Transcript File

Non-Pharmacological Management of
Chronic Pain
Afton L. Hassett, Psy.D.
Associate Research Scientist, Department of Anesthesiology
Chronic Pain & Fatigue Research Center
University of Michigan, Ann Arbor, MI
Disclosures
Research funded by Bristol-Myers Squibb and Pfizer Inc.
Consultant to Bristol-Myers Squibb, Pfizer Inc. and Lexicon
Pharmaceuticals.
Non-Pharmacological Pain Management
Topics
The
evidence for some of the most commonly encountered nonpharmacologic (behaviorally-oriented) treatments.
Organizing the approach - addressing the six “ExPRESS” domains.
Cases: Conceptualizing and tailoring non-pharmacological treatment.
Building your “tool box” – tossing in a few strategies for building
resilience!
Non-Pharmacological Pain Management
Complexity: Multiple Symptoms
Most common complaints:

Chronic widespread pain

Fatigue

Sleep disturbance

Poor mood

Cognitive difficulties

Muscle stiffness
Frequently occurring complaints:

Gastrointestinal symptoms

Headache

Genitourinary

Numbness and tingling

Dizziness/loss of balance

Weakness

Skin changes
Clauw DJ. JAMA 2014;311;1547-55
Mease et al. Arthritis Rheum 2008;59(7):952-60
Complexity: High Rates of Co-Morbidity

Comorbidity with other chronic pain states
42-70% of patients with FM also meet criteria for CFS
32-80% of patients with FM meet criteria for IBS
42% of back pain patients meet criteria for FM
Aaron & Buchwald. Ann Intern Med 2001;134:868–81
Brummett, Goesling, Tsodikov, Meraj, Wasserman, Clauw &Hassett.
Arthritis Rheum 2013;65:3285-92.

Co-Morbidity with chronic systemic disease
Rheumatoid arthritis, lupus, inflammatory bowel disease
Lee et al. Ann Rheum Dis 2013;72:949-54.
Bliddal et al. Best Prac Res Clin Rheumatol 2007;21:391-402
Schlesinger, Hassett et al. Ann Rheum 2009

Psychiatric co-morbidity – mostly anxiety and depression.
Depression and pain commonly occur.


Between 30-60% of
individuals with pain report
having comorbid
depression.2,3,4
Approximately half of patients
with depression report pain.1
1) Katona et al. Clin Med. 2005;5:390-5; 2) Bair et al. Arch Intern Med 2003;163:2433-45
3) Hassett et al. Curr Pain Headache Rep. 2014;418:36; 4) Arnold et al. J Clin Psychiatry 2006;67:1219-25
Neurobiological perspective.
Brain regions associated with physical pain overlap with psychological
pain processing:


Sensory discriminative dimension
– Somatosensory cortices (S1, S2)
– Dorsal posterior insula
Affective emotional dimension
– Anterior insula
– Prefrontal cortex
– Anterior cingulate cortex
– Thalamus
– Amygdala
– Hippocampus
Goesling, Clauw & Hassett. Curr Psychiatry Rep. 2013;15:421
Neurobiological perspective.
Neurotransmitters – pain
Neurotransmitters - depression
Serotonin

Norepinephrine

Glutamate

GABA





Serotonin
Norepinephrine
Glutamate
GABA
Similar neurotransmitter anomalies exist.
Both respond to SNRIs, but SSRIs provide little pain relief.
SNRIs might be better thought of as “neuromodulators.”
Pain relief with SNRIs is often independent of changes in
depression.
Ablin, Buskila & Clauw. Curr Pain Headache Rep 2009;13:343-9
Merging of pain and emotion results in
significant clinical challenges!
A 44 yo Caucasian male presents with severe chronic low back pain
that began in college seemingly due to a football injury. He has
undergone multiple back surgeries, none resulting in adequate pain
relief. The most recent surgery was complicated by sepsis nearly
resulting in the patient’s death. He is currently prescribed multiple
analgesics yet the pain persists. In addition, is under the care of an
orthopedist, urologist, otolaryngologist and endocrinologist and
carries additional diagnoses of irritable bowel syndrome (that began
in childhood) and adulthood chronic prostatitis, headache, myofascial
pain syndrome, reactive depression and insomnia. The GI symptoms
at times are severe enough to cause total incapacitation, yet are
second to the back pain which plagues him constantly.
Be Patient with Your Patients
 Perspective – feel terrible, usually a little frightened, searching
for answers, often feel dismissed and alone.
 A relatively small but difficult subgroup of patients, primarily
those with personality pathology, provoke the greatest levels of
healthcare provider frustration (others are guilty by association)
 A hardy subgroup of patients exists with no history of
psychopathology, high positive affect, less catastrophizing and
less dysfunction and in some cases, higher levels of pain!
Giesecke et al. Arthritis Rheum 2003;48:2916-22
Hassett et al. Arthritis Rheum 2008;59:833-40
Toussaint, Vincent, McAllister, Oh & Hassett. Scand J Pain;2014;5:161-166
Non-Pharmacological Interventions
Non-Pharmacological Interventions
The Evidence for Behavioral Interventions
 Education and educational/support programs
 Behavioral Therapies (e.g., CBT, ACT, self-management,
positive activities)
 Physical Activity/Exercise
 Movement Therapies (Yoga, Tai Chi)
 Mindfulness Meditation
Non-Pharmacological Interventions
Education



