Ronald J. Kulich, Ph.D.Professor, Tufts University

Lecturer, Harvard Medical School, Department of Anesthesia, Pain

Medicine and Critical CareMassachusetts General Hospital

History: Functional Restoration, Operant and Classical Conditioning in Clinical Pain Rehabilitation

Reissued 2014

Classical Conditioning

CS

UCS

UCR

SalivationFear

Autonomic ArousalEscape

FoodPain

Nausea

BellWork Tasks

WalkingBoss

Permanent Changes?

Operant Conditioning

Edward L. Thorndike

(1874-1949) B.F. Skinner

(1904-1990)

Behavior Consequence+R

TimeInjury

Tx

Tx

Tx

TxTx

TxTx

Tx Tx

Tx

Tx

Tx

Tx

TxTx TxTx Tx

Tx

Tx

Figure 1

Initial Development of Chronic Pain with Pain Contingent Activity

PainActivity

Tx Multiple treatmentsKulich & Gottlieb, 1985Stone & Kulich, 2015

Time

reduced activity

Tx

Tx

Tx

Tx

TxTx

TxTx

Tx

Tx

Tx

TxTx

Tx

Tx

Tx

TxTx

Tx

pain-based

activity

Figure 2

Development of Disability with Chronic Pain

PainActivity

Tx Multiple treatmentsKulich & Gottlieb, 1985Stone & Kulich, 2015

Functional Restoration & Operant TX (Fordyce, 1967,1968; Mayer, 1987, 1988)

Time limited Group based Highly selective Focus on function v. pain Targets RTW Focuses on perception of

ability Uses quota-based exercise Outpatient

Fordyce, 1976

Fordyce, 1976

Operant Pain Rehab History

70s “Operant” Fordyce 80s “Functional Restoration: Mayer Late 80s “Work Hardening” Mathieson 80s-90s Interdisciplinary Pain Management

and Faux Functional Restoration Early 90s Inpatients Units Closed, then

Outpatient Programs Closed 2012 Structured programs reemerge in

Colorado, Holland

Clinician Beliefs: Who makes patients disabled?

Lotters et al 2011, Occup. Rehab regardless of the severity of the pain disorder,

merely visiting a subspecialist was associated with a failure to fully return to work.

Who makes patients disabled?

Differentiated between physical therapists on their biomedical vs biopsychosocial orientations towards non-specific back pain.

Therapists with biomedical orientation viewed daily activities as more harmful for the back of a LBP patient

Consistent with van der Windt D, Hay E, Jellema P, et al. 2008 on PT training with chronic pain population

Houben et al. European J. Pain (2005)

Exercise, chronic pain and other variables

There appears to be little or no relationship between improved physical functioning & performance and measures of mobility, trunk extension, trunk flexion strength, and other related variables.

Psychologists fail as well

Few current “behavioral” treatment models address objective function or employ operant principles

Preliminary data from Jackson & colleagues show <5% of 76 “mindfulness” chronic pain studies employed objective measures of physical functioning

A return to time limited, quota-based exercise?

Exercise & Pain

“…exercise should be a core treatment ... irrespective of age, comorbidity, pain severity and disability. Exercise should include: local muscle strengthening [and] general aerobic fitness.”

(National Institute for Health and Care Excellence (NICE) 2014; Geneen L, Smith B, Clarke C, Martin D, Colvin LA, Moore RA, 2014; Wieland, 2013, Busch, 2013).

Quota-Based Exercise vs Symptom Contingent “Pacing”

“Compared graded exercise therapy (GET), in which patients gradually increase the length or intensity of a set of exercises; adaptive pacing therapy (APT), a strategy to set modest exercise goals but to stay within an maximum “envelope” of exertion defined by the illness; and cognitive behavioural therapy (CBT), which aims to identify and adjust the thought processes that lead to unhelpful behaviours.”

Adapted pacing therapy added nothing to physical function scores White et al., 2011, The Lancet

Jan 17, 2015

Screening: Who is Appropriate? No medical contraindications for a progressive, quota-based

exercise Objective, realistic “micro” and “macro: functional goals No severe psychiatric disorder: Substance abuse, cognitive

deficits Somatic focus, fear avoidance, and pain contingent activity is

present Depression, anxiety, and “unhappy” with current status Acceptance of the concept that pain relief will not be targeted Acceptance of a diagnostic and pain amelioration endpoint Non-solicitous family or option of family intervention Absence of significant financial support for disability Co-treating clinician cooperation Opioids and other controlled substances ?

