1 Advances in Cognitive- Behavioral Therapy for Pain: 3 steps forward Steven J. Linton Professor of Clinical Psychology Örebro University SWEDEN Oulu Finland, April, 2014
3 Örebro University
4 Örebro Castle
5 AIMS Examine the effects of CBT Explore 3 advances in recent years Early detection and interventions New approaches Exposure, endurance, acceptance Addressing co-occurring problems E.g. insomnia/depression and pain
6 CBT treatments 4 Basic elements Operant graded activity Time-contingent medication use Activity pacing Coping strategies e.g. relaxation Gatzounis et al, 2012
7 However! Great diversity Many settings Different professionals Aimed at many different variables Often combined with other modalities Makes empirical evaluation difficult
8 REVIEW YEAR CONCLUSION Linton 1982 Approach is promising Flor,FydrichTurk 1992 effect on variety of outcomes Ostelo, van Tulder, Vlaeyen, Linton et al seems effective CBT & relaxation>wlc; BT=exercise CBT>WLC; BT>TAU on short term,no long term consistency Eccelston, Williams, Morley Kerns, Sellinger & Goodin CBT has a small effect (ES about.25) 2011 Promising, but much work to be done!
9 The Way Forward
10 Early Interventions?
11 2. The Screen Örebro Musculoskeletal Pain Screening Questionnaire 25 items/long, 10 items/short Psychosocial focus Identifies >80% who risk sickleave 0-10 response scales Better than clinical judgments! 5-10/2-3 minutes to complete <2 minutes to score
12 Example: Cognitive-behavioral group therapy risk Six 2 hr sessions Program focuses on psychological risk factors in ÖMPSQ Trained behavior therapist Goal: develop your own coping program Part of a primary care intervention
13 Percent long-term sickleave % 6 4 Decreased risk! CBT Usual+info 2 0 Base 1yr 5yr Linton & Nordin, Spine, 2006
14 Approach with subgrouping Startback tool: Keele Univ. (UK) 9 items (8=yes/no) Subgrouping by level of risk Low, medium and high Used to allocate amount of treatment Large trial N=851 Stratified or Treatment as usual
15 Results of Startback trial Low risk group = No advantage of more treatment; guidelines best! Medium= S better than usual care High= longer care NS better Some other advantages CONCLUSION: targeted was effective mainly because low risk is not overtreated.
16 Implementing early workplace and worker interventions to prevent disability Recruitment via occupational health ÖMPSQ, short version >39 no red flags Randomized:TAU=52: Work & worker=50 Worker = 3 sessions, supervisor=2 sess. Education, Communication & problem solving
17 Differences in sick leave due to pain (days per month). Significant difference!
18 Differences in utilization of health care visits per month. Significant difference!
19 Differences in perceived health status (range 0-100) Significant difference!
20 Review of early psychosocial interventions: Decade of Flags 18 RCTs of early psych intervention Musculoskeletal pain Most in primary care settings Nicholas, Linton, Watson & Main, 2011
21 Results of the Review 11 studies targeted psychological risks (6 studies selected ONLY those at risk ) 7 studies did NOT target or select at risk
22 Results of the Review 11 studies show Significant improvements compared to Usual Treatment Identifying and targeting works! 7 studies showed little or no effect as compared to Usual Treatment B*U*T did not identify risk or specifically target it Nicholas, Linton, Watson & Main, Phy Therapy, 2011
23 New approaches Exposure Endurance Third wave: ACT + DBT
24 Example: Fear-avoidance Dysfunction Depression Injury Recovery Avoidance Fear Vigilance and tension Pain Confronting Catastrophizing Normal fear Warning signal Based on Vlaeyen & Linton, 2002
25 Exposure in-vivo Develop hierarchy of feared movements Tampa Scale, Catastrophizing PHODA pictures of movements Provoke fear in exposure trials Challenge cognitions Test & disconfirm expectations Generalize to everyday life
26 Jessica A. Lohnberg,2007 Review of the literature The author concludes that graded exposure in vivo appears to be the most effective treatment for chronic pain in individuals with increased fear and avoidance.