Neck pain: very low quality
evidence for education alone1
Arthritis: knowledge and
compliance improved short- and
long-term, but health status
changes were minimal2
FM: Education associated with
some improvement in physical
function but best combined with
a multimodal intervention3
Educational interventions typically
include group sessions, videos,
pamphlets, etc. with information
about the illness and self-care,
activation strategies, pain coping,
and workplace ergonomics
1) Gross et al. Cochrane Database Sest Rev 2012 Epub. 2) Niedermann et al. Arthritis Rheum 2004;51:38898. 3) Hassett & Gevirtz. Rheum Dis Clin N Am 2009;35:393-407
Non-Pharmacological Interventions
Education

“The evidence base is limited by the
small numbers of studies, their
relatively small sample sizes, and the
diversity in types of education studied.”

Education is an important aspect of
treatment and building a good working
relationship.

Educational programs alone are likely
not enough.
Geneen et al. Syst Rev 2015;4:132
Non-Pharmacological Interventions
Cognitive–Behavioral Therapy
CBT
exists for many illnesses
– Mental illnesses

e.g., depression, OCD, phobia,
PTSD, generalized anxiety
– Physical illnesses

e.g., cardiovascular disease,
diabetes, asthma, cancer, obesity,
chronic pain.
Skills
vary based on disorder
Common underlying principles
Beck. Cognitive Therapy: Basics and Beyond. 1995; Craighead. Behavior Modification: Principles,
Issues, and Applications. 1981; Meichenbaum. Cognitive-Behavioral Modification. 1977.
CBT: Event => Thoughts => Feelings => Behavior
Event
Thoughts about
the event
Emotions
Behaviors
CBT: Event => Thoughts => Feelings => Behavior
Event
Thoughts about
the event
Emotions
Behaviors
Non-Pharmacological Interventions
Cognitive –Behavioral Therapy (CBT)
A
wide variety of skills are taught as platforms to
promote adaptation through:
– New learning and behavioral change
– New cognitive formulations of the problem/solutions
Target:
Pain, fatigue, sleep, cognition, mood and
functioning.
Williams, DA (2010). Pain and painful syndromes. In J. Suls, KW Davidson, & RM Kaplan (Eds),
Handbook of Health Psychology and Behavioral Medicine. New York, NY: The Guilford Press; 476-493.
Non-Pharmacological Interventions
Elements of Cognitive and Behavioral Therapies for Chronic Pain
Cognitive Methods
Behavioral Methods
Socratic questioning and guided discovery
Monitoring pain and activity levels
Keeping thought change records
Activity pacing
Identifying cognitive errors (automatic thoughts)
Relaxation training
Generating rational alternative thoughts
Breathing retraining
Imagery
Pleasant activity scheduling
Role play and rehearsal
Distraction techniques
Non-Pharmacological Interventions
CBT Evidence

Based on numerous
RCTs, reviews and metaanalyses, there is strong
support for the efficacy of
CBT for improving pain,
physical functioning and
mood in many chronic
pain states.
Non-Pharmacological Interventions
CBT Evidence




CBT superior to other
psychological treatments
for pain reduction in FM.
Effect size for pain 0.60
Dose response
Improvement in other
symptoms (e.g., sleep,
mood) and functioning.
Non-Pharmacological Interventions
CBT Access a Problem
 Medical school curricula do not devote sufficient
attention to non-pharmacological approaches

