Passive vs. Active Engagement in Chronic Pain Management

Daniel Duhigg, DO, MBAMedical Director for Addiction Services, Presbyterian Health Services

Clinical Associate Professor, Dept of Psychiatry & Behavioral Sciences, UNM

Learning objectives

1. Differentiate active and passive coping strategies in chronic pain

2. Be familiar with clinical tools used to evaluate passive coping strategies in chronic pain

3. Be familiar with the ingredients of cognitive behavioral therapies for chronic pain

4. Be familiar with the ingredients of acceptance and commitment therapy for chronic pain

The most important

determinant of suffering with chronic pain is how one copes

"Despair" Alex Grey

Definitions

• Active: engaging or ready to engage in physically energetic pursuits.

Synonyms: energetic, lively, sprightly, spry, mobile, vigorous, vital, dynamic, sporty

• Passive: accepting or allowing what happens or what others do, without active response

Synonyms: submissive, acquiescent, unresisting, unassertive, compliant, pliant, obedient, docile, tractable, malleable, pliable

Latin pass- (from pati) means "suffer"

Definitions in chronic pain management

• Active coping: using an internal locus of control to engage in (mostly) physically energetic pursuits in order to improve/sustain function, despite living with chronic pain

• Passive coping: expending (mostly) emotional energy focused on suffering and an external locus of control in response to living with chronic pain

Active vs. Passive Copingin the literature

Passive Coping Active Coping

Less likely to improve function

More likely to improve function

Associated with worse pain intensity

Associated with less pain intensity

Associated with higher levels of psychological distress and

depression

Associated with lower levels of psychological distress and

depression

Covic, et al. Rheumatology, 2000;39(9):1027-1030

Snow-Turek, et al. Pain, 1996;64:455-462

Executive summary

Passive Coping Active Coping

Restricting or cancelling social activities

Engaging in physical exercise or physical therapy

Thinking "I can't do anything to lessen this pain."

Staying busy or active

Focusing on where the pain is and how much it hurts

Participating in leisure activities

Praying for reliefClearing your mind of bothersome

thoughts or worries

Relying on procedures to fix the pain

Engaging in self care

TOOL: Vanderbilt Pain Management Inventory18-item questionnaireGood validity, even in patients with comorbid depression

Examples of passive vs. active coping

Snow-Turek, et al. Pain, 1996;64:455-462

Vanderbilt Pain Management Inventory

Esteve, et al. Psychology in Spain, 2005;9(1):49-56

Passive Strategies

Catastrophizing

Highly associated with negative mood, higher pain intensity, and impairment

Highly associated with negative mood, higher pain intensity, and impairment

Inversely associated with negative mood, higher pain intensity, and impairment

Active Strategies

Catastrophizing: it's the worst!• Assuming catastrophic implications of painful

sensations

• Sub-category of passive coping

• Predicts a poor prognosis in chronic pain management!!

• Degree of catastrophizing associated with:

Pain intensity

Disability

Employment status

Forsythe, et al. Pain Research and Management, 2008;13:335-341

Sullivan et al. Pain, 1998;77:253-260

Keefe, et al. Pain, 2000;87;325-334

TOOLS: Pain Catastrophizing Scale, STarT Back Screening Tool

Pain Catastrophizing Scale• Study sample of n=851

(51%/49% M/F)

• Of those who scored above 30:

• 70% remained unemployed 1 year post injury

• 70% describe themselves as totally occupationally disabled

• 66% have moderate depression

Sullivan, et al. Psychological assessments, 1995;7:524-532

Empathy differs from sympathy

Sullivan M, PCS user manual, McGill University

Catastrophizing is modafiable

• Multiple studies show reductions in catastrophizing in programs focused on functional recovery and adaptation to pain

• These programs typically incorporate:

• Education (reduce the perception of threat from the condition)

• Activity resumption (normalize aches, increase function)

• Instruction in self management skills (increase self-efficacy, reduce helplessness)

Sullivan M, PCS user manual, McGill University

Progressive Goal

Attainment Program

(PGAP)

• Program created to reduce disability

• For those absent from work greater than 6 months: PGAP resulted 62% returning to work

• For those absent from work 3- 6 months: PGAP resulted 78% returning to work

PGAP Curriculum:

Session # Content

1 Establish relationship, intro to model

2Intro to activity planning, re-establishing Pre-injury

activity structure and walking routine

3Goal setting, planning activity involvement in

relation to goals

4 Techniques targeting disability beliefs

5Into to thought monitoring to target catastrophic

thinking

6Exposure techniques to facilitate engagement in

previous activities

7 Continued application of techniques from #s 5 & 6

8Applying task-decomposition techniques to feared

activities of the workplace

9 Final evaluationSullivan & Adams, Physiotherapy Canada, 2010;62(3):180-189

STarT Back Screening Tool

• Matched treatments:

• Low risk: encourage activity and self-management, Avoid medicalization and labels

• Medium risk: Brief course of PT based on physical findings, focus on general functional activities, refer up only of needed

• High risk: 6 sessions of PT using a combined physical and CBT approach, specific focus on cognitive, emotional and behavioral responses to pain and their impact on function

Hill C, et al. The Lancet, 2011;378(9802):1560-1571

Total score 3 or less: low risk for disabilityScore 3 or less from Q5-9: medium risk for disabilityScore 4 or more from Q5-9: high risk for disability