27 RCT of exposure to prevent work disability Randomized: Exposure WLC N=46, spinal pain Includes exposure first And exposure after WLC period Linton et al, European Jr. of Pain
28 Effects of exposure: RCT Within group changes! ES=.9 Pre Post 3mo ES=.8 ES=1.1 Pain Quebec Disability TSK
29 Leeuw et al, Pain 85 CLBP patients Randomized to: Exposure Graded Activity
30 Clinically Significant: 6mo fu 100 NS/p= % exp graded 0 complaints Function
31 Endurance Model of Pain Hasenbring et al, 2008 PAIN Thought suppression/distraction Changes in mood Muscular overload Development of CLBP
32 Acceptance and Change Accept what cannot be changed Focus on pursuing life goals, NOT PAIN Mindfulness and Exposure Systematic review of ACT 22 studies ES for pain=.37 = CBT Additional method for some patients Veehof et al, Pain, 2011
34 Common with comorbidity Both pain & depression are bedfellows with a variety of other disorders Psychological e.g. stress, anxiety disorders, fatigue, eating disorders Physical health e.g. weight loss/gain, fatigue, diabetes, cardiovascular
35 Pain Insomnia Depression A B C Transdiagnostic factors A B C Treatments aim at factors
36 Effects of depression on pain Common: 52% of pain patients also depressed More intense pain Pretreatment depression associated with poor treatment outcome Depression related to relapse 2x more sickleave Linton & Bergbom, 2011; Bair, 2003; Shaw et al, 2006
37 BDI (dep) as function of initial BDI BDI score Clinical Depression at post: High = 81% Moderate = 45% Mild High 0 Sullivan et al, Jr of Occ Rehab, 2006 wk 1 wk 4 wk 9
38 Depression (post) and RTW % % RTW maximized by early intervention 60% that reduces depression 26% 0 None Mild Mod-severe Sullivan et al, Jr of Occ Rehab, 2006
39 Does depression trigger pain? Difficult to pinpoint when depression/pain first occur Data are mixed Relationship: not necessarily a causal one Likely bi-directional or nonlinear relationship, catalyze each other Depression Pain
40 Treating depression & pain Depression is often undetected in health care 76% of patients only report physical symptoms Usual treatment focuses on pain in hope that depression will disappear when pain is reduced Bair et al 2003; Linton & Bergbom, 2011)
41 Does treating pain relieve depression? No convincing evidence 9 weeks of oral morphine in doses up to 120 mg daily may be of analgesic benefit, but is unlikely to confer psychological or functional benefit Sullivan, earlier slide
42 Does treating depression relieve pain and improve function? Some studies find an effect Cochrane review (Urquhart et al, 2008) concluded: no better than placebo Small ESs for pain for both antidepressives and analgesics (chou 2007, Perrot, 2008) even though pharmacological treatment (for depression) is often recommended, it has limited effects on pain and few documented effects on function Linton & Bergbom, 2011
43 Treating both depression and pain Farmer 2010, USA 553 pats fulfill depression & pain criteria Receiving any depression treatment was associated with better mental health (on SF-12) and less interference of pain on work (but mean change just 2 points)
44 Treating depression & pain Kroenke et al 2009 CBT activation program for pain & pharmacological for depression S improvement in depression & pain BUT, only 26% improved in both!! Analyses of predictors (2010) Fear-avoidance predicted pain and activity interference