Reimbursement is typically challenging

Stigma associated with “psychological” treatments
delivered by mental health professionals
Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:299-309
Non-Pharmacological Interventions
Non-Pharmacological Interventions
CBT Access a Problem = Web-based Interventions
Living Well with Fibromyalgia Study
Avera Research Institute – Sioux Falls, SD
54 clinics, catchment radius of 500 miles
WEB (n=59)
TAU (n=59)
Endpoint: 6 months
Williams DA et al. Pain. 2010
Non-Pharmacological Interventions
CBT Access a Problem => Web-based Interventions
Pain Responders:
30% improvement
• WEB:
• TAU:
29%
8%
•NNT: 5
Williams DA et al. Pain. 2010
Non-Pharmacological Interventions
Between Class Comparisons of FDA Approved
Medications for Fibromyalgia (All Doses Pooled)
• NNT for 30% reduction in pain
– Duloxetine 7.2 (95% CI 5.2, 11.4)
– Milnacipran 19.0 (95% CI 7.4, 20.5)
– Pregabalin 8.6 (95% CI 6.4, 12.9)
– Living Well Online CBSM: 5.0
Häuser W et al. J Pain. 2010; 11:505-521.;
Williams DA et al. Pain. 2010
Living Well with FM expanded to “FibroGuide”
http://fibroguide.med.umich.edu/
Non-Pharmacological Interventions
Acceptance & Commitment Therapy
(ACT)
Based
on acceptance and mindfulness
Get
to know unpleasant feelings, learn not
to act on them, do not avoid situations
Meta-Analysis:
When ACT was compared to
various forms of CBT a non-significant effect
size of 0.16 was obtained. However, an
evidence-base evaluation showed that ACT is
probably efficacious for chronic pain
Ost. Behav Res Ther 2014;61:105-21.
Non-Pharmacological Interventions
CBT Access: American Psychological Association
http://locator.apa.org/
Non-Pharmacological Interventions
Physical Activity



Over 80 studies evaluating
exercise interventions.
Multiple reviews and metaanalyses, and professional
society guideline statements.
Leave little doubt that exercise is
broadly considered to be an
effective treatment for patients
with chronic pain.
Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:299-309
Non-Pharmacological Interventions
Physical Activity
“exercise” can
be aerobic or more focused on
increasing strength and flexibility
Can be of high intensity and
frequency or involve only adding a
few steps each day.
Land- or water-based, whole-body
exercise to cycling
Structured approaches: yoga,
Pilates and Tai Chi.
Evidence-based
Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:299-309
Non-Pharmacological Interventions
Physical Activity - Exercise

Aerobic training at moderate intensity can improve pain,
fatigue, depressed mood and physical limitations
– Attrition rates can be high (range: 27-90%)
– Fitness gains not always associated with symptom improvement
– Increase time and intensity slowly (start low, go slow).

Strength training may decrease pain, and depression, and
improve overall well-being
– Need more high-quality studies
Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:299-309.
Hauser et al. Arthritis Res Ther 2010;12:R79. Jones et al. Rheum Dis Clin North Am
2009;35:373-91. Arnold. Psychiatr Clin North Am. 2010;33:375-408.
Non-Pharmacological Interventions
Physical Activity – Exercise
Graded,
low-to-moderate intensity (under supervision)
Adherence an important hurdle (fun, access, interest)
High-risk patients may require prior evaluation
30 minutes of moderate intensity exercise
2-3 times per week, 10 weeks or more
Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:299-309.
Hauser et al. Arthritis Res Ther 2010;12:R79. Jones et al. Rheum Dis Clin North Am
2009;35:373-91. Arnold. Psychiatr Clin North Am. 2010;33:375-408.
Non-Pharmacological Interventions
Physical Activity

