Restorative Pain Medicine Physicians
Pain Medicine – Anesthesiology – Board Certified
It is not a surprise that such a sweet and loving boy was born on Valentine’s Day!
Because of his Havanese Heritage there was a wonderful Cuban lunch provided and we could not forget his own special Whipped Cream Cake.
5 solutions for living your best life.
The effective and safe treatment of chronic pain is on everyone’s radar.
The opioid epidemic, poorly covered pain treatment, and a lack of information are a triple threat for those living with chronic pain. Even practitioners, healthcare systems, and insurers are scrambling to find safe and effective ways to treat, manage, and reverse chronic pain.
Where do people who are suffering turn for safe and effective treatments to live a healthier life with less pain?
As global healthcare systems pivot toward a comprehensive (biopsychosocial) approach for pain, the spotlight is shining on psychological interventions. Cognitive and behavioral treatments have a long history of helping people cope with pain, and are supported by rigorous scientific testing.
Just as there is no single pharmacologic silver bullet for chronic pain, different psychological approaches for the treatment of pain have blossomed from the rich fields of psychology, physical therapy, and others. Five distinct cognitive-behavioral interventions are leading the pack and easing pain with safe, effective, and long-term solutions.
#1: Cognitive-Behavioral Therapy (CBT)
The grand poobah of psychological treatments for pain is cognitive-behavioral therapy (CBT). The primary aim of CBT is to help patients develop positive coping mechanisms for dealing with pain. A cognitive-behavioral approach targets distorted thoughts and pain beliefs and how they influence behavior. Dysfunctional thoughts are identified, challenged, and replaced with more helpful ones to support improved functioning and enhanced quality of life.
CBT is currently considered the gold-standard approach and has a deep history of randomized controlled trials and meta-analyses that consistently demonstrate positive outcomes. Traditional CBT protocols for pain may include:
The primary theoretical mechanism of action in CBT is proposed to be cognitive change, which is expected to lead to improvements in other symptoms via cascading effects. The most immediate focus of CBT is on symptom reduction—although improved functioning is also a long-term goal of treatment.
#2: Acceptance and Commitment Therapy (ACT)
Moving toward unpleasant sensations in the service of deeply held personal values may just be the way to move beyond pain. Acceptance and Commitment Therapy (ACT) is fast becoming a crowd favorite in many pain rehabilitation programs.
Riding high on the third wave of cognitive-behavioral therapies, ACT uses acceptance, mindfulness, commitment, and behavior change strategies to increase psychological flexibility. While traditional CBT zooms in on modifying distorted cognitions and beliefs, ACT works more through the modification of behavioral avoidance patterns rather than changing distorted cognitions.
ACT has two major goals. The first is to foster acceptance of unwanted private experiences that are out of one’s personal control, and the second is to facilitate commitment and action towards living a valued life. Acceptance is promoted instead of changing one’s inner experiences, clarifying personal values are used as a basis for motivating behavior, and cognitive defusion is employed versus cognitive restructuring.
With over 300 randomized controlled trials for mental and physical health conditions, and at least five meta-analyses supporting chronic pain, ACT is a crowd favorite. For many professionals, it is the treatment of choice when one is caught in a struggle with pain control and avoiding life. In many ways, ACT challenges conventional notions of pain management that focus on pain reduction and other “feel good” approaches.
#3: Pain Neuroscience Education (PNE)
Know pain, know gain! When it comes to pain, a fundamental part of coping is how much a person knows about pain.
Pioneered by physical therapists, and widely adopted by all licensed health professionals, pain neuroscience education (PNE) is an educational intervention that focuses on teaching people about the neurobiological and neurophysiological processes involved in the pain experience. Through metaphor, stories, and analogies, PNE simplifies complex topics and teaches people about pain physiology including:
A reconceptualization occurs through explaining pain, including the important distinction between acute pain (an indicator of tissue damage) versus chronic pain (a condition of the CNS and poorly related to tissue damage). This reconceptualization reduces the threat value of pain. People feel reassured and reengage with movement and activity without the fear of damaging their bodies.