45 Hybrid exposure Combines exposure for movement & emotions Particularly good if patient is distressed?!
46 Treatment Stage I Analysis, Goals & emotions Stage II Id stimuli & Skills training Stage III Exposure: clinic & home Stage IV Generalize/maintain Validation,Chain analysis, Values & goals Dialectics, Selfvalidation, emotion/pain regulating skills training Exposure for sensitive emotional/movement stimuli
49 PERCENT IMPROVEMENT CATASTROPHIZING ACCEPTANCE PAIN FUNCTION 1 77% 72% 57% 37% 3 77% 224% 70% 11% 4 42% 138% 50% 37% 5 91% 138% 66% 82% 6 57% 121% -7% 15% 8 90% 210% 68% 66% MEAN 72% 127% 51% 41%
50 THE SIGNIFICANCE OF CO- OCCURRING SLEEP AND PAIN
51 Pain and sleep disturbances Large epidemiological study (n=2406) Random sample of adults PAIN 61% report active pain symptoms OF THOSE: 58% also report sleep problem SLEEP 50% report active sleep disturbance OF THOSE: 70% also report pain Linton & MacDonald, 2004
53 Chronic pain: co-occurrenc with insomnia 11% 23% No clinical insomnia Subthreshold insomnia Moderate clinical insomnia 42% 24% Severe clinical Insomnia 53%, vs 3% in matched pain-free controls Tang, Wright & Salkovskis, 2007
54 Conte, Boersma, Linton, in preperation Symptoms over time Hi Pain & sleep 55% HI/HI 18% pain 18% sleep Only 6% remit to no symptom Lo Pain & sleep 29% develop symptom
55 The effect of sleep on pain Do Sleep Disorders Contribute to Pain Sensitivity? (Okifuji & Hare, 2011) Poor sleep = increased pain Sleep deprivation attenuates analgesia Effects probably bidirectional Curr Rheumatol Rep (2011) 13:
56 Effect of pain on sleep Pain= difficulty in initiating sleep Pain disrupts deep sleep Pain related to wake time and early waking
57 Treating insomnia Well developed behavioral treatment for insomnia (CBT-I) developed by pioneers like Morin, Harvey, & Edinger Well defined outcomes from self-report (ISI) to objective measures (time in bed; EEG)
58 Stimulus control & Sleep restriction Go to bed only when you are sleepy. Bedroom only for sleep & sex Get up if you do not fall asleep LARGE (15min) Repeat above Get up at the same time every day Do not take a nap! Maintain daytime activities EFFECT! Sleep deprivation increases liklihood of falling asleep & sleep effectiveness
59 CBT-I for sleep & pain (Bohra & Espie, 2013 ) Study Design Main results Currie, 2000 Edinger, 2005 WLC; N= 60 Sleep improved (S). NS pain or depression Hygiene; TAU, N=47 Sleep improved (S) Pain: NS for CBT-I Jungquist, 2010 Vitiello, 2009 Therapist control; N=28 Attention; N=51 Sleep improved (S). Pain: interference S, all others NS Sleep improved (S) Pain: mixed results
60 Bohra & Espie, 2013 Mean ES Sleep Latency Sleep Efficiency Wake After Sleep Onset Between groups BUT no reliable ES for pain variables!
61 Does treating chronic pain improve sleep? CBT for pain is not as standardized as for sleep Many techniques, often combined with Tx Outcomes are not as straight forward Small to moderate ES
62 What to do?
63 GOOD: Treat one effectively! Will likely have a positive effect on the other symptom CBT for insomnia is a great choice Relatively easy to administer Cost-effective Probable effect on pain
64 BETTER: Target both problems Need treatment for both for best results Shown in other areas as well Start with one (CBT-I) and observe the effect If needed, continue with CBT for pain
65 Transdiagnostic processes Attention Catastrophic worry Daytime activity levels Avoidance
66 MODEL Avoidance Negative affect Dysfunction Depression Attention bias Catastrophic worry symptoms
67 Hybrid treatment targeting both (Tang et al, 2012) 4 sessions, 2 hrs. targeting both insomnia and pain (n=10) Versus symptom monitoring control (n=10) Hybrid CBT > monitoring for sleep (ISI), pain interference, and mood Hybrid CBT NS > monitoring for pain intensity
68 A long way to go.. To fulfill the promise of a transdiagnostic approach!
69 Conclusions Early identification and intervention using CBT has potential when applied New methods e.g. exposure are promising Co-occurring problems is common Addressing both problems is a way forward Underscores need to identify causal processes More research needed of course!!
70 Thank You for Your Attention!