Does not necessarily mean
going to the gym!
Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:299-309
Non-Pharmacological Interventions
Movement Therapies
Tai Chi:
– Improves balance, well-being,
and fitness, maintain BMD
– Studies mostly of low quality
– Some evidence for pain relief in
FM*, RA, headache and LBP
– 5 RCTs in OA “strong evidence”
for pain relief, improved physical
functioning and psychological
well-being.
Tai Chi is an ancient martial and
health art that involves flowing
circular movement of the upper limbs
and weight shifting of lower limbs.
Meditation, breathing, moving qi and
learning mind-body control
Peng. Reg Anes Pain Med 2012;37:372-82
*Wang et al. N Engl J Med 2010;363:743-54
Non-Pharmacological Interventions
Movement Therapies
 Yoga:
– Attention to posture, deep breathing,
gentle movement, strength building
and ROM.
– Arthritis 4 RCTs evidence for
decreased disease symptoms
(tender/swollen joints)
– Meta analysis in FM effects on pain,
fatigue, depression and HRQOL
(short term).
– Meta analysis in pain (OA, RA, LBP,
FM) 17 studies: improvement in
pain and functioning
Yoga involves theories and practices
that originated in ancient India. Refers
to mind/body integration. Physical
practice of yoga is referred to as
“hatha” which was intended to help
prepare for meditation. Specific bodily
postures or poses.
Haaz & Bartlett. Rheum Dis Clin North Am. 2011:37:33-46.; Langhorst et al. Rheumatol Int
2012 Epub. Ward et al. Musculoskeletal Care 2013;11:203-17.
Non-Pharmacological Interventions
Mindfulness Meditation



Stress reduction (MBSR) and MB
cognitive therapy (MBCT)
Decreases stress and improves
depression and anxiety in many
populations.
Some evidence that MBSR can
decrease pain, improve insomnia
and increase pain coping and
acceptance.
Mindfulness meditation involves a state
of consciousness where the focus is on
attention, awareness and moment-bymoment experience. Have an attitude of
curiosity, openness, and acceptance.
Decrease analytical self-referential
rumination, “This pain is not me.”
Exposure, self-regulation.
Marchand. J Psychiatr Pract 2012;18:233-52.
*Wetherell et al. Pain 2011;15(9):2098-107
Non-Pharmacological Interventions
Mindfulness Meditation


Meta-Analysis using 16 RCTs. In 10
of 16, there was significantly
decreased pain intensity in the MBI
group.
Results from follow-up assessments
reveal that reductions in pain intensity
were generally well maintained.
Mindfulness meditation involves a state
of consciousness where the focus is on
attention, awareness and moment-bymoment experience. Have an attitude of
curiosity, openness, and acceptance.
Decrease analytical self-referential
rumination, “This pain is not me.”
Exposure, self-regulation.
Reiner et al. Pain Med 2013;14:230-42
Interventions that enhance
positive emotions and resilience!
Negative emotions associated with chronic pain
• Numerous studies linking negative
affect to key factors in chronic pain:
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Higher pain report
Worse weekly pain
Lower pain tolerance
Increased experimental pain sensitivity
Hyperalgesia
Greater use of pain medication
Worse analgesia (pentazocine)
Pain-related disability
Increased fatigue
More physical symptoms
Higher levels of psychiatric comorbidity
Poor quality of life
Poor self-efficacy for pain management