The research supporting PNE is growing like wildfire with meta-analyses supporting its use to decrease pain, disability, fear-avoidance, pain catastrophization, limited movement, and health care utilization. In clinical trials, PNE is delivered in a single, two-hour session, and may require follow-up booster visits to reinforce learning. To fully optimize patient outcomes, PNE should be combined with exercise versus being used as a stand-alone intervention.
#4: Psychologically Informed Physical Therapy (PIPT)
The more the merrier—and perhaps the more effective for the treatment of pain. Psychologically Informed Physical Therapy (PIPT) is a term used to define a more comprehensive (biopsychosocial) approach by incorporating certain cognitive-behavioral principles into the practice of physical therapy.
The theory and research supporting PIPT are sound, and its practical application aligns well with a physical therapist’s mission to help improve patient outcomes and improve the quality of life. By including cognitive-behavioral techniques like reframing thoughts, mindfulness, breathwork, relaxation training, and positive coping skills, PTs are able to address both the physical and psychological factors of pain.
Additionally, the expectation is that physical therapists should be able to recognize pain that comes from psychosocial distress and to adjust their course of treatment accordingly. Physical therapists are not diagnosing or treating psychopathology. They are trained to recognize “orange flags” alerting the clinician to serious distress or potential psychopathology which requires referral to a skilled mental health provider.
PIPT intervention techniques included the following:
#5: Mindfulness-Based Stress Reduction (MBSR)
What do you get when you blend science, medicine, psychology, Buddhist meditative traditions, and gentle yoga? This winning combination has helped tens of thousands of people since its inception cope with both the physical and emotional experience of pain. Mindfulness-Based Stress Reduction (MBSR) is an eight-week program that teaches people better ways to manage stress and their experience of pain.
MBSR is typically delivered in a group setting led by an instructor and includes techniques such as:
Through mindfulness and meditation techniques MBSR helps people notice attitudes toward pain, with the end-goal of reframing pain as a distinctly transient event. MBSR has helped people who suffer from a variety of chronic pain syndromes, including irritable bowel syndrome, chronic low back pain, and fibromyalgia. Additionally, it also helps with overlapping conditions associated with pain, including depression, anxiety, and PTSD.
Which intervention is your favorite to use in practice? Do you rely on one or infuse bits and pieces of all of them into practice? Psychologically-informed methods provide a safe, effective, and more holistic way to help people who have been stuck in the vicious cycle of pain.
References
Keefe, F. J., Main, C. J., & George, S. Z. (2018). Advancing Psychologically Informed Practice for Patients With Persistent Musculoskeletal Pain: Promise, Pitfalls, and Solutions. Physical Therapy, 98(5), 398–407. doi:10.1093/ptj/pzy024
Richmond, H., Hall, A. M., Copsey, B., Hansen, Z., Williamson, E., Hoxey-Thomas, N., … Lamb, S. E. (2015). The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. PloS one, 10(8), e0134192. doi:10.1371/journal.pone.0134192
Godfrey E, Galea Holmes M, Wileman V, et al. Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomized controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain BMJ Open 2016;6:e011548. doi: 10.1136/bmjopen-2016-011548
Wood, L., & Hendrick, P. (2018). A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: short- and long-term outcomes of pain and disability. European Journal of Pain. doi:10.1002/ejp.1314
Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., … Maglione, M. A. (2017). Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 51(2), 199–213. doi:10.1007/s12160-016-9844-2
Slowing the downward spiral of pain catastrophizing.
For those who suffer from chronic pain, dealing with daily discomfort can be frustrating and exhausting. Beyond the physical discomfort, people also must cope with the complicated and equally exhausting psychological and emotional side of living with chronic pain. It’s not easy.
Many who live with chronic pain also struggle with the overwhelm caused by negative thoughts, also known as pain catastrophizing, a concept that comes packaged with a heated debate by many pain experts and people living with pain.
Why? Just the sound of the words “pain catastrophizing” is scary and may be perceived as judgmental by those living with pain, for good reason. I prefer the term negative thoughts or just negative thinking because we all have negative thoughts. It is part of being human, whether you have pain or not.
Catastrophizing is a concept developed in 1962 by physician Albert Ellis; pain catastrophizing was later refined by psychologist Michael Sullivan. It is a type of thinking in which people have persistent negative thoughts and emotional responses to persistent pain that interfere with daily function.
