Transcript A Lifestyle for Wellness - Full Circle Center for Integrative Medicine

Healing Groups
for People Living with Chronic Pain
Mind-Body Medicine at the
Full Circle Center for Integrative Medicine
A Proven Approach
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Pain. 1992 Mar;48(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 2000;69:205-215 (DOI:
10.1159/000012395)
Pain. 1995 Nov;63(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 Dec;6(4):213-22. Cognitive-behavioral treatment of rheumatoid arthritis
pain: maintaining treatment gains. Keefe FJ, Van Horn Y.
Altern Ther Health Med. 1998 Mar;4(2):67-70. A pilot study of cognitive behavioral therapy in
fibromyalgia. Singh BB, Berman BM, Hadhazy VA, Creamer P.
J Pediatr. 2002 Jul;141(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. . . .
Session 1 Outline
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Staff Introductions
Review course format, group expectations
Introduce Diaphragmatic breathing
Understanding Pain – The Physiology of Pain
Integrative Pain Management
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Diagnosis
Treatment of underlying causes
Medical treatment of pain
Mind/body/spirit medicine for pain management
Staff Introductions
Course Format
Introductory Session: didactic (Connie will drone on and on)
o Future groups more interactive/experiential:
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o Relaxation Response Exercise
o Check-in
o Medical Presentation
o CBT exercise
o Med check
o Closure/Relaxation Response
Course Format
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Homework – pain diaries, other
Comfort issues
o Feel free to stand or move when you need to
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Confidentiality issues
o 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
Diaphragmatic Breath Awareness
Breathing
Understanding Pain
Acute Pain
Adaptive:
Indicates tissue injury
Initiates protective behavior
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
Effects of Chronic Pain
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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.
Pain Perception:
the plot thickens
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Sensory Nerves
o A-delta Fibers – myelinated, 40 mph, well-localized
and rapid message, respond to tissue pressure. Fatigue
with repeated stimulation.
o 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.
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Sensitization – chemical mediators from
inflammation or injured tissue can sensitize
small fibers, so that non-painful stimuli will be
perceived as painful.
Pain Perception
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Spinal Cord
o 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)
Pain perception
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Brain
o Can tonically amplify or suppress the messages
coming in from the periphery
o Gives meaning to the pain experience
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Differences in pain levels of victims of automobile
accidents vs. those responsible for the accident
Carolyn Myss insights, etc.
John Sarno and repressed anger
Gate Control Mechanism/Theory
Imagine. . .
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The brain has messages coming in and has caller
ID.
o It can screen calls
o Some callers are filtered out altogether
o 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.
Gate Control Mechanism/Theory
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 Jun;27(5):314-26
Integrative Pain Management
Pain may be mandatory,
but suffering is optional
Pain Diary Instructions
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Physical sensation
Aching
Throbbing
Dull
Sharp
Tender
Numb
Burning
Shooting
Stabbing
Penetrating
Nagging
Gnawing
vs.
o Emotional Response
Frustration
Fear
Anger
Anxiety
Hopelessness
Sadness
Helplessness
Numerical Ratings
Rating
0
Physical Sensation/activities
No painful physical sensation
Emotional Response
No negative emotional response
1-4
Mild intensity of physical pain,
Minimal effect on activities
Minimal/low level of negative
emotions
5-6
Moderately intense physical
Sensation, increased body tension,
Moderate restriction of activities
Moderate negative emotions
7-8
Significant pain sensation, difficulty
Moving, decreased activities
Significant negative emotions
10
Severe pain sensation associated
with inability to move
Severe depression, anxiety,
or despair.
The Rules of Tacks
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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.
Corollaries to the Rule of Tacks
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Accurate diagnosis is important
o Do not rush to control symptoms and ignore the
message about an underlying health problem
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Remove tacks where possible, i.e. treat underlying
causes
o Surgical treatment
o Physical therapies
o Specific medical treatment for neuropathy, systemic
inflammation related to gut disturbances, etc.
o Sleep, hormonal influences on tissue healing
o Counseling - History of trauma
Symptom Management:
Medical Treatment of Pain
WHO's pain ladder
- developed for cancer
pain, now applied for
nonmalignant chronic pain
as well
Step 1: Non-Opioid Analgesics
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Aspirin
Tylenol
Other NSAIDs
Tylenol toxicity
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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
Adverse effects of NSAIDs:
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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
“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 NSAIDrelated 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 underappreciated.”
Am J Med. 1998 Jul 27; 105(1B): 31S-38S
The “safer” anti-inflammatories?
NSAIDs Impair Joint Repair
In vivo studies with NSAIDs at physiologic concentrations have
shown that several NSAIDs reduce glycosaminoglycan
synthesis.
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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
Downsides of NSAIDs
Suppression of COX robs cartilage of the prostaglandins that are
necessary for the production of glycosaminoglycans:
o “PGD(2) and PGF(2)alpha enhanced chondrogenic
differentiation and hyaline cartilage matrix deposition.”