Abeare et al. Clin J Pain 2010;26:683-9
Cogan et al. J Behav Med 1987;10:139-44
Carcoba et al. J Addict Dis 2011;30:258-70
Fillingim et al. Biol Psychol 2005;69:97-112
Finan et al. Psychosom Med 2009;71:474-82
Finan et al. Health Psychol 2010;29:429-37
Finan et al. Psychosom Med 2013; 75:463-470
Hamilton et al., Ann Behav Med 2005;29:216-24
Hanssen et al. Pain 2013;154:53-8
Hassett et al., Arthritis Rheum 2008; 59:1742-9
Hassett et al., Arthritis Rheum 2008; 59:833-40
Hirsch et al. Qual Life Res 2012;21:18794
Kamping et al. Pain 2013; Epub ahead of print
Kenntner-Mabiala et al. Biol Psychol 2008;78:114-22
Krok and Baker. J Health Psychol 2013; In Press
Parrish et al. Health Psychol 2008;27:694-702
Schon et al. Psychophysiology 2008;45:1064-7
Seeback et al. Pain 2012;153:518-25
Siblile et al. Clin J Pain 2012;28:410-7
Smith et al. Pain 2008;138:354-61
Staud et al. Pain 2003;105:215.22
Staud. Curr Pain Heachache 2005.9:316-21
Stran et al. J Psychosom Res;60:477-84
Tang et al. Pain 2008;138:392-401
Vwesteeg et al. Qual Life Res 2009;18:953-60
Wesler et al. J Psychosoc Oncol 2013;31:451-67
Zautra et al. Pain 2007;128;128-35
Zautra et al. J Consult Clin Psychol 2005;73:212-20
Positive emotions might even be more important!
• Solid prospective and experimental
studies found PE related to:
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Lower overall pain ratings
Lower pain intensity scores
Decreased same day pain report
Decreased subsequent day pain report
Decreased subsequent week pain report
Increased induced pain tolerance
Decreased induced pain sensitivity
Longer tolerance to pain
Evoked potential moderation
Decreased use of pain medication
Lower post-op pain ratings
Greater walking times post-surgery
Length of stay in colorectal cancer surgery
Adams et al. Activities, Adaptation and Aging 1986;8:157-75
Alden et al. Appl Psychophysiol Biofeedback 2001;26:117-26
Avia et al. Cognit Ther Res 1980;4:73-81
Bruel et al. Pain 1993;54:29-36.
Chaves et al., J Abnorm Psychol 1974;83:356-63
Clum et al. Pain 1982;12:175-83
Cogan et al. J Behav Med 1987;10:139-44
Connelly et al., 2007;131:162-70
Finan et al. Psychosom Med 2009;71:474-82
Finan et al. Health Psychol 2010;29:429-37
Finan et al. Psychosom Med 2013; 75:463-470
Gil et al., Health Psychol 2004;23:267-74
Hamilton et al., Ann Behav Med 2005;29:216-24
Hanssen et al. Pain 2013;154:53-8
Hertel et al. Psychol Rec 1994;33:207-20
Horan et al. Percept Mot Skills 1974;39:359-62
Hudak et al. Psychol Rep 1991;69:779-86
Kamping et al. Pain 2013; Epub ahead of print
Kenntner-Mabiala et al., Biol Psychol 2008;78:114-22
Meagher et al., Psychosom Med 2001;63:79-90
Meulders et al. J Pain 2014;15:632-44
Morgan et al. Percept Mot Skills 1978;47:27-39
Pickett et al. J Consult Clin Psychol 1982 ;50:439-41
Powell et al., Rehabil Psychol 2009;54:83-90
Rosenbaum et al. J Abnorm Psychol 1980;89:581-90
Sharma et al., Colorectal Dis 2008;10:151-6
Stevens et al. Psychol Rep 1989;64:284-6
Strand et al., J Psychosom Res 2006;60:477-84
Tang et al., Pain 2008;138:292-401
Weaver el al. Percept Mot Skills 1994;78:632-4
Weisenberg et al. Pain 1998;76:365-75
Worthington et al. J Couns Psychol 1981;28:1-6
Zautra et al. J Consult Clin Psychol 2005;73:212-20
Zelman et al. Pain 1991;36:105-11
Interventions that enhance resilience
Social Support Round Robin