The “Functional Restoration” Program Objective “Micro/Macro” Goals, excluding Pain

Relief Identify Overt and Covert Pain Behaviors Identify “Well” behaviors Identify Reinforcers Address Barriers, e.g., Fear-avoidance, belief about

opioids, solicitious family, sabotaging clinicians, “hurt versus harm”

High frequency continues +R to intermitant +R Digital monitoring/self-monitoring, structured

visits, social reinforcement Consistent Communication + Treatment Agreement

Identifying Pain Behaviors Complains of pain Grimacing, limping Maladaptive thoughts, e.g., ruminations about injury,

pathophysiology, “correct” posture Use of cane, braces, TENS units Pain contingent medication use Pain contingent physician visits Pain contingent passive treatments, e.g. massage, rest,

ice, meditation Pain severity & symptom monitoring “Pacing” to eliminate “flares”

Biological Serious pathology Medical & Psychiatric co-

morbidity

Personal and environmentalFactors (Psychosocial)

Orange flags Yellow flags

• Depression • PTSD• Somatoform Disorder/# sites

Avoidant coping strategies Emotional distress Passive role

Blueflags

Perceived low social support at wk

Perceived unpleasant work

Low job satisfaction Perception of excessive

demands

Environmental (systemic)

Black flags

Legislative criteria for compensation

Nature of workplace (eg. heavy work)

Threats to financial security

Red flags

Chronic Pain and Disability “Flags”adapted from Main et al 2008 ; Stone & Kulich, 2016

Pharmacotherapy & Operant TxCan they mix?

The pattern of medication use or other “pain relief” interventions are subject to the same operant principles

Physicians reported increases and decreases in function to be the most important measure of success with chronic opioid therapy

…while objective functional gains for COT remain elusive N = 82 PCPs, 65 Pain Specialists

Nishimori, Kulich, Carwood, Okoye, Kalso, & Ballantyne (2006)

Examples: Realistic Goals w/ Fixed Dates Increase function, e.g., walk 30 minute to grocery

store by May 20, sit through movie with wife by May 30, lift 30 pound grandchild by May 15

Improve mood and sleep habits, e.g. 10 point change in CES-D, utilize 4 sleep hygiene skills

Reduce medical visit frequency, e.g., PCP visit 1x per mo., ortho 1x per year

Reduce/eliminate inappropriate medications, (specific medications and dates)

Improve relaxation/mindfulness skills Return to volunteering by June 15

Is a Work Goal Realistic?Job & Supervisor Satisfaction?

Job Satisfaction Predicts Injury(Bigos et al., 1991)

3000 Aircraft Employees over 4 years The Item: “I hardly enjoy tasks involved in

my job.” “Yes” predicts 2.5 x more likely to incur a

back injury Consistent with Frymoyer’s later data on

reinjury after discectomy

Operant/Functional Restoration Program Sample Treatment Plan and Agreement

  Congratulations on your enrolment in the Functional

Restoration Program. The program is designed for individuals suffering from chronic pain who desire to return to normal levels of physical functioning in all area of life. Similar selective programs have shown great success with motivated individuals who often have tried a long history of other pain treatments, physical therapy and other rehabilitation efforts in the past. Rather than attempting to eliminate pain or providing additional diagnostic tests, the program is designed to assist you in improving overall function and developing the best quality of life despite pain. Our team works closely with you to achieve these goals.

agreement cont’d The first step involves determining your specific goals that can

be achieved over a 6-8 week period. (See Sample Goal List). After review with your clinician, these goals include:

 Goal Date

1  Walk to corner store (20 minutes) Exercycle (30 Minutes)

 May 1

2  Lift Grandchild (20 pounds) Free weights floor to weights (40 pounds)

 June 1

3  Improve sleep habits Improve Mood (CES-D)

 May 10

4  Out to movies with wife (3x) Volunteer work contact + Visit with Mass Rehab Commission

 June 1

5  Eliminate cane Establish follow-up “crisis” plan

 April 22

agreement cont’d Achieving Your Goals: We know that goals change. With

respect to your exercises or other quality of life goals, we do occasionally adjust these goals in an individual bases, while goals are not changed or adjustment on more than one occasion in the program in order to better insure a clear pain of success. Goals and the components of your program are closely viewed by each clinician on several occasions throughout the day.

Schedule: The program is scheduled 2 days per week for approximately 3-4 hours per day . You are expected to attend all sessions, regardless of pain. Given the program’s intensity and goals you have target, absence from two sessions results in discharge.

agreement cont’d Other Treatments: One goal of the program is aimed toward

minimizing unnecessary medical visits. During the period of the program, all participants are asked to end other pain and physical therapy related treatments.

