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Pain Management: Cognitive Therapy for Chronic Pain and Fibromyalgia
Mr.H had a multidisciplinary assessment and the following will highlight some of the important issues in that process.
Psychological assessments is an integral part of the process along with assessments by others in the core group of the multidisciplinary team, it involves evaluation of current psychosocial functioning, personality, social and relationship functioning, mental status and so forth and that help to determine whether there are any significant "barriers" to rehabilitation; and provide treatment to help patients to progress through the program. Specific goals of psychological assessment were suggested by Romano et al. as to identify: (a) psychosocial factors that may affect pain perception and behavior as well as functional impairment, (b) specific treatment goals for each patient and (c) intervention strategies that may produce maximum patient improvement.
It is also thought that psychological factors play an important role in the prognosis of some pain conditions especially in regards to disability. Vlaeyen proposed the fear-avoidance model, based on that and other pain related-psychological studies, the idea of "yellow flags" being important psychological warning signs that need to be recognized and addressed have become an essential element in the psychological evaluation of pain patients. These are divided into four main areas: work related belief related, behavioral and affective. In addition to the classical clinical interview, the use of questionnaires here is a popular and efficient way in this evaluation process.
Mr.H had both, and the case history showed the result of that assessment and therefore, his suitability to benefit from a cognitive behavioral pain program. For a detailed description on different psychological constructs involved in that testing and the tools used in that assessment in terms of validity, reliability and a specific description of each of those questionnaires please refer to attachment (A) included at the end of this report. In terms of the effect of the ongoing litigation with the insurance company on Mr.H presentation, it is unclear as Mr.H reports that the issue is only about payment of medical expenses.
A full pain history should be based on a biopsychosocial approach. This approach will involve a biomedical history which is usually conducted by a physician aiming to establish rapport with the patient, establish a putative tissue and mechanism diagnosis differentiate between acute and chronic as well as nocioceptive and neuropathic pain, assess prior treatment efficacy, check for red flag conditions and uncover any major issues like substance abuse or legal agendas. In 1937, Ryle's suggested elucidating eleven features in regards to patient's complaints of pain.
More recently, the NHMRC produced some guidelines in regards to taking proper pain history. As for the physical examination in relation to back pain, the existing evidence base shows that no particular clinical sign, or a combination of signs, found by this process, allows a valid or reliable diagnosis of the back pain to be made in anatomical or pathological terms. However, many clues can be found or elicited on examining the pain patient which in combination with other parts of the assessment can confirm or rule out possible diagnoses. Mr.H had a general examination and further neurological examination in relation to his back pain that ruled out the possibility of significant neuropathy.
Furthermore, the possibility of red flag conditions being the cause of his pain was ruled out based on the history, physical examination and the imaging studies. Mr.H was thought to have low back pain with radiation to the right leg attributed to the disc prolapse found on the MRI scan (1999) causing slight thecal sac and right S1 nerve root compression. But due to the fact that the pain involved more leg distribution than what could be explained through this mechanism alone, it was also thought there might be an element of facet Joint referred pain. Therefore it was justified that he gets the diagnostic medical branch blocks.
The prevalence of zygapophysial joint pain is reported as 15% in young injured workers and up to 40% in older patients. The two most common levels involved are L5/S1 and L4/L5; therefore it is common that interventional pain specialist perform blocks at these two levels. Mr.H had diagnostic medial branch blocks of the right L5/S1 and L4/L5 facets and the response was negative. This indicated to a large extent that the facet joint had no contribution to his low back and right leg pain.
CBT is the application of the principles of learning as well as empirically-derived methods to, (a) change the ways in which pain sufferers perceive and react to their pain and (b) help these patients develop better coping skills to adjust more effectively to the continuing demands of chronic pain. CBT is targeted at each specific area identified at the assessment process- for example: inactivity (activity avoidance), depressed mood, unhelpful beliefs or fears, and excessive reliance on medications . As for the efficacy of CBT or what sometimes is referred to as multidisciplinary treatments (MDT), a systematic review has concluded that MDT was superior to no treatment, waiting list controls, or single-discipline treatments and cautioned that the quality of design and study descriptions were marginal.
As the authors indicated, most of the original studies included in the review are considered weak in the current standard of assessing trials. In another review included 25 trials on chronic pain patients. The conclusion was that when compared with the waiting list control (WLC) conditions, CB treatments were associated with significant effect size on all domains. Compared to other active treatments CB treatments had a significantly greater changes for the domains of pain experience, cognitive coping and appraisal and reduced behavioral expression of pain. The authors also raised concerns on difficulty in blinding in CBT trials as well as how difficult it is to obtain dichotomized outcome in this field.
Another review showed strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration (MDBRFR) improves function when compared with inpatient or outpatient non-multidisciplinary rehabilitation. It also showed moderate evidence that intensive MDBRFR reduces pain when compared with outpatient non multidisciplinary rehabilitation or usual care. Bogduk argues that there is contradictory evidence in the result of this review and what was shown was considered in term of vocational outcomes.
It was finally possible to secure a place for Mr.H in a CBT program which happened to be after he showed no improvement with the diagnostic medial branch blocks. Mr.H participated in an intensive 7-week CBT program that included a 3-week hospital based full time attendance and 4- week home based management. At the end of the program all his mediations were ceased except the antidepressant. His physical disability was thought to have at least normalized to the pain clinic average. His confidence in his ability to manage his pain was thought to have worsened compared to his status at presentation. He was reported to continue having fear-avoidance beliefs and as for his catastrophic thinking, it was thought to have significantly improved.
Spinal cord stimulation for the treatment of chronic pain is another intervention that proved to be effective. In terms of evidence based medicine, a recent updated review by Turner et al looked at the effect of spinal cord stimulation on pain and functioning and the rate of complications. The review included patients with CRPS and FBSS. They included 3 studies on FBBS. The studies were rated as class III evidence-base wise (all were case series). There analyses were as follows:
As seen in this case report and what seems to apply to many pain patients, who receive implantable pain interventions, it is difficult to predict how they will respond to an intervention. When a patient is thought to qualify for both treatments, what should they receive first, the CBT or the SCS. Should Mr.H have received the SCS then attended the CBT to complete the management plan rather than what actually happened. There are no clinical trials available that could provide an answer to this important question.
Reflection Exercise #9
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