Make eye contact with somebody sitting next to you. Give him or her a fist bump.

Take a moment and think about something you really like about that person.

Choose something special about him or her that is generally seen as a character
strength (creativity, intelligence, integrity, courage, sense of humor, perseverance).

If this person is a stranger, choose something about his or her presentation or
demeanor.

If this person is somebody with whom you have a conflict, all the more important to
identify something you like and/or respect.

Now, tell the person what it is that you appreciate and/or admire.
Interventions that enhance resilience
Keeping a Gratitude Diary
1. Every day, write down 3 things for which you are grateful. It can be anything feeling the sunshine on your face, happy that a friend phoned, receiving a
present, being able to take a walk, anything. Work out a time to do this. Ideally,
around the same time every day works best.
2. Make a commitment to yourself that you will write down 3 things every day this is very important.
3. The 3 things MUST be DIFFERENT each time. Never repeat anything.
4. Smile as you write them down. This will help you to feel grateful.
5. You can write a lot about each thing, get really detailed, write why you are
grateful for it. Or if you don't have time, just write one line.
Interventions that enhance resilience
Savoring a Beautiful Day:
1.
Set aside a block of time for your own pleasures. Set aside a minimum of
one hour or a maximum of a full eight-hour day. A half-day is just about
perfect for the first time you do this exercise.
2.
Block that time out on your calendar now, and do not let anything interfere,
if possible. Next plan one activity or, even better, a sequence of activities
that brings you real pleasure, and carry them out as you planned them.
3.
Here is the further twist. Savor each of the activities using all of your
senses and with feelings of gratitude and optimism.
Adapted from: Seligman, Park & Peterson
Interventions that enhance resilience
Three Good Things
Every night for the next week, right before
you go to bed, write down three things
that went particularly well on that day.
These things can be ordinary and small in
importance or relatively large in
importance. Next to each positive event
in your list, answer the question, “Why
did this good thing happen?”
Seligman ME, Rashid T, Parks AC. Positive psychotherapy. The American psychologist.
Nov 2006;61(8):774-788. Seligman et al. American psychologist2005;60(5):410-42.
Positive Piggy Bank
Every evening think about the people, things or events that made you happy that
day. You may make a list if you like. Pick one of these and spend a moment savoring
it. What made it so special to you? Now, write down this moment on a “currency”
slip. Use enough detail that you can immediately recall what happened later. Next,
add the date, fold up your happy memory “currency,” and drop it in the piggy bank.
You will make these happy memory “deposits” in the same way every evening for
the next 30 days.
At the end of 30 days, you will “close your account.” This means that you will
withdraw all of the “currency” from your piggy bank and read each and every one of
the deposited happy memories. As you read them, try to recall details of the happy
event and what made it so special to you at the time. Enjoy!
Hassett et al. Studies underway
Positive Piggy Bank
Preliminary Data!
General population, adults 18-80, English speaking, able to give consent and low
levels of depressive symptoms (PHQ9 ≤ 9).
Completed questionnaires and were randomized to PPB or WLC.
Hassett et al. Preliminary data.
Positive Piggy Bank
Preliminary Data!
All participants with pre- and post-intervention data (n=89):
 Psychologically healthy sample (PA: 34.8±7.0; NA: 15.6±6.0)
 Significant improvement in life satisfaction (t[87] = -1.98, p = 0.050)

Significant improvement in life satisfaction in those with
depressive symptoms (PHQ ≥3; n=38) could be more
pronounced (t[87] = -2.16, p = 0.037)
Hassett et al. Preliminary data.
ExPRESS Approach for Chronic Pain
Putting it all together:
The six things you need to think about when
treating patients with chronic pain.
Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:393-407
ExPRESS Approach for Chronic Pain
ExPRESS Factors:
 Exercise
 Psychiatric Co-Morbidity
 Regaining Function
 Education
 Sleep Hygiene
 Stress Management
Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:393-407
Exercise
ExPRESS Factors:
 Exercise
–
–
–
–
–
Don’t feel good (pain!)
Limited energy/time
Low motivation (fun?)
Obese, embarrassed
Stress and poor habits
Graded Exercise
Increase activity gradually:
Ask the patient for an activity they enjoy doing.
“Walking”
Ask patient, “What would be a reasonable amount of walking in minutes
to achieve in the next month?”
“20 minutes a day”
Negotiate down from patient’s stated goal.
“15 mins. day 5 x wk”
Begin with the smallest of steps (No Fail scenario) “5 mins day 3 x wk”
Encourage keeping a daily log
Emphasize, exercise regardless of symptoms!
Graded tasks – Break tasks down into small manageable bits, too.
Exercise

Resistant to starting formal
program?

Begin with extra steps commitment.

Activity trackers – Fitbit ($100) and
pedometers can be found for as
little as $10.

Every day beat the day before by
50 steps.

Healthy: 10,000 steps a day

(18 – 1,900 steps in a mile)
ExPRESS Approach for Chronic Pain
ExPRESS Factors:
 Exercise
 Psychiatric Co-Morbidity
 Regaining Function
 Education
 Sleep Hygiene
 Stress Management
Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:393-407
Pain, Depression and Sleep Triad
Pain
Depression
(anxiety/stress)
Sleep
Psychiatric Co-Morbidity

Use screening tools like the PHQ-9 for depression and GAD-7 for
anxiety. Checklists and VAS for “Depression” or “Anxiety.”

Consider treating more mild conditions – most patients choose not
to follow up with psychiatric referrals.*
*Arnold LM. Management of fibromyalgia and comorbid psychiatric disorders. J Clin
Psychiatry 2008;69 (suppl 2):14-19.
Psychiatric Co-Morbidity

Normalize psychiatric co-morbidity.
“In most chronic illnesses like heart disease, diabetes and chronic
pain, depression is common and important to treat. It can be really
tough dealing with pain and all of the changes these illnesses
cause. Plus, depression makes symptoms like pain and fatigue
worse. So it’s important that we address your depression, too.”
ExPRESS Approach for Chronic Pain
ExPRESS Factors:
 Exercise
 Psychiatric Co-Morbidity
 Regaining Function
 Education
 Sleep Hygiene
 Stress Management
Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:393-407
Regaining Function
Identify Achievable Goals:
1) Functional improvement not cure.
2) Increased ability to live with and decrease symptoms.


