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Chronic pain management: A paradigm change
Abstract
Chronic pain is a common condition with significant impact on patients' functional ability, mood and quality of life. The economic burden of chronic pain is also severe due to the cost of healthcare utilisation, litigation and compensation claims, social welfare benefits and loss of productivity. Chronic pain is now recognised as a multifaceted condition that includes physical, psychological, social and spiritual dimensions. Over the last decade, the focus of chronic pain and its management has shifted from primarily a biomedical to a biopsychosocial approach. In many patients, pain persists despite treatment of physical cause or when physical cause is absent. Patients with chronic pain are often frustrated, have low self-efficacy and are depressed as the result of their persistent pain, failed treatments, physical disability and associated abnormal psychosocial effects. They develop pain behaviour such as fear avoidance and catastrophise their pain leading to inactivity and physical disability. A pain management programme embracing an integrated cognitive-behavioural therapy and exercise approach has been shown to be effective in improving the outcome in patients with chronic pain. Family physicians play an important role in identifying "yellow flags", initiating early intervention and maintaining patients' adherence to treatment.
... Chronic pain is a very common, complex, and disabling health problem (Chen, Wong, & Chu, 2004). Depression frequently complicates the problem of chronic pain and further reduces quality of life (Chen et al., 2004). ...
... Chronic pain is a very common, complex, and disabling health problem (Chen, Wong, & Chu, 2004). Depression frequently complicates the problem of chronic pain and further reduces quality of life (Chen et al., 2004). Soares and Grossi (2000) stated that persons with chronic pain who struggled with depression had a low self-evaluation of their performance potential. ...
... Others may feel unable to cope with pain and see themselves as ineffective in tolerating pain. Cognitive behavioral therapy (CBT) has been introduced as a means of improving self-efficacy as well as depression in persons with chronic pain (Wells-Federman et al., 2002;Wells-Federman et al., 2003;Chen et al., 2004;Turk, 2003). CBT suggests that the interaction of cognitions, affect, and behaviors affects management of chronic pain. ...
Chronic pain is a complex and often disabling condition compounded by depression and poor self-efficacy. The purpose of this evidence-based project was to explore the relationship of cognitive behavioral therapy (CBT)-focused groups with self-efficacy and depression in persons with chronic pain at an intensive interdisciplinary 3-week pain rehabilitation center (PRC). The project sample consisted of 138 persons admitted to a PRC and scoring ≥27 on the Center for Epidemiological Study Depression Scale (CES-D) and then completing the Pain Self-Efficacy Questionnaire (PSEQ). After completing the PRC program, including CBT-focused groups, discharge CES-D and PSEQ scores were analyzed. A comparison group of CES-D scores from 134 persons admitted to the PRC from a 9-month time period preceding the addition of the CBT-focused groups was also examined. There was a significant increase in self-efficacy after participation in the intensive pain rehabilitation program including CBT-focused groups. Patient groups both before and after introduction of CBT-focused groups showed the same rate of improvement on the depression scores, suggesting that persons who participated in CBT-focused groups improved equally compared with persons who did not participate in these groups. Ninety-three percent of the participants expressed satisfaction with the CBT groups. This evidence-based practice is well supported in the literature and can be implemented with knowledgeable staff and engaged stakeholders.
... This result is in accordance with the previous studies on spinal cord injury patients [32], and patients with fibromyalgia [15]. On the contrary, in a meta-analysis by Cheng et al. on adults with chronic musculoskeletal pain !3months, no statistically significant support in terms of alleviating mood and mental symptoms with CBT was observed [33]. ...
Objective
This study was designed to explore the efficacy and feasibility of cognitive behavioural therapy(CBT) along with pregabalin and compare it with pregabalin monotherapy for the management of neuropathic pain in post-herpetic neuralgia (PHN) patients and to explore the modulation of mRNA expression of interleukin (IL)-6 and mammalian target of rapamycin-1 (mTORC1) genes in these patients.
Design
Randomized controlled pilot study
Methods
The patients aged >18 years of age with an established diagnosis of PHN with evident allodynia and hyperalgesia who had pain for at least 3 months after healing of rash with pain intensity ≥4/10 on NRS-Pain Scale were enrolled. The trial was registered with the Clinical Trials Registry-India (CTRI/2019/03/018014). A detailed baseline assessment regarding type and duration of pain and disability using pain-relevant self-report questionnaires was done. Two ml venous blood samples were collected for gene expression studies at base line and at end of 12 weeks of treatment. Patients were randomized into one of the two groups. Group PR received pregabalin and Group CP received CBT along with pregabalin. The pain intensity was measured using numeric rating scale (NRS)-Pain scale, neuropathic component of the pain by using Neuropathic Pain Symptom Inventory (NPSI) and Pain Detect Questionnaire (PDQ), sleep interference by NRS-Sleep, pain-related catastrophic thoughts by using Pain Catastrophizing Scale (PCS), depression and quality of life using Beck Depression Inventory-II (BDI-II) and Short Form-12 (SF-12), respectively. The research funding was supported by the intramural grant from the institution.
