Re-wiring the Chronic Pain Brain: Coaching as a Means to Patient Transformation

Re-wiring the Chronic Pain Brain: Coaching as a Means to Patient Transformation Becky Curtis

Disclosure Nothing to Disclose

Learning Objectives Recognize how a patient’s focus on curing their pain can contribute to an increase in the pain experience Describe how negative thought patterns create a brain-body loop which accentuates the pain experience Describe the unique perspective coaching offers to put a patient in a “rewiring mode” Recognize the powerful effect gratitude, movement and relaxation has in building a pain resistant brain

Jeep

Barriers to Change Support and structure is lacking Confidence is low Feel overwhelmed at the thought of change Negative thinking patterns Fear avoidance behavior

“Imaging studies have shown, for example, that pain signals are processed differently in chronic pain than they are in acute pain, with a shift in brain activation to regions that are more closely related to psychological influences. These spatial shifts may help explain the increased emotional impact that chronic pain may have on its sufferers.

Neuroimaging to evaluate effect of emotional states on pain processing has shown that negative mood states increased pain evoked activity in several limbic regions, particularly the ACC. Conversely, positive mood states may decrease such activity�

The Brain and Pain, By Christine Rhodes, MS, The Pain Practitioner, Summer, 2011, Volume 21, Number Two

Pain is Experienced in the Brain

Neuroplasticity “…the brain’s ability to continually adapt to new information and experiences by changing its structure, function, or chemistry”

The Brain and Pain, By Christine Rhodes, MS, The Pain Practitioner, Summer, 2011, Volume 21, Number Two

“The notion of brain plasticity is fundamental to new developments in pain management. There is recognition that the same neuronal changeability that contributes to the persistence of pain could potentially allow its resolution.

Evidence suggests that ‘focused attention’ can increase neuronal plasticity and hence be used to positively reprogram brain pathways”

Lifestyle Medicine, managing Diseases of Lifestyle in the 21st Century, Second Edition Gary Egger/Andrew Binns/Stephen Rossner, McGraw-Hill, Australia, 2011, page 259

1.

Pain signal: the alarm that goes off when nerve endings in the periphery sense danger

The Gift of Pain, Why We Hurt and What We Can Do About It, Paul Brand, M.D., Zondervan, Grand Rapids, Michigan, 1997, Pg 202

2.

The spinal cord and base of the brain act as a `spinal gate’ to sort out which of the many millions of signals deserve to be forwarded as a message to the brain

The Gift of Pain, Why We Hurt and What We Can Do About It, Paul Brand, M.D., Zondervan, Grand Rapids, Michigan, 1997, Pg 202

3.

Takes place in higher brain-especially cerebral cortex— which sorts through the prescreened messages and decides on a response. Indeed, pain does not truly exist until the entire cycle of signal, message, response has been completed

The Gift of Pain, Why We Hurt and What We Can Do About It, Paul Brand, M.D., Zondervan, Grand Rapids, Michigan, 1997, Pg 202

“What takes place in a person’s mind is the most important aspect of pain—and the most difficult to treat or even comprehend. If we can learn to handle pain at this third stage, we will most likely succeed in keeping pain in its proper place, as servant and not master”

The Gift of Pain, Why We Hurt and What We Can Do About It, Paul Brand, M.D., Zondervan, Grand Rapids, Michigan, 1997, Pg 203

“Pain is a subjective experience that varies between people in different situations�

Clinical Essentials of Pain Management, Robert J Gatchel, American psychological Association, Washington,DC, 2005

The Brain Learns Pain: 5% of nerve cells are normally dedicated to pain processing Chronic pain expands this to 15-25% of the cells The process of repetition reinforces the strengthening of brain pathways This causes anatomical changes in the brain Michael H. Moskowitz, MD, Marla Golden, DO, Neuroplasticity: Changing the Brain in Pain, Vol. 1, No. 1, April 2010, http://www.neuroplastictransformation.com/sites/default/files/Brain%20Training%20Newslestter%202.pdf, (accessed April 2012)

“The brain-body loop passes information and directions electronically via the nervous system 30 times a second…The brain reads the body and tells it how to adjust making an astonishingly adaptive brain body loop. Throughout our lives our physical and emotional perception of ourselves is constantly changing”

Michael H. Moskowitz, MD, Marla Golden, DO, Neuroplasticity: Changing the Brain in Pain, Vol. 1, No. 1, April 2010, http://www.neuroplastictransformation.com/sites/default/files/Brain%20Training%20Newslestter%202.pdf, (accessed April 2012).

“Neuronal plasticity happens daily. Connections are continually strengthened or weakened—a minute bit at a time—as sensory input changes owing to external stimuli. The perception of pain varies greatly from one individual to another because it is influenced by a number of psychological factors, including culture (not everyone can walk on hot coals), previous life experiences, and current mental status”

John Ratey, A Users Guide to the Brain, Random House, New York, 2001, pg 86)

Perception Problem?