Obtain baseline data for later comparisons (VAS, PROMIS, FIQ)
Improved functioning, return to some previous activities
– Identify specific activity, “Tending to my roses” or “Returning to work.”
– Poor goals = “feel better” or “not have pain like I do today”

Graded tasks
– “What is one thing you are willing to do between today and our next
appointment to start moving you towards your goal?”
ExPRESS Approach for Chronic Pain
ExPRESS Factors:
 Exercise
 Psychiatric Co-Morbidity
 Regaining Function
 Education
 Sleep Hygiene
 Stress Management
Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:393-407
Education
Provide basic education without jargon and deliver 3 key messages:
Message 1 - Psychiatric co-morbidity is normal: “People with chronic pain also
often experience stiffness, fatigue, sleep disturbance and depression (or anxiety
when applicable).”
Message 2 – I believe you: “Current research suggests that some chronic pain
conditions may be the result of changes in the central nervous system.
Somehow the pain signal has become amplified.”
Message 3 – We are partners in treatment: “The good news is that there are things
you can do to get better, but you will need to be an active partner in your
treatment.”
Education
Arthritis
Foundation
arthritis.org
ExPRESS Approach for Chronic Pain
ExPRESS Factors:
 Exercise
 Psychiatric Co-Morbidity
 Regaining Function
 Education
 Sleep Hygiene
 Stress Management
Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:393-407
Pain, Depression and Sleep Triad
Pain
Depression
(anxiety/stress)
Sleep
Sleep Hygiene
“Sleep and sleep hygiene”
DHHS
64 million Americans have chronic insomnia (> 20%)
Disrupting slow wave sleep over several nights in sedentary middleaged females (without reducing total sleep efficiency) results in a
decreased pain threshold, increased discomfort, and fatigue.
Lentz et al., J Rheumatol 1999, 26(7), 1586-1592.
In
FM, >75% report sleep disturbances.
Insomnia up to 65%, snoring and arousals up to 78%, RLS up to 41%,
excessive daytime sleepiness up to 93%.
FM with sleep studies = obstructive sleep apnea ~ 80%
Abad et al., Sleep Med Rev 2008;12:211-28
Sleep Hygiene











Get up and go to bed at about the same time every day.
Do not take naps.
Stay away from caffeine, nicotine, and alcohol 6 hours before bed.
No exercise at least 4 hours before bed.
Take a hot bath 90 minutes before bed (core temperature drops).
Develop sleep rituals like having a light snack, brush teeth, set alarm.
The bedroom should be quiet, comfortable and dark.
The bed should be used only for sleeping (no critters, no eating).
Go to bed only when feeling sleepy.
If sleep does not come within 20 mins, get up and do something
boring until sleepy again.
Do not clock watch – cover it if necessary!
ExPRESS Approach for Chronic Pain
ExPRESS Factors:
 Exercise
 Psychiatric Co-Morbidity
 Regaining Function
 Education
 Sleep Hygiene
 Stress Management
Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:393-407
Stress Reduction
Decrease the psychophysiological response to
stress:

Relaxation techniques
–
–
–
Slow breathing – in through nose/out through pursed lips
Progressive muscle relaxation
Imagery and visualization
Biofeedback (esp. HRV) Hassett et al. Appl Psychophysiol Biofeedback 2007;32(1):1-10
Meditation, Yoga, Qigong
Exercise programs (walking, yoga and aqua therapy)
Cognitive strategies – new things to think instead
Positive Psychology interventions

–
Gratitude lists, pleasant activity scheduling, savoring, mindfulness
activities, piggy bank
Non-Pharmacological Interventions
Cases to Consider
Claire is a 45 yo marketing consultant who has struggled
with a life-long series of medical conditions. Chronic
abdominal pain in childhood, severe PMS in adolescence,
IBS in adulthood and now, insomnia, OA and widespread
musculoskeletal pain. She has been treated for depression
off and on over her lifetime and has begun to experience
panic attacks that are “completely unnerving!” Claire has
tried numerous medications for her pain and other
symptoms with little relief and feels frustrated by the
medical community. Today her affect seems a little brighter
when she poses that maybe she should consider trying
yoga.
– What do you tell her?
Non-Pharmacological Interventions
Cases to Consider