Results
A total of 40 patients with 20 in each group were included. Following integrated approach encompassing CBT and Pregabalin, group CP had significant downregulation of mRNA expression of IL-6; however, no such correlation was observed with mTOR expression. A significant decline in the intensity of pain, NPSI scoring for burning, allodynia, and pain-related catastrophizing were observed; also a significant improvement in depressive symptoms and quality of life were observed with the use of CBT.
Conclusions
A significant downregulation of mRNA expression of IL-6 was observed; however, no significant correlation was observed between NRS pain score and ΔCt values of mRNA expression of both mTORC1 gene and IL-6 gene at baseline and at the end of 12th week. In addition, we note a significant decrease in pain intensity, depressive symptoms, and pain-related catastrophizing while improving QOL was observed with the use of CBT as a clinical adjunct along with pregabalin in PHN patients.
... Complicated cases of chronic pain may benefit from a multidisciplinary and multimodal treatment approach. 33 ...
To evaluate the health-related quality of life in Hong Kong Chinese patients with chronic non-cancer pain.
Prospective cross-sectional survey.
Regional public hospitals, Hong Kong.
Patients attending out-patient pain management clinics between 1 July 2002 and 28 February 2003 were approached to complete a set of standardised questionnaires.
Demographic profiles, treatment modality, litigation, compensation, social welfare status, Hospital Anxiety Depression Scale, and Medical Outcomes Survey short-form health survey (SF36).
Data from 166 patients were analysed. The median numeric pain rating score was 6 (interquartile range, 2-10). Work-related injury occurred in 34.3% of patients, while another 34% were involved in pain-related litigation and 32% were receiving disability or unemployment benefit. Sixty-four percent of patients were managed by three or more disciplines, while 54.8% were also receiving complimentary alternative medical treatment, mainly traditional Chinese medicine (49.7%). The Hospital Anxiety Depression Score indicated clinical anxiety or depression in 71.1% of patients. All SF36 subscale scores were lower than the local population norm. Unemployed patients had higher depression scores (P = 0.005), while students or retirees had lower physical functioning scores (P = 0.004). Patients who were single had higher role emotion scores than those who were married or separated/widowed (P = 0.011). Logistic regression analysis showed that younger age (odds ratio = 0.95), being married (6.62), work-related injury (15.63) or higher general scores (1.03) were more likely to be associated with litigation. Social welfare benefit was associated with unemployment (3.39) and a lower level of physical functioning (0.98).
There was a high prevalence of clinical anxiety, depression, and severe impairment in the health-related quality of life in Hong Kong Chinese patients with chronic non-cancer pain. Specific factors affected the health-related quality of life, likelihood of litigation, and social benefit.
Pain management is a dynamic clinical area. Basic research is generating new drugs and new technologies for their delivery. Clinical research has demonstrated the important roles of psychological and environmental factors in the complaint of pain. Surgical strategies are improving. The recognition that the human brain plays a major role in pain perception and pain behaviours has led to the development of multidisciplinary teams that can bring a diversity of diagnostic and therapeutic skills to clinical medicine. The specialty of pain management is gaining momentum throughout the world. Australian health care delivery needs to respond to these developments to permit the citizens of this country to receive state-of-the-art care. Not only will this be more humane, but it will permit a reduction in the enormous financial costs of the poor management of both acute and chronic pain.
Chronic pain is a major public health problem in the United States. Estimates from the National Institutes of Health put the cost of chronic pain at 40 billion dollars a year. They estimate that as many as 15 million adults suffer from low back pain with a minimum cost of 5 billion dollars in direct medical costs and 93 million work days lost every year. In an attempt to cope with this massive problem, multidisciplinary pain units have arisen which attempt to address the complex, multi-faceted aspects of a chronic pain problem. The importance of this new treatment approach is made evident by the 1981 overview of multidisciplinary pain centers published by the National Institutes of Health. In this publication, the history and success of these units since their first development by Bonica are evidenced. The purpose of the present paper is to briefly, critically summarize one small aspect of these programs, specifically follow-up analysis of the patients after discharge.
To describe potential adherence-related difficulties encountered in the implementation of a secondary prevention, early intervention study with acute low back pain patients. An additional goal is to provide recommendations, based on the authors' experience, on how best to overcome these potential obstacles for future research.
The study used a predictive algorithm, identified through previous research, to identify which patients presenting with acute low back pain were at risk for developing chronic problems. These subjects were then treated prophylactically with an interdisciplinary intervention. Specific difficulties initially encountered during the pilot stage of implementation of this intervention included securing adequate physician referrals to the study and helping patients to progress through treatment in the most efficient manner.
Potential difficulties are discussed in the contextual framework of treatment adherence and factors affecting it, including the impact of personality factors, satisfaction, comprehension, side effects, financial issues, length of treatment, type of regimen, social issues, patient beliefs, and biologic factors. It is hoped that the present authors' experience will enable future investigators to anticipate these common problems, and structure their research endeavors accordingly.