Objectives Significant Costs Of Chronic Pain Pain Catastrophizing

Effectiveness of a Comprehensive
Pain Rehabilitation Program
in the Reduction of Pain
Catastrophizing
Michele Evans, MS, APRN-C, CNS,
March 27, 2007
Objectives
• Define the concept of pain catastrophizing
• Review the research on pain
catastrophizing and its impact on chronic
pain
• Describe how cognitive behavioral
treatment within a pain rehabilitation
program can improve functionality while
reducing pain catastrophizing
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Significant Costs Of Chronic
Pain
• Chronic pain affects 30 to 70 million
Americans
• 20 to 50 million partially or totally disabled
• 80 to 100 million lost work days/year
• $80 billion/year medical care for chronic pain
Pain Catastrophizing
• Sullivan (1995) proposed that
catastrophizers experience difficulty
controlling pain related thoughts
• Catastrophizing- a psychological construct
incorporating elements of rumination,
magnification and helplessness in regards
to pain
Pain Catastrophizing
• Described as an “exaggerated negative
‘mental set’ associated with actual or
anticipated pain experiences”
• Important predictor of functional outcomes
with chronic pain
Pain Catastrophizing
• Elements include:
– Rumination- “I can’t stop thinking about the
pain”
– Magnification- “I worry they’ve missed
something serious”
– Helplessness- “There’s nothing I can do”
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Pain Catastrophizing Scale
(PCS)
• Developed by Sullivan (1995) to:
Pain Catastrophizing Scale
(PCS)
– measure pain catastrophizing
– better understand the mechanism by which
catastrophizing impacts the experience of
pain
• 13 item instrument (< 5 minutes)
• Requires 6th grade reading level
• Asks participants to reflect on “past painful
experiences”
• Each question uses a 5 point Likert scale
(O= not at all, 4=all the time)
PCS Assessment
PCS Assessment
• Yields a total score and a score on each
of the three subscales
(rumination/magnification/helplessness)
• Excellent internal consistency
• Coefficient alphas:
– Total= 0.87
– Rumination= 0.87
– Magnification= 0.66
– Helplessness= 0.78
PCS Assessment
• Yields a score=sum of the 13 items
– Range 0-52
• Clinically relevant if the score is>38
– >38 corresponds to the 75th % of clinic sample
Why is measuring pain
catastrophizing important?
• Research has linked high scores on the
PCS to:
– Greater pain intensity
– Increased perceived disability
– Increased occupational impairment
– Greater emotional distress
– Increased medication use
– Greater use of health care services
• Catastrophizing may interfere with the
efficacy of treatment strategies including
coping strategies
• Catastrophizing is even an important
variable in research in pain-free subjects
undergoing experimental pain tasks
2
Despite this, there is minimal
research on effective
interventions to decrease pain
catastrophizing
Does pain rehabilitation
reduce pain catastrophizing?
Chronic Pain Rehabilitation
Overview
Chronic Pain Rehabilitation
Overview
• Multidisciplinary, multimodal
therapies
• Rehabilitation rather than relief
• Establish expectations
• Limited medical evaluation
•
•
•
•
•
Pain Rehabilitation Center
• Comprehensive Multidisciplinary Approach
– MD
– RN/Case Manager
– CNS
– Psychologist
– Physical Therapy
– Occupational Therapy
– Pharmacist
Limited treatment of nociception
Improve functional status
Reduce behavioral morbidity
Address psychiatric co-morbidity
Improved quality of life
Who are our Patients?
•
•
•
•
•
•
•
400 Patients per year (approximate)
62% Married
83% Midwest area residents
73% Female
Mean age = 45 years
Duration of pain = 8 years
Years of education = 14 years
3
Cognitive Behavioral Model
Thinking
“Hope does not lie in a way
out but in a way through”
Robert Frost
Behavior
Feeling
Process of Change
Key Educational Concepts
• Interventions focus not only on improving
physical functioning but also on shifting
expectations of and reactions to their
chronic pain
• Interventions target catastrophic thoughts
with both education and actual experience
• Differences between acute pain and chronic
pain (to reduce beliefs about pain as a signal
of harm/damage)
• Information regarding pathophysiology of
chronic pain including sensitization of pain
pathways
• Discussion regarding interplay between
physiologic and emotional events
Key Educational Concepts
• Role of pain behaviors in heightening the
pain experience
• Limited effectiveness of narcotics and other
analgesics in treating chronic pain
• Information regarding opioid-induced
hyperalgesia
• Specific planning for management of a
difficult day
Increased Activity Involvement
• Steady exposure to safe exercise helps
overcome fears regarding injury, increased pain
• Emphasis on consistency in activity level despite
pain levels
• Importance of graduated and paced activity
• Energy saving techniques and proper body
mechanics
• Incorporation of regular fitness activity posttreatment
4
Cognitive and Emotional
Change
• Group environment reduces sense of
isolation
• Structured goal setting improves self
action and mastery
• Communication sessions for improved
emotional coping
• Reduction of pain behaviors as
communication
Cognitive and Emotional
Change (cont)
• Restructuring of specific catastrophic
thoughts and fears
• Skill practice in monitoring/modifying
self-defeating thoughts
• Family support group session
Additional Self-Management
Strategies
•
•
•
•
•
•
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Socialization
Moderation
Relaxation and biofeedback
Relapse prevention
Decrease dependence on health care system
Yoga
Diversional strategies for reducing attention to
physical sensations
Does pain rehabilitation
actually reduce pain
catastrophizing?