Rheumatology. 2004; 43: 852-857
o Suppression of COX robs bone of the prostaglandins that are
necessary for bone remodelling:
o “COX-2 inhibitors currently taken for arthritis and other
conditions may potentially delay fracture healing and bone
ingrowth.” J Orthop Res. 2002 Nov;20(6):1164-9
o 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
Use of NSAIDs
Inhibition of
proteoglycan
synthesis,
subchondral
osteonecrosis
pain and
"arthritis"
Increased intestinal
permeability:
"leaky gut"
Excess antigen
and endotoxin
absorption
Joint
degeneration
Immune activation
and dysregulation
(e.g., superantigens
and NF-kappaB)
Intraarticular
immune
complex
deposition
Rheum Dis Clin North Am. 1991 May;17(2):309-21
Adjunctive Medications
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Topical – lidocaine, capsaicin,
antiinflammatories, other
Antidepressants
Anticonvulsants
Antiarrhythmic drugs
Ultram
Antidepressants for Pain
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Work by affecting neurotransmitters
Do not only work for treating pain by
improving depression.
o Work as well in non-depressed people as in
people with depression
o Effectiveness for pain does not correlate with
effectiveness for depression
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Do not work for all types of pain.
Opioids in Chronic Pain
Management
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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
Questions to Ask:
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Is the person’s 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 person’s 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?
Signs Someone is Being Harmed more
than Helped by Pain Medication
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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
Timing
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Short-acting/Rescue medications: codeine,
hydrocodone, oxycodone, morphine
Drug level
time
Problems with Short-acting Medications
Drug level
Loaded
In pain
Time
Long-acting narcotics:
Drug level
Time
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Fentanyl patches (Duragesic)
Methadone
MS Contin
OxyContin
o Need to be dosed on a schedule, not prn
Making Use of the
Mind-Body Connection
in Chronic Pain Management
After the break. . . .
Stress
A Definition
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.
o 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)
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The Response to Stress, in 3 Phases:
o Alarm Reaction
o Stage of Resistance
o Stage of Exhaustion
Alarm Reaction: Fight-or-Flight
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Evolutionary Role: escape from predator or
acute physical danger
Alarm Reaction
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Physiological changes: Adrenal hormones
adrenaline (epinephrine) and norepinephrine
o Metabolism increases
o Heart rate increases
o Blood Pressure increases
o Breathing Rate increases
o Muscle Tension increases
General Adaptation Syndrome
(GAS)
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The Response to Stress, in 3 Phases:
o Alarm Reaction
o Stage of Resistance
o Stage of Exhaustion
Stage of Resistance
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HPA (hypothalamo-pituitary-adrenal
axis: Cortisol increases when stress
becomes chronic
o Block energy storage and help mobilize energy
from storage sites
o Increase cardiovascular tone
o Inhibit anabolic processes such as growth,
repair, reproduction and immunity
General Adaptation Syndrome
(GAS)
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The Response to Stress, in 3 Phases:
o Alarm Reaction
o Stage of Resistance
o Stage of Exhaustion
Adrenal Exhaustion
Coping responses cannot sustain their response if
stressor is sufficiently severe and prolonged
o “Diseases of adaptation" may arise
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o Hypertension
o Ulcers
o Heart disease
Symptoms that disappeared during the stage of
resistance may reappear
o 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
Maladaptive Symptoms with
Acute Stress Hormones
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Cold Hands and Feet
Palpitations
Diarrhea or Constipation
Decreased sleep
Maladaptive Changes with
Chronic Stress
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Worsened blood sugar control/increased
insulin resistance
Increased visceral fat deposition (appleshaped weight gain)
Increased inflammation
Decreased immunity
Documented Relationship of
Illness to Chronic Stress
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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 325:606-612 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.
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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, 495–499 (2003)
Blaming or Taking Responsibility
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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
Mind-Body and Body-Mind
Interactions in Chronic Pain
How Emotions and Stress
Affect Chronic Pain
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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
How Chronic Pain Affects
Emotions and Stress
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Body tension is perceived as emotional by
the brain
Secondary effects on:
o Sleep
o Disability and financial fall-out
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Side effects of treatments
Vicious Cycles
Poor
Sleep
Stress
Decreased
GH
Increased
cortisol
Pain
Decreased
Tissue
Repair
Vicious Cycles
Muscle
Tension
Stress
Decreased
Circulation
Pain
Tissue
Injury
The Relaxation Response
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Counterbalancing mechanism to the Fight-orFlight Response
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Metabolism decreases
Heart rate decreases
Blood Pressure decreases
Breathing Rate decreases
Muscle Tension decreases
May be consciously elicited
o Generally needs to be practiced
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Benefits of the Relaxation
Response
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Immediate:
o Getting through procedures and short-term stress
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Long-term:
o Used consistently, there are carry-over effects
Program Overview
or, How you can learn to manage stress and maximize joy
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Relaxation Response
Cognitive restructuring, Coping, Stress
Hardiness
Nutrition
Exercise/Body Awareness
Spirituality
Techniques Which Can Elicit the
Relaxation Response
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Diaphragmatic
Breathing
Meditation
Body Scan
Mindfulness
Repetitive exercise
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Repetitive prayer
Progressive muscle
relaxation
Yoga Stretching
Imagery
(Music)
Common Elements of Techniques Used
to Elicit the Relaxation Response
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Focusing of attention through repetition of
words or physical activity
Passive disregard of everyday thoughts
when they occur, and return to the repetition
Common Problems
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No time
Restlessness
Falling Asleep
Noises
Thoughts
Anxiety
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“Old Stuff” surfacing
Insomnia
Increase in Dreaming
“Doing it right” –
perfectionism
Changes in bodily
perceptions
Feeling Worse
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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.
Homework for the First Session
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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
Self Portrait Exercise
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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