Negative thoughts related to pain develop from what I call the 3 “I”s of pain. These include thoughts that the pain may be:
This helps us notice that the experience of pain is much more complicated and layered than just the physical perception of pain. Negative thinking (pain catastrophizing), in addition to being associated with a physical disability, also impacts self-efficacy and the ability to function in social situations.
While negative thoughts related to pain are unique to the person living with pain here are a few common signs that negative thinking may be impacting the quality of life:
Here are some negative thoughts associated with persistent pain:
When people with pain struggle and are unable to find a qualified and compassionate practitioner who understands pain, it is normal for these thoughts to develop.
However, negative self-talk can have a profound impact on our physical and psychological health. It can affect you in some pretty damaging ways. Negative self-talk is linked to higher levels of stress and lower levels of self-esteem. This can lead to decreased motivation as well as greater feelings of helplessness. This is one of the reasons why the rates of depression, anxiety, and suicide are so high in those with persistent pain.
However, there is hope—as people begin to notice and acknowledge the way that pain manifests emotionally and psychologically they can begin to break free from the chains of negative thoughts.
#1 Cognitive Defusion
Acceptance and Commitment Therapy (ACT) is a type of therapy that focuses on willingly accepting some pain without judgment. However, the end goal of ACT is not simply to accept your situation —part of ACT is identifying values that align with your desires and goals for your life and committing to pursuing them. With regard to pain, ACT operates from the belief that in dealing with pain, the pain itself is not the source of suffering; instead, it is the psychosocial struggle of dealing with the pain that is the challenge.
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A central process in ACT is called cognitive defusion.
Cognitive defusion allows you to see thoughts as what they are, not as what they say they are. This means thoughts about pain does not have to take the wheel and control your life.
One of the simplest cognitive defusion techniques is simply to say “I’m having the thought that ______” when you notice negative thoughts arise about pain.
Some examples might include:
By placing “I’m having the thought that” in front of your thinking, it helps you create some space between the thoughts you have and the actions they sometimes dictate.
#2 Positive Self-Talk
There are lots of ways of slowing the waterfall of thoughts before they take you over the falls. Positive self-talk can help to change the narrative about yourself that has been building.
While ACT focuses on accepting pain, cognitive behavioral therapy (CBT) operates from the notion that our emotions and behavior are formed by our beliefs, thoughts, ideas, and attitudes. CBT for pain aims to reframe mental habits in order to provide relief and has been shown to be one of the most effective methods of treating pain catastrophizing.
If positive self-talk is like stepping foot into a foreign country without a map, you may need some help to get you going. It might be difficult to know where to begin in terms of effective positive statements and phrases to develop. It’s important to know that not everyone’s positive self-talk will be the same, and you should try a few different approaches to find the ones that ultimately work for you.
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Here are three positive self-talk statements regarding pain to get you started:
#3 Moving With Your Mind
This is one of my favorite techniques. It is beneficial for many people with pain, including those with fibromyalgia, chronic lower back pain, osteoarthritis, and rheumatoid arthritis.
As you rebuild your physical strength sometimes your mind will get a bit anxious and want to keep you safe from potential harm. The way it does that is constantly broadcasting doom and gloom or the worst-case scenario.
As a simple exercise, try this:
It may look like this:
Continue walking and notice if the thoughts subside.
You may be surprised how fast thoughts subside or change. They may even completely go away or morph into other related or unrelated thoughts.
This is a simple way to address the mind-body connection. Physical therapy exercises supplement CBT nicely, including the fact that exercising without disastrous consequences improves one’s self-confidence and decreases pain-related anxiety and fear. Cognitive-behavioral techniques combined with physical therapy have some of the best evidence to help you overcome pain and live life to the fullest!
References
Schütze, R., Rees, C., Smith, A., Slater, H., Campbell, J. M., & O’Sullivan, P. (2018). How Can We Best Reduce Pain Catastrophizing in Adults With Chronic Noncancer Pain? A Systematic Review and Meta-Analysis. The Journal of Pain, 19(3), 233–256. doi:10.1016/j.jpain.2017.09.010.Morereferences
About the Author
Restorative Pain Medicine Physicians 