Lisa is a 27 year old graduate student with SLE. Her
disease is well-controlled but she continues to report
“achiness” deep in her muscles. She also describes
severe fogginess at times and fatigue almost always. She
indicates that school has been stressful and her
dissertation chair does not like her. She confided that she
feels like a failure and that everything she does is not
good enough. Now, her pain is so bad that she feels like
she should just drop out of school.
Non-Pharmacological Interventions
Cases to Consider

James is a 58 yo small business owner who had been in
good health until the past year when he was in an
automobile accident. He was treated for whiplash and
currently reports persistent severe neck and back pain.
The pain has made it difficult for him to run his shipping
business and he appears increasingly withdrawn and
irritable. He reports giving up golf and no longer goes to
the gym. He has put on 20 pounds in 4 months. When
asked what troubles him the most about his condition, he
states it’s his “restless mind – I can never just stop. It’s
so stressful.”
Non-Pharmacological Interventions
Cases to Consider

Robert is a 78 yo retired high school history teacher with
a 15-year history of OA of the hip. THA two years ago but
has persistent hip pain in both hips and is considering
THA in the other hip. You determine that the pain is
widespread and increasingly worse since he stopped
exercising. He sleeps 8 hours but does not feel refreshed
in the morning. He has a history of past depression.
– What else would you want to know?
– Is he a good candidate for a second THA?
Cases to Consider

N=655 participants undergoing arthroplasty

Pain outcomes assessed at 6 months.

Fibromyalgia survey score was a robust predictor of
poorer arthroplasty outcomes, even among individuals
whose score falls well below the threshold for the
categorical diagnosis of fibromyalgia (estimate -0.25, SE
0.044; P < 0.00001).
Brummett, Urquhart, Hassett et al. Arthritis Rheum 2015;67:1386-94
Difficult Patient Subgroup
Cases to Consider
David is a 42 yo electrical engineer with chronic low back pain.
He states that he can no longer work and wants you to sign his
disability papers, “Now.”
He is clearly depressed but refuses to seek mental health care
(I’m NOT crazy! If you people could fix my pain I’d be fine). He is
often hostile to your front desk staff and refuses to see anybody
but you (you’re the only one who understands his special case).
He has been taking high doses of Oxycontin for almost two years
but still reports pain as being an 8 on a 1-10 scale (getting worse
over time). He has been going through his medication too fast
and leaves multiple messages with the nursing staff demanding
refills and to speak with you. You have sent him to PT and he
refuses to go regularly because he thinks the physical therapist
does not respect him.
Psycho – Physiological Continua
Neurobiological Dysfunction
HIGH
LOW
Psychological Dysfunction
LOW
HIGH
Personality Disorders
Personality Disorders (N=72) 38.9% in FM (vs. 21.1% controls)

Histrionic (19.4%) and Narcissistic (8.3%)

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Exaggerated personality traits
Underlying raw emotional processes of
rage, fear, hate, dependency and shame.
Cognitive distortions and poor coping.
Self-defeating or self-destructive behaviors.
Manipulative, charming, disarming, dangerous.
Hassett et al. Am J Med 2009;122:843-50
Narcissistic Personality Disorder-Criteria
Medical setting behavior:
• Demanding and entitled.
• Become easily enraged (two year old-like tantrum)
• Medical illnesses can be a blow to his/her sense of self
(threatening).
• Reinforce that they are respected and deserving of the best
treatment available.
• Set limits on demanding behavior.
• Do not give in to the urge to strike back verbally or become
defensive.
Know when to hold ‘em…
$64,000 question:
“If we could magically heal all of your symptoms today,
what would you do tomorrow?”
Acknowledgments
Daniel J. Clauw, MD
Chad M. Brummett, MD
Jenna Goesling, Ph.D.
Richard E. Harris, Ph.D.
Steven E. Harte, Ph.D.
Ronald Wasserman, MD
David A. Williams, Ph.D.
Alex Tsodikov, Ph.D.
Stephanie Moser, Ph.D.
Jennifer Wolfe, MA
Meghan McCloe, BA
Natalie Gulau, BA
Andrew Clauw, BA
Emily Hogan
Funding:
National Institute of Mental Health
Bristol-Myers Squibb, Inc.
American Society of Regional Anesthesia & Pain Medicine
Metzger Family Foundation
University of Michigan, Department of Anesthesiology
Follow me:
@AftonHassett