompassing determinant of their lives. Rather, a variety of resources are available for confronting pain, and pain will come to be viewed by patients in a more diﬀerentiated manner. CBT encourages patients to maintain a problem-solving orientation and to develop a sense of resourcefulness, instead of the feelings of helplessness and withdrawal that create a life revolving around bed rest, physician visits, and trips to the pharmacy.

Phases of Cognitive-Behavioral Therapy for Pain Phase 1: Assessment The ﬁrst two phases of CBT, assessment and reconceptualization, are highly interdependent. The assessment phase serves several distinct functions, as outlined in Table VI. Assessment information is obtained by interviewing patients and signiﬁcant others, as well as by using standardized Table VI Functions of the assessment phase Establish the extent of physical impairment. Identify levels and areas of psychological distress. Collaboratively establish behavioral goals covering areas such as activity level, utilization of the health care system, patterns of medication use, and responses of significant others. Provide detailed information about the patient’s perceptions of his or her medical condition, opinions about previous treatments, and expectations of the current treatment. Analyze the patient’s occupational history and goals regarding work. Examine the important role of significant others in the maintenance and exacerbation of maladaptive behaviors and determine how these individuals can be positive resources for the process of change. Begin the reconceptualization process by helping patients and significant others to become aware of the situational variability of the pain and the psychological, behavioral, and social factors that influence the nature and degree of pain.

Applying the Cognitive-Behavioral Approach

441

P: Not really. T: Good—oh, but what happens if it rains on Tuesday, the day you planned to begin? P: Hmm, I didn’t think of that… I guess I would wait until Wednesday. The day doesn’t really matter. T: Right—you can set a schedule for yourself, but you can modify it if something comes up that gets in the way. The important thing is to stick to a plan. The details can be flexible—the key is to begin getting active again. Remember, start low and go slow! Work until you meet your goal and not just until you feel some discomfort. Don’t do to much or too little at the beginning. In the interchange described above, we attempted to involve the patient by trying to match his interest with increased activities. We tried to make the goals specific and measurable. We asked the patient to keep a record of his activities so that we could review his progress at the next session. Finally, we had him acknowledge any concerns, anticipate any potential impediments, and think about how he would flexibly deal with these problems if they should arise. The therapist also expresses the interrelationship and interdependence of behavior and physiological processes. Psychophysiological assessment may be of particular value by clearly demonstrating to the patient how behaviors and feelings can influence physiology, using the patient’s experience as an example. T: It is very clear from your pain activity diaries that you tend to stop doing anything and just lie down when your pain gets really bad. P: Yeah, I guess so … it just hurts so bad that I can’t think of anything else. T: What happens to the pain when you lie down? P: Well, it doesn’t really go away unless I take some medication. T: Right. What happens to your “pain gate” when you lie down and just focus on the pain? P: Huh, I don’t know—maybe it gets opened when I kind of focus on it. T: Yes, and the frequent lying down may over time allow your muscles to become weaker, and then they hurt more and more, and then more activities cause pain, so you do even less. Therefore, a vicious circle is created where pain causes inactivity and inactivity leads to more muscle weakness, more isolation, and consequently more pain. So one

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Cancer Pain: From Molecules to Suffering Editors: Judith A. Paice, Rae F. Bell, Eija A. Kalso, and Olaitan A. Soyannwo June 2010 Pharmacology of Pain Editors: Pierre Beaulieu, David Lussier, Frank Porreca, and Anthony Dickenson February 2010 Functional Pain Syndromes: Presentation and Pathophysiology Editors: Emeran A. Mayer and M. Catherine Bushnell April 2009 Fundamentals of Musculoskeletal Pain Editors: Thomas Graven-Nielsen, Lars Arendt-Nielsen, and Siegfried Mense July 2008 IASP brings together scientists, clinicians, health care providers, and policy makers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide. IASP Press publishes timely, high-quality, and reasonably priced books relating to pain research and treatment. International Association for the Study of Pain 111 Queen Anne Avenue N., Suite 501 Seattle, WA 98109-4955 USA www.iasp-pain.org

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