Objectives. Significant Costs Of Chronic Pain. Pain Catastrophizing. Pain Catastrophizing. Pain Catastrophizing

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1 Effectiveness of a Comprehensive Pain Rehabilitation Program in the Reduction of Pain Catastrophizing Michele Evans, MS, APRN-C, CNS, March 27, 2007 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. MAYO, MAYO CLINIC and the triple shield Mayo logo are trademarks and service marks of MFMER 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 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 Described as an exaggerated negative mental set associated with actual or anticipated pain experiences Important predictor of functional outcomes with 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 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 1

2 Pain Catastrophizing Scale (PCS) Pain Catastrophizing Scale (PCS) Developed by Sullivan (1995) to: measure pain catastrophizing better understand the mechanism by which catastrophizing impacts the experience of pain 13 item instrument (< 5 minutes) Requires 6 th 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 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 75 th % of clinic sample PCS Assessment 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 Why is measuring pain catastrophizing important? 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

3 Despite this, there is minimal research on effective interventions to decrease pain catastrophizing Does pain rehabilitation reduce pain catastrophizing? Chronic Pain Rehabilitation Overview Multidisciplinary, multimodal therapies Rehabilitation rather than relief Establish expectations Limited medical evaluation Chronic Pain Rehabilitation Overview Limited treatment of nociception Improve functional status Reduce behavioral morbidity Address psychiatric co-morbidity Improved quality of life Pain Rehabilitation Center Comprehensive Multidisciplinary Approach MD RN/Case Manager CNS Psychologist Physical Therapy Occupational Therapy Pharmacist 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

4 Cognitive Behavioral Model Thinking Hope does not lie in a way out but in a way through Behavior Feeling Robert Frost Process of Change 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 Key Educational Concepts 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

5 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 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 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 Outcome Measures Pain Catastrophizing Scale CES-D Pain Anxiety Symptom Scale Multidimensional Pain Inventory 5

6 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 Studies- Depression (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< *p<.001 *p< Pain Severity (MPI) Depression Pain Anxiety (CES-D) (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

7 Results Treatment Outcomes Following Pain Rehabilitation *ES = 1.1, p<.001 *ES =.80, p<.001 *ES = 1.2, p<.001 *ES =.98, p<.001 Catastrophizing (PCS) Pain Severity (MPI) Depression (CES-D) Pain Anxiety (PASS) Upon completion of the 3 week program, patients reported significant decreases in pain catastrophizing, pain severity, depression, and pain-related anxiety Means Before Rehabilitation After Rehabilitation *ES = Effect Size (Cohen's d) Results Percent of Patients with Clinically Significant Pain Catastrophizing Before Rehabilitation Low PCS (0 to 49th%ile) 32% Moderate PCS (50th% to 74th%) 26% High PCS ( 75th%ile) 42% At admission a large percent of patients (42%) reported clinically significant pain catastrophizing (> 75 th percentile) Over one-quarter of the patients demonstrated moderate levels of pain catastrophizing Results Percent of Patients with Clinically Significant Pain Catastrophizing After Rehabilitation Low PCS (0 to 49th%ile) 81.5% Moderate PCS (50th% to 74th%) 12.5% High PCS ( 75th%ile) 6.0% 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. 7

8 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 Upon completion of a pain rehabilitation program, patients demonstrated a significant reduction in 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 Kerns, R.D, Turk, D.C., Rudy, T.E. (1985) The West Haven-Yale Multidimensional Pain Inventory, Pain, 23, 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), 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), 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. References Sullivan, M.J.L, Bishop, S. and Pivik, J., The Pain Catastrophizing Scale: Development and validation, Psychological Assessment, 7, (1995) Turk, D.C. & Gatchel, R.J. (2002). Psychological Approaches to Pain Management. Guilford Publications, Inc., New York, NY. 8