Medication: You are expected to continue on a stable of “fixed” dose of their medications during the program. The medication plan of care is outlined at the beginning of the program by your physician. These include:

 Medication Dose Prescribed by

1 clonazepam.5  2x per day Jones-PCP2  oxycodone 5mg 3x per day  BPCC3  gabapentin 600 mg 3x per day  BPCC4 fluoxetine 20mg  1x per day  Smith-Psychiatry

agreement cont’d Pain Behavior commonly occurs with individuals who have

persistent pain over many months or years. This can be observed by others around you. Other “covert” behaviors include thoughts about your pain that may get in your way of improved functioning. “Well behavior,” physical capacity and improved coping skills are intended to reduce pain behavior. Current pain behaviors discussed by you and your clinician include:

 Pain Behaviors

1  Use of the case2  Limping, grimacing3  Increasing oxycodone4 As-needed use of ice 5  Use of back brace

Solicitious Behavior

Family members are often important supports for helping you return to functioning. In some cases, it’s helpful to have them observe your exercise effort and plan other family events together: “My family member interested in participating is….” _________________________

TimeInjury

Tx

Tx

Tx

TxTx

TxTx

Tx Tx

Tx

Tx

Tx

Tx

TxTx TxTx Tx

Tx

Tx

Figure 1

Initial Development of Chronic Pain with Pain Contingent Activity

PainActivity

Tx Multiple treatmentsStone & Kulich, 2015

Time

reduced activity

Tx

Tx

Tx

Tx

TxTx

TxTx

Tx

Tx

Tx

TxTx

Tx

Tx

Tx

TxTx

Tx

quota-based activity increase

Figure 2

Development of Disability with Chronic Pain and Introduction of Quota-based Activity

PainActivityQuota-based activity

Tx Multiple treatmentsStone & Kulich, 2015

Time

reduced activity

Tx

Tx

Tx

Tx

TxTx

TxTx

Tx

Tx

Tx

TxTx

Tx

Tx

Tx

TxTx

Tx

pain-based

activity

Figure 2

Development of Disability with Chronic Pain

PainActivity

Tx Multiple treatmentsStone & Kulich, 2015

Time

reduced activity

TxTx Tx

quota-based activity increase

Figure 3

Development of Disability with Chronic Pain and Introduction of Quota-based Activity

PainActivityQuota-based activity

Tx Fixed treatments

Walk

ing t

o the

groc

ery s

tore

Bowlin

g 20

min

utes

Kulich & Backstrom, in press

Electronic Activity Trackers Glorified pedometers “Use of pedometer is

associated with significant increase in physical activity and decrease in body mass index and blood pressure.”

10-15% error, FitBit 10.1% error

“the widespread integration of this technology into medical practice remains limited.”(Appleboom, 2014)

• Bravata DM, Smith-Spangler C, Sundaram V, et al. Using Pedometers to Increase Physical Activity and Improve Health: A Systematic Review. JAMA. 2007;298(19):2296-2304. doi:10.1001/jama.298.19.2296.

• Appelboom et al.: Smart wearable body sensors for patient self-assessment and monitoring. Archives of Public Health 2014 72:28

Kulich RJ, Berna C, Backstrom J, Mao J. APS 2015

Kulich RJ, Berna C, Backstrom J, Mao J. APS 2015

The early history of aggressive operant approaches

Silas Weir Mitchell (1874) offered a treatise on “a lad of 16, who, while oppressed under certain family troubles, still contrived to lead his class… (Then) the headache came on…within a week so severe as to prevent all study….”

…the pain was absent, or rare, as long as he rode on horseback, or idled at the seashore, but the slightest methodological use of his brain caused him hours of pain.”

Describing a tenderness of the scalp and occipital area pain with increasingly diffuse pain, Mitchell also noted that the patient became progressively irritable and depressed as his pain persisted.

He diagnosed that patient as having headache “from over use of brain.” (Mitchell, 1874).

Mitchell suggested that the patient assume “a semi-barbarous life,” shelving all academic interest, and returning to “camp life…as an incomparable means of cure.” He essentially instituted an intensive, quota-based exercise regimen.

In commenting on causation for these stress induced physical maladies, the Boston Medical and Surgical Journal (1853) editorial noted that “many a bright young fellow is broken down by being over-wrought.” by their studies.

Follow-up

Post Treatment Assessment FU Assessment FU Crisis Protocol for Relapse Work, Avocational, Independent Exercise Family +R well behavior FU Treatment Protocol

Individual non-prn visits PCP + Managed Subspecialists The correct S. Groups, Relapse Groups