“Abnormal perception can corrupt a person’s experience. If perception distorts our picture of the world, everything that lies downstream from sources can cause eventual brain dysfunction”

John Ratey, A Users Guide to the Brain, Random House, New York, 2001, pg 86)

CP Patient - Perception Curative Passive Angry Hopeless

“For many patients, the goal may not be abolition of pain but adaptation to pain. Accepting pain rather than expecting it to be cured or banished can often lead to improved quality of life, with the focus shifting to managing the pain and living with it.�

Lifestyle Medicine, Managing Diseases of Lifestyle in the 21st Century, Second Edition Gary Egger/Andrew Binns/Stephen Rossner, McGraw-Hill, Australia, 2011, page 259

“Results from the present study of chronic pain sufferers demonstrate that responses to pain such as carrying on with activity, while acknowledging that pain is present, were associated with better physical, psychosocial, and emotional functioning over time.�

A Prospective Investigation of Acceptance and Control-Oriented Coping with Chronic Pain Lance M. McCracken, Kevin E. Vowles and Jeremy Gauntlett-Gilbert

The Paradigm Shift

Moving from a passive “cure me� mentality to realizing that there are active things they can do to manage their experience of pain

Coaching for Wellness Motivated for change Preparation or Action stage Confident

Coaching for Chronic Pain Hopeless Pre-contemplation Passive

“Health-care providers are trained to deliver prescriptions and advice, and often work harder than the patients do in trying to help. But the expert approach actually lets patients off of the hook, sending the subtle message: You aren’t in charge”

Joos & Hickam, 1990).Coaching Psychology Manual, pg 12,13

“It is important to remember that the way communication is provided often has just as big an impact as what is said.

Strategies that demonstrate a nonjudgmental approach and a sense of support help to encourage the patient to self-explore�

Lifestyle medicine Gary Egger/Andrew Binns/Stephen Rossner

A coach… identifies with patient

establishes trust and intimacy

A coach… Instills and loans confidence –stories of success

–encouraging small forward steps

–celebrating victories

A coach… Helps develop a simple plan –perspective –visioning –smart goals

A coach… Helps patients get their head in the game –what went well –gratitude

The Coach Approach Builds a working relationship based on respect for the patient’s ability to choose the right path for functionality.

–this style increases self-motivation.

–the patient has a greater sense of ownership.

–patient will be more likely to start making and continue behavior change.

How is this done? Create a discrepancy between where the patient is and where they would like to be –benefits

–costs

help reduce the ambivalence about getting there Lifestyle Medicine, Gary Egger/Andrew Binns/Stephen Rossner

“I cannot tell…you how to be rich. But I can tell you how to feel rich… be grateful. It's the only totally reliable to-get-rich-quick scheme” Ben Stein

“By stimulating the release of opioid-like substances in the body, positive emotions produce less sensitivity to pain and greater pain tolerance�

Dr. Emmons writes of research by Sheldon Cohen, PhD

Robert A Emmons, PhD, Thanks! How Practicing Gratitude to Can Make You Happier, Houghton Mifflin Company, New York, 2007.

“We no longer think of the emotions as having less validity than physical or material substance, but instead must see them as cellular signals that are involved in the process of translating information into physical reality, literally transforming mind into matter.�

Candace Pert

Candace Pert, Molecules of Emotion, Touchstone, New York, 1999

“…positive emotions such as joy and gratitude can be increased with practice, and they can provide similar benefits to physical exercise.”

Catherine Hart Weber, PhD

Our bodies “listen� and respond to our mental chatter.

Might a grateful mind produce a happier body?

“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it�

Plato

“Exercise has been shown repeatedly in any chronic pain state to be an effective treatment.�

Dr. Daniel Clauw

Exercise is an antidepressant not reliant on any specific activity, such as running. Anything that gives an aerobic boost—climbing the stairs, raking leaves, taking a brisk walk—is known to increase serotonin production (the “well-being” neurotransmitter). "Exercise is really for the brain, not the body. It affects mood, vitality, alertness, and feelings of well-being"

Dr. Ratey

Jean Lawrence, “Train Your Brain With Exercise,” Quoting John Ratey, http://www.webmd.com/fitness-exercise/guide/train-your-brain-with-exercise, June 2007 (accessed April 2012)

“You want to ready your brain for learning. For that to happen, all the chemicals must ‘jog’ into place”

Dr. Ratey

Jean Lawrence, “Train Your Brain With Exercise,” Quoting John Ratey, http://www.webmd.com/fitness-exercise/guide/train-your-brain-with-exercise, June 2007 (accessed April 2012)

Diaphragmatic breathing is a simple way to retrain the brain in pain. We apply our conscious mind to alter an automatic function (a voluntary choice that affects an involuntary function). In the process, we slow the body – reduce stress and anxiety – and improve circulation so the body can relax

Ability to Borrow Courage

Name the process by which the brain is able to adapt to new information/experiences Identify the three stages in the experience of pain Describe the paradigm shifts necessary for forward motion in a chronic pain patient