Methods
Methods
Outcome Measures
• Subjects consisted of 1182 consecutive
patients admitted to the Mayo
Comprehensive Pain Rehabilitation Center
beginning August 2003
• Demographics
– Female 75%
– Married 63%
– High school graduates 93%
– Duration of pain: mean of 9.4 years
•
•
•
•
Pain Catastrophizing Scale
CES-D
Pain Anxiety Symptom Scale
Multidimensional Pain Inventory
5
Outcome Measures
• Pain severity—Multidimensional Pain
Inventor
– Widely used measure of psychosocial
functioning in chronic pain
– Kerns, Turk and Rudy 1985
– Raw scores are transformed to standardized
scores
Outcome Measures
• Centers for Epidemiologic StudiesDepression (CES-D) scale
– Measures the presence and severity of
depressive symptoms
• Radloff 1977
• Scores ranger from 0 to 60, with higher scores
indicating more pronounced depressive
symptomatology
• Standard cutoff of >16 =acutely depressed
outpatients, >20= requires intervention
Outcome Measures
• Pain-Related Anxiety—Pain Anxiety
Symptom Scale (PASS-20)
– McCracken et al 1992
– Good reliability and validity
– Patients with high PASS scores tend to avoid
potentially painful physical exertion to reduce
their fears
Results
Results
Differences upon Admission to the Pain Rehabilitation
Center
Based on Pain Catastrophizing Scores
60
*p<.001
*p<.01
50
*p<.001
40
*p<.001
30
20
10
0
Pain Severity
(MPI)
Depression
(CES-D)
Pain Anxiety
(PASS)
Means
PCS >= 75th%ile
PCS < 75th%ile
Using Opioids
(%)
– Group differences in pain severity,
depression, Pain-related anxiety, and opioid
use on admission based on PCS scores
– Patients with clinically significant PCS scores
at admission reported greater pain severity,
depression, pain-related anxiety, and greater
likelihood of using daily opioids than those
with low or moderate scores.
6
Results
Treatment Outcomes Following Pain Rehabilitation
*ES = 1.1, p<.001
50
*ES = .80, p<.001
45
40
35
30
*ES = 1.2, p<.001
*ES = .98, p<.001
25
20
15
– Upon completion of the 3 week program,
patients reported significant decreases in pain
catastrophizing, pain severity, depression,
and pain-related anxiety
10
5
0
Catastrophizing (PCS)
Pain Severity (MPI)
Depression (CES-D)
Pain Anxiety (PASS)
*ES = Effect Size
(Cohen's d)
Means
Before Rehabilitation
After Rehabilitation
Results
Percent of Patients with Clinically Significant
Pain Catastrophizing Before Rehabilitation
Low PCS (0 to 49th%ile)
32%
High PCS (≥75th%ile)
42%
Moderate PCS (50th% to
74th%)
26%
– At admission a large percent of patients
(42%) reported clinically significant pain
catastrophizing (> 75th percentile)
– Over one-quarter of the patients
demonstrated moderate levels of pain
catastrophizing
Results
Percent of Patients with Clinically Significant
Pain Catastrophizing After Rehabilitation
High PCS
(≥75th%ile)
6.0%
Moderate PCS
(50th% to 74th%)
12.5%
Low PCS (0 to
49th%ile)
81.5%
– Upon completion of the program, patients
reported significant decreases in pain
catastrophizing with only 6.0% reported
clinically significant pain catastrophizing
– Upon completion of the program, the majority
of patients (81.5%) reported low levels of pain
catastrophizing.
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Conclusions
• At admission patients with clinically
significant pain catastrophizing also
reported greater pain severity, depression,
pain-related anxiety and were more likely
to be using opioid medication for their pain
than patients with lower pain
catastrophizing
Conclusions
• These findings support the feasibility and
effectiveness of a pain rehabilitation
program that incorporates a cognitive
behavioral model to decreased pain
catastrophizing and promote utilization of
adaptive coping strategies
References
• Radloff, L. S. (1977). The CES-D Scale: A selfreport depression scale for research in the
general population. Journal of Applied
Psychological Measures, 1(3), 385-401
• Rome, J.D. Editor in Chief (2002). Mayo Clinic
on Chronic Pain (2nd Ed) Contributing Medical
Editors: Hodgson, J., Luedtke, C., Kensington
Publishing Corporation, New York, NY.
Conclusions
• Upon completion of a pain rehabilitation
program, patients demonstrated a
significant reduction in pain
catastrophizing
References
• Kerns, R.D, Turk, D.C., Rudy, T.E. (1985) The
West Haven-Yale Multidimensional Pain
Inventory, Pain, 23, 345-356
• McCracken, L.M., Zayfert, C., Gross, R.T. (1992)
The Pain Anxiety Symptom Scale: Development
and validation of a scale to measure fear of pain,
Pain, 50 (1), 67-73
References
• Sullivan, M.J.L, Bishop, S. and Pivik, J., The
Pain Catastrophizing Scale: Development and
validation, Psychological Assessment, 7, (1995)
524-532
• Turk, D.C. & Gatchel, R.J. (2002). Psychological
Approaches to Pain Management. Guilford
Publications, Inc., New York, NY.
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