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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. © 2005.

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”

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Pain Catastrophizing Scale (PCS)

• Developed by Sullivan (1995) to:– measure pain catastrophizing– better understand the mechanism by which

catastrophizing impacts the experience of pain

Pain Catastrophizing Scale (PCS)

• 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• 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

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

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Despite this, there is minimal research on effective

interventions to decrease pain catastrophizing

Does pain rehabilitation reduce pain catastrophizing?

Chronic Pain RehabilitationOverview

• Multidisciplinary, multimodal therapies

• Rehabilitation rather than relief• Establish expectations• Limited medical evaluation

Chronic Pain RehabilitationOverview

• 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

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Cognitive Behavioral Model

Thinking

Behavior Feeling

“Hope does not lie in a way out but in a way through”

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 post-

treatment

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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?

MethodsMethods• 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

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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

0

10

20

30

40

50

60

Pain Severity(MPI)

Depression(CES-D)

Pain Anxiety(PASS)

Using Opioids(%)

MeansPCS >= 75th%ile PCS < 75th%ile

*p<.001

*p<.001

*p<.001

*p<.01

Differences upon Admission to the Pain Rehabilitation Center

Based on Pain Catastrophizing Scores

Results

– Group differences in pain severity, depression, Pain-related anxiety, and opioiduse 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.

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05

1015

2025

303540

4550

Catastrophizing (PCS) Pain Severity (MPI) Depression (CES-D) Pain Anxiety (PASS)

Means

Treatment Outcomes Following Pain Rehabilitation

Before Rehabilitation After Rehabilitation

*ES = .98, p<.001

*ES = .80, p<.001*ES = 1.1, p<.001

*ES = 1.2, p<.001

*ES = Effect Size (Cohen's d)

Results

– Upon completion of the 3 week program, patients reported significant decreases in pain catastrophizing, pain severity, depression, and pain-related anxiety

Percent of Patients with Clinically Significant Pain Catastrophizing Before Rehabilitation

High PCS (≥75th%ile)42%

Moderate PCS (50th% to 74th%)26%

Low PCS (0 to 49th%ile)32%

Results

– 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

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%

Results

– 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

• 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, 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

• Radloff, L. S. (1977). The CES-D Scale: A self-report 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.

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.