For Low Back Pain

Keele University

CBT approach in Chronic Pain• Components:

• Collaborative

• Problem-oriented

• Skill acquisition and practice, in clinic and at home

• Encourages expression, then control of maladaptive thoughts and behaviors

• Addresses the relationship between thoughts, feelings, physiology, and behavior

• Fundamentals:

• Goal is to adopt a self-management approach

• Behavioral activation

• Time-based pacing

• Relaxation/stress reduction skills training

• Problem solving skills training

• Cognitive restructuring

Jensen, et al. Journal of pain, 2003;4(9):477-492

Example of CBT for painSession # Content

1 Rationale for treatment

2 Theories of pain, breathing

3 Progressive muscle relaxation, Visual imagery

4 Cognitive errors

5 Cognitive restructuring

6 Stress management

7 Time-based activity pacing

8 Pleasant activity scheduling

Robert Kerns, PhD, National program director for pain management, Veterans Health Administration

CBT vs. Back Surgery

• RCT of lumbar spinal fusion vs. CBT in 64 patients with documented disc pathology at L4/L5 and/or L5/S1

• Inclusion criteria: spondylosis, pain greater than 1 year, ages 25-60

Brox, et al. Spine, 2003;28:1913-1921

Study #1

Sarindam7 at en.wikipedia

CBT vs. Back Surgery

• CBT intervention: 1 week in clinic, 2 weeks at home, then 2 more weeks in clinic (average 25 hours per week)

• Content:

1) a lecture on pain receptors in the discs, facet joints and muscles; reflexive interplay

between structures; ability to suppress and reinforce peripheral stimuli; an explanation

that the disc/back can not be harmed by performing normal ADLs; instructions to use and

bend their backs, and not be overly careful;

2) fear of exercise and activity was challenged daily;

3) lessons in lifting ergonomics;

4) individualized exercise regimen and individualized rehabilitation goals defined;

5) 3 workouts daily (aerobics, water gymnastics, individual work out);

6) group and peer discussions

Brox, et al. Spine, 2003;28:1913-1921

Study #1

CBT vs. Back Surgery

• Surgical intervention: posterolateral fusion with transpedicular screws at L4/L5 and/or L5/S1

Brox, et al. Spine, 2003;28:1913-1921

Study #1

CBT vs. Back Surgery

• Pre-study belief that surgery was better than non-surgery: twice as likely in both groups

• At 3 mo, 6 mo, and 1 year: no differences between groups in pain, medication use,or employment.

• CBT group has significantly less fear-avoidance behaviors

Brox, et al. Spine, 2003;28:1913-1921

Study #

Sarindam7 at en.wikipedia

1

CBT vs. Back Surgery

• RCT of lumbar spinal fusion vs. CBT in patients with a prior history of surgical repair of disc herniation

• CBT and surgical intervention identical to study #1

• Only subject difference between studies is the history of prior surgery

Brox, et al. Pain, 2006;122:145-155

Study # 2

Wait: Why do they need another surgery?

• Adjacent Segment Degeneration

1996 2005

Levin, et al. Bull NYUH Joint Dis, 2007;65(1):29-36

Narrowed disc space, osteophyte complex,

anterior spondylolisthesis

CBT vs. Back Surgery

• Outcome variables included: overall function, fear-avoidance with physical activity and work, back pain, emotional distress, medication use, lower limb pain, full-time employment, fingertip-floor distance

• CBT group: improved in all areas except pain, emotional distress, employment

• Surgical group: improved only in back pain

Brox, et al. Pain, 2006;122:145-155

Study #2

CBT vs. Back Surgery

Brox, et al. Pain, 2006;122:145-155

Study #2

*2 subjects in this group had back surgery in the 1 year of follow up

*

Acceptance & Commitment Therapy: an alternative to CBT

• Targets ineffective control strategies and experiential avoidance by fostering psychological flexibility

• 6 core processes:

• Acceptance (embrace pain rather than futilely try to avoid/eliminate it)

• Cognitive diffusion (modify function of thoughts, rather than their content or frequency)

• Being present & Self as context (non-judgmental interaction between the self and private thoughts and events)

• Values (values used as guides for choosing behaviors and interpretations)

• Committed action (realize behavior changes consistent with valued living)

Roditi & Robinson, Psychology research and behavior management, 2011;4:41-49

Acceptance and Commitment Therapy outcomes in Chronic Pain

• RCT of ACT vs wait-list: significant improvements in pain Catastrophizing, pain-related disability, life satisfaction, fear of movement, & psychological distress

• Another RCT of ACT: improvements in depression, pain-related anxiety, disability, medical visits, work status, & physical performance

Roditi & Robinson, Psychology research and behavior management, 2011;4:41-49

Conclusions

• Addressing Catastrophizing may be the most important intervention that you have to improve a patient's quality of life

• Showing empathy is helpful, but over-emphasizing the difficulty of a patient's situation may inadvertently harm them

• Focusing on returning to normal function over all other concerns predicts improvements in quality of life

Thank you.

Daniel Duhigg, DO, MBAMedical Director for Addiction Services, Presbyterian Health Services

Clinical Associate Professor, Dept of Psychiatry & Behavioral